United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 29, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/28/2012 - 11/29/2012

** EVENT NUMBERS **


48056 48523 48528 48530 48531 48541 48542 48544

To top of page
Power Reactor Event Number: 48056
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHARLES BROESCHE
HQ OPS Officer: JOE O'HARA
Notification Date: 06/29/2012
Notification Time: 13:04 [ET]
Event Date: 06/29/2012
Event Time: 10:28 [EDT]
Last Update Date: 11/29/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JONATHAN BARTLEY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO INCREASE IN PROBABLE MAXIMUM FLOOD LEVEL

"On June 29, 2012, TVA issued an updated calculation titled 'PMF Determination for Tennessee River Watershed' The calculation resulted in an increase in the Watts Bar Nuclear (WBN) probable maximum flood (PMF) level from Elevation 734.9 to Elevation 739.2. All flood sensitive safety related systems, structures, and components have been reviewed and been determined to remain unaffected by the revised PMF surge elevation, with the exception of the Thermal Barrier Booster Pump Motors and Essential Raw Cooling Water (ERCW) equipment required for flood mode operation located on Elevation 722 of the Intake Pumping Station (IPS). The updated PMF of Elevation 739.2 could impact the ability of the thermal barrier booster pumps and the Elevation 722 IPS ERCW equipment to perform their design accident protection function. Because of the unanalyzed condition. the potential existed for WBN to exceed its PMF design basis and adversely affect plant safety.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(ii)(B).

"Compensatory measures have been prepared to install a temporary flood protection barrier around the thermal barrier booster pumps and provide additional protection of Elevation 722 of the IPS in the event of a flood alert.

"The potential for the increased PMF level and the associated compensatory measures were previously discussed in a public meeting between TVA and the NRC on May 31, 2012 and in correspondence between TVA and the NRC dated June 13, 2012 and June 25, 2012.

"All safety related equipment is currently operable. There are no indications of conditions that might result in a flood in the near term.

"The licensee notified the NRC Resident Inspector of this condition."


* * * UPDATE FROM MICHAEL BOTTORFF TO VINCE KLCO AT 1435 EST ON 11/29/12 * * *

"Based upon continuing engineering reviews, the chilled water circulating pump motors for the Train A and B Main Control Room and 6.9kV Shutdown Board Room, including various sub-components, would be partially submerged during a Probable Maximum Flood (PMF) event. These components were not previously considered as affected by the PMF. The affected components are located on floor elevation 737.0 of the auxiliary building.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(ii)(B).

"Compensatory measures have been prepared to install temporary flood protection barrier around the chilled water circulating pump motors and provide additional protection of Elevation 722 of the IPS in the event of a flood.

"All safety related equipment is currently operable. There are no indications of conditions that might result in a flood in the near term.

"The licensee notified the NRC Resident Inspector of this condition.

"Licensee Event Report 50-390/2012-002-00 will be supplemented to include a description of the potential PMF affects on the chilled water circulating pump motors."

Notified the R2DO (Ernstes).

To top of page
Non-Agreement State Event Number: 48523
Rep Org: U. S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-328-38-01
Agreement: N
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/20/2012
Notification Time: 11:41 [ET]
Event Date: 10/29/2012
Event Time: [EST]
Last Update Date: 11/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
BILLY DICKSON (R3DO)
FSME EVENTS (EMAI)
RAY KELLAR (R4DO)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

MISSING IMPROVED CHEMICAL AGENT MONITOR

An ICAM (Improved Chemical Agent Monitor) is missing at Fort Riley, KS. The ICAM contains a 10 mCi Nickel-63 source. The licensee has initiated a formal investigation and notified NRC Region 3 Inspector (McGraw).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 48528
Rep Org: STAMFORD HOSPITAL
Licensee: STAMFORD HOSPITAL
Region: 1
City: STAMFORD State: CT
County:
License #: 06-066-9702
Agreement: N
Docket:
NRC Notified By: SARAH BULL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2012
Notification Time: 12:31 [ET]
Event Date: 05/01/2012
Event Time: [EST]
Last Update Date: 02/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES DWYER (R1DO)
FSME RESOURCE (EMAI)

Event Text

MEDICAL EVENT - ACTUAL DOSE DIFFERED FROM PRESCRIBED DOSE

An NRC Region I Inspector (Abogundi) performed an inspection at the licensee facility and determined that a medical event occurred and should have been reported.

In May, 2011, a patient received prostate LDR (Low-Dose Rate brachytherapy) treatment using 86 Pd-103 seeds for a prescribed dose of 125 Gy. During post-treatment evaluation, it was determined that the patient received between 72% and 75% of prescribed dose. The prescribing physician was notified and will not be notifying the patient due to treatment success.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * * RETRACTION FROM SARAH BULL TO HOWIE CROUCH AT 1130 EST ON 2/4/13 * * *

After reviewing their reporting procedures and in consultation with their Regional NRC Inspector (Abogundi), the licensee determined that this event did not meet their activity-based (versus dose-based) reporting criteria. Based on this information, the licensee has retracted this event notification.

Notified R1DO (Powell) and FSME Resource via email.

To top of page
Agreement State Event Number: 48530
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON SUBURBAN HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-099-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VELEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2012
Notification Time: 15:09 [ET]
Event Date: 11/21/2012
Event Time: [CST]
Last Update Date: 11/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
FSME RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the Commonwealth of Kentucky via facsimile:

"Kentucky Radiation Health Branch was notified on November 21, 2012 by the [licensee's] Medical Physicist, that a medical event occurred during the final hours of a gynecological radiation implant using Cs-137. The 40 hour procedure was scheduled to end today at 0915 CST. Upon arrival at 0910 to remove the applicators, the patient stated [that] shortly after 0600 she felt something had moved or urination or gel had come out of her. As the Medical Physicist pulled back the patient's gown, she saw the packing from the implant completely out of the patient. The top of the packing was approximately 1cm from the perineum. The sources were quickly removed from the applicators and put in a shielded transport container. The Medical Physicist's initial dose estimate to the skin on the patient's thigh and surrounding area is close to 450 cGy based on the applicator being out for 3 hours. There were a total of 5 sources used, 3 in the tandem all had the same activity (96.11 cGy*cm2/hr) and one in each ovoid, both having an activity of 29.63 cGy*cm2/hr. Radiation survey measurements of the applicators, patient, and room were below background. The RSO, patient, and prescribing physician are aware of the event that occurred and a follow-up is scheduled. The State will continue to keep NRC informed of the status of our investigation."

KY Event Report ID# KY120014

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

To top of page
Agreement State Event Number: 48531
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SOUTHERN OHIO MEDICAL CENTER
Region: 3
City: PORTSMOUTH State: OH
County:
License #: 02120 74 0002
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/21/2012
Notification Time: 17:50 [ET]
Event Date: 11/21/2012
Event Time: [EST]
Last Update Date: 11/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
FSME RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL DEFECT OF HDR UNIT

"At 4:45PM on November 21, 2012 the Radiation Safety Officer of the Southern Ohio Medical Center (OH license number 02120 74 0002) located in Portsmouth, OH called the Ohio Department of Health Bureau of Radiation Protection to make a telephone notification of a potential defect with a Nucletron microselectron HDR unit (SN 10281).

"The following event telephone report was made in accordance with OAC 3701:1-38-23(b)(2) (equivalent to NRC 10 CFR Part 21.xx).

"The nature of the defect was that prior to initiation of a patient treatment today, the computer console error code indicated a communication problem between the computer console and the HDR unit. The software indicated that the computer system needed to be rebooted which the licensee did. Upon restarting the computer it indicated a delivered treatment time of 24.6 seconds without the licensee initiating the treatment. The licensee did not see the radiation monitor light up, and entered and surveyed the room and patient with a handheld survey instrument. The licensee does not believe that the source left the shielded position.

"The licensee was able to complete the treatment fraction as planned, which was fraction number ten of ten fractions of 390 seconds. This did not result in a medical event.

"The Radiation Safety Officer notified their management and the manufacturer."

Ohio Event Report Number: 2012-033.

To top of page
Power Reactor Event Number: 48541
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL KENNEDY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/28/2012
Notification Time: 02:38 [ET]
Event Date: 11/27/2012
Event Time: 20:38 [PST]
Last Update Date: 11/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JACK WHITTEN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM VENTILATION SYSTEM WILL NOT AUTOMATICALLY START IN PRESSURIZATION MODE

"The control room ventilation system (CRVS) pressurization mode is required to be actuated by a safety injection signal, control room radiation atmosphere air intake, and operator manual actuation in accordance with Technical Specification (TS) 3.3.7.

"On November 27, 2012 at 2038 hrs. PST, Pacific Gas and Electric Company (PG&E) identified that none of the CRVS four pressurization fans would operate continuously if they started in response to a safety injection or control room radiation atmosphere intake actuation signal. All of the pressurization fans remain capable of continuous operation via manual actuation. At 2050 PST the Unit 2 CRVS was manually placed in pressurization mode in accordance with TS 3.3.7, ACTION B.1.1.

"This was determined to be caused by a recent flow balancing of the CRVS that raised the static air pressure. The increased system static pressure actuates the fan-run pressure switches for each of the four associated pressurization fans, when only a single pressurization fan is operated. This results in the system logic securing all pressurization fans started by the CRVS automatic actuation signals. If all pressure switches actuate, automatically started pressurization fans will be secured until air pressure decays below the fan-run switch setpoint, at which time the pressurization fan would restart. This would result in cyclic operation of the pressurization fan.

"The fan-run pressure switches are not part of the manual actuation circuitry for the pressurization fans.

"Diablo Canyon (DCPP) is making this 8-hour, non-emergency notification under 10 CFR 50.72(b)(3)(v)(D).

"Plant personnel notified the NRC Resident Inspector."

To top of page
Power Reactor Event Number: 48542
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RICH PROUTY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/28/2012
Notification Time: 10:50 [ET]
Event Date: 11/28/2012
Event Time: 10:19 [EST]
Last Update Date: 11/28/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
ANN MARIE STONE (R3DO)
CHUCK CASTO (R3RA)
DAN DORMAN (NRR)
JOHN LUBINSKI (NRR)
JANE MARSHALL (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO TOXIC GAS IN RADWASTE CONTROL ROOM

"Entered an Unusual Event [under Emergency Action Level] MU1, toxic gas, carbon monoxide (CO), detected in the Radwaste Control Room. Levels rose to 34 ppm and the Radwaste Control Room was evacuated prior to reaching the First Energy exposure limit of 35 ppm. The source of the CO has not been determined. There is no radiation release from this event."

There were no personnel injuries and offsite assistance was not requested. There was no effect on plant operations. The licensee has notified state and local authorities and the NRC Resident Inspector.

Notified DHS SWO, FEMA, DHS NICC and NuclearSSA via email.

* * * UPDATE AT 1504 EST ON 11/28/12 FROM MARIKIO BLOUNT TO HUFFMAN * * *

" [At 1452 EST, the licensee] terminated the Unusual Event for MU1, due to toxic gas - carbon monoxide, detected in the Radwaste Control Room. The source of the carbon monoxide readings was determined to be from a leaking acetylene bottle. The acetylene bottle has been removed from the building. Carbon monoxide readings have returned to normal."

The licensee noted that the acetylene is detected as carbon monoxide by the toxic gas monitoring devices.

The licensee has notified State and local authorities and the NRC Resident Inspector.

Notified R3DO (Stone), NRR (EO) Lubinski) , IRD (Marshall), DHS SWO, FEMA, DHS NICC and NuclearSSA via email.

To top of page
Power Reactor Event Number: 48544
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RICK O'CONNOR
HQ OPS Officer: VINCE KLCO
Notification Date: 11/28/2012
Notification Time: 19:47 [ET]
Event Date: 06/03/2012
Event Time: [EST]
Last Update Date: 11/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
ANN MARIE STONE (R3DO)
JOHN LUBINSKI (NRR)
JANE MARSHALL (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION (UNUSUAL EVENT)

"At 1930 [EST] on November 28, 2012, it was determined that a Notification of Unusual Event (NOUE) was not declared for an event that occurred on June 3, 2012, when an equipment failure resulted in a deposit of ion exchange resin onto the floor of the Radioactive Waste building. Subsequent radiological surveys indicated that conditions met the requirements for a NOUE in accordance with the Perry Nuclear Power Plant Emergency Plan.

"This report is being provided within one hour of the recognition of the undeclared event. As discussed in NUREG 1022, Revision 2, an actual declaration of an Unusual Event is not necessary. The Initiating Conditions for the emergency classification no longer existed at the time of recognition.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, February 28, 2013
Thursday, February 28, 2013