United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 17, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/16/2013 - 04/17/2013

** EVENT NUMBERS **


48864 48895 48899 48902 48903 48922 48926 48927 48928 48929 48932 48934
48935 48936 48937 48938 48939 48940

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Agreement State Event Number: 48864
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ROSA OF NORTH DALLAS LLC
Region: 4
City: DALLAS State: TX
County:
License #: 06186
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/28/2013
Notification Time: 17:58 [ET]
Event Date: 03/27/2013
Event Time: [CDT]
Last Update Date: 04/11/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE IN BRACHYTHERAPY TREATMENT DUE TO USE OF WRONG LENGTH GUIDE WIRE

The following information was provided by the State of Texas via email:

"On March 28, 2013, the Agency [Texas Department of Health] was notified by the licensee that a medical event occurred on March 27, 2013. The licensee stated that the wrong length guide wire was used during 3 of 4 HDR [High-Dose Rate Brachytherapy] treatments. The error was discovered after the third treatment. The Radiation Safety Officer (RSO) stated the desired area of treatment was under dosed by more than 50 percent. The treatment plan prescribed 2400 cGy over 4 treatments. He stated that the patient and their physician were notified as soon as the error was discovered. The RSO is not at the facility and is trying to gather the information on the event over his phone. The licensee has suspended all HDR treatments until their process and procedures have been reviewed. Additional information will be provided as it is received in accordance with SA - 300.

"Texas Incident #: I-9059"

* * * UPDATE ON 4/11/13 AT 2126 EDT FROM ART TUCKER TO DONG PARK * * *

The following information was provided by the State of Texas via email:

"On April, 9, 2013, the licensee provided the following information: The Physicist of record retrieved tube connectors from the HDR supplies on shelves in the dosimetry area. The tube/connectors were stored, coiled in Ziploc bags. The Physicist selected green tubes when he saw the black tubes used previously were not on the shelf. He was unaware that there were two sets, each a different length when he selected the green set. The black tubes measure 120cm in length and the green tubes measure 132cm. The Senior Physicist, who was on vacation during the first two out of the four treatments, stored the black tube set in a drawer across the room. Physicist selected tubes which attached to the patient's treatment device. The Physicist planned the patient's treatment with the treatment lengths (119.9 cm) stated in our facility's HDR tandem and ring treatment planning procedure and forms but used the 132cm tube for the treatment delivery for three out of four fractions. Only the black tubes were used historically in tandem and ring HDR procedures and since their given length were known, they were not measured at the time of treatment delivery. The green tubes were also not measured prior to treatment delivery. The Physician of record saw the green tubes and believed their use was intentional. This medical event meant the patient's tissue to be treated (cervix) received less total radiation dose than that prescribed: 1,390 cGy (mean dose delivered) vs. the 5,139 cGy the cervix would have received over the four treatments. This is more than a 50 cGy (50 rem) effective dose equivalent difference to the cervix. In addition, the mean total dose delivered to the cervix over the four treatments differed from the prescribed dose by more than 20% (42.1% is the actual variance) and the delivered dose for at least one of the fractions differed by more than 50% from the prescribed dose (fraction #1 cervix mean dose delivered was 42.5 cGy vs. the 1,192.4 cGy expected) (fraction #2 cervix mean dose delivered was 34.6 cGy vs. the 1,416.3 cGy expected) and (fraction #3 cervix mean dose delivered was 45.2 cGy vs. the 1,262.2 cGy expected). The patient's urethra received a mean dose of 1,607 cGy for the four fractions. The maximum dose to 1 cc of the urethra for the four fractions was 1,849 cGy. The patient's anterior vagina received a mean dose from the four fractions of 1,549 cGy. The maximum dose to 1 cc of the anterior vagina for the four fractions was 3,049 cGy. The Agency [Texas Department of Health] has requested additional information from the licensee. Additional information will be provided in accordance with SA 300."

Notified R4DO (Deese) and FSME Events Resource via email.

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.

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Agreement State Event Number: 48895
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AMERICAN SOIL TESTING
Region: 4
City: SAN JOSE State: CA
County:
License #: 5059
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2013
Notification Time: 14:00 [ET]
Event Date: 12/02/2012
Event Time: [PDT]
Last Update Date: 04/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGES

The State of California provided the following information via email:

"On December 5, 2012, . . . American Soil Testing notified RHB [California Radiologic Health Branch] that his storage facility had been broken into and two CPN Moisture Density gauges (Serial numbers MD00405615 & M17031878) had been stolen. The licensee was advised to post a notice and reward in the local newspapers and on Craigslist and to notify local law enforcement.

"Note: Miscommunication resulted in the NRC not being notified until 4/8/13."

CA 5010 Number: 120512

These CPN Moisture Density gauges contain two (2) sources each, i.e., 10 mCi Cs-137 and 50 mCi Am-241/Be.

HOO Note: See EN #48867 - Report from Nevada concerning recovery of M17031878 gauge.

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

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Agreement State Event Number: 48899
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ALPHA-OMEGA SERVICES, INC.
Region: 4
City: BELLFLOWER State: CA
County:
License #: LA-10025-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2013
Notification Time: 16:50 [ET]
Event Date: 04/02/2013
Event Time: [PDT]
Last Update Date: 04/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PATTI SILVA (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A MIS-DELIVERED SHIPMENT OF RADIOACTIVE MATERIAL

The following information was provided by the State of Louisiana via email:

"Event date and Time: On 04/02/2013 [the] RSO for A & O [Alpha-Omega Services, Inc.] called in a mis-delivery of an Ir-192 source intended for Radiation Oncology Center of Nevada (ROCN). ROCN is a client/customer of A & O, but [the common carrier] delivered the source to Cardinal Health (CH). ROCN and CH are both radioactive material licensees and both have facilities in Las Vegas, NV.

"Event Location: Around the Las Vegas, NV area. The source was intended for ROCN in Las Vegas, NV, but was delivered to Cardinal Health, [also in] Las Vegas, NV. The source delivery occurred in the morning to CH. CH notified ROCN that their source was delivered to CH by [the common carrier]. [The common carrier] was notified and picked up the source at 1300 [PDT] and delivered it to ROCN.

"Event type: Delivery of a radioactive source by the [common] carrier to the wrong licensee. Except during transport, the source was in possession of someone who was a licensee and well trained in radiation safety practices.

"Notifications: A notification was made to LA DEQ [Louisiana Department of Environmental Quality] Radiation Assessment after the incident was basically over and entirely under control. The notification was made to [a Louisiana representative] located in [the Louisiana] Southwest Regional office. A & O was involved in the recovery of the source by phone after learning of the mis-delivery. The source was delivered to the wrong licensee. CH, the licensee where the source was delivered, was licensed for radioactive material and well trained in the handling of radioactive material.

"Event description: [An] Ir-192 source was delivered to the wrong licensee by [the common carrier]. When the error was discovered by CH, CH notified ROCN that they were in possession of licensed radioactive material that belonged to ROCN. [The common carrier] was called and they picked up the source and delivered it to ROCN around 1300 [PDT]. The source shielding and shipping container was intact during the entire incident. It was not damaged nor was the container opened.

"Transport vehicle description: [The common carrier] picked up the source from the A & O facility [in] Venton, LA which was being shipped to a client, ROCN [in] Las Vegas, NV. [The common carrier] delivered the Ir-192 source to the wrong address. The source was delivered to Cardinal Health (CH), [also in] Las Vegas, NV."

Event Report ID No.: LA-120015

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Agreement State Event Number: 48902
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: FRONTIER EL DORADO REFINING, LLC
Region: 4
City: EL DORADO State: KS
County:
License #: 22-B145-01
Agreement: Y
Docket:
NRC Notified By: DAVID J. WHITFILL
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2013
Notification Time: 11:52 [ET]
Event Date: 04/03/2013
Event Time: [CDT]
Last Update Date: 04/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT INVOLVING DIFFICULTY IN RETRACTING A FIXED GAUGE SOURCE

The following information was provided by the State of Kansas via fax:

"This letter is to inform [the Kansas Department of Health & Environment] that yesterday afternoon [on 4/3/13, the RSO] had attempted to move a source from its drywell into its source holder to prepare for maintenance activities in the vessel. The source seemed to be stuck in the drywell. Because the cable restraining the source does not allow the shutter to close until it completely retracted, the shutter would not close. Later last night, after consulting with VEGA Americas and [the company] on-site engineers, [the RSO] attempted again to remove the source and it was free. The source has been safely stored in its holder. There were no reportable personnel exposures. Because of the position of this source 8 feet inside a large vessel with 5 [inch] steel walls, it is shielded at least as well as inside its holder.

"The shutter in question is on an Ohmart/VEGA model SHLM-CR3 source holder S/N 19077664, containing 2 Ci of Cs-137 in a model A2102 sealed source S/N 0587CO.

"The source is located at [the company facility] in EI Dorado, KS . . .. It is approximately 140 feet above the ground. Operations and maintenance personnel were notified of the issue. A wipe sample was collected to check for gross leakage. None was indicated.

"What [the RSO] believe[s] caused this situation was the combination of two (2) things. The reactor was being cooled with nitrogen over the past few days. It has also been raining and snowing. [The RSO] believe[s] water was drawn into the well during cooling and the nitrogen cooled that area of the reactor enough to freeze the water in the well. Ice was present on the cable as it was pulled out. Because the reactor was sufficiently cooled, the nitrogen purge was reduced, thus allowing the reactor to warm slightly by 8 PM when [the RSO] tried again.

"[The RSO] feel[s] that this was not, in fact, a shutter issue, but an operational issue which [the RSO] will be cognizant of in the future. [The RSO] will simply make sure the internal temperature of this vessel is above 40 degrees F before attempting to remove the top source. Normally it is over 500 Degrees, so water intrusion is not an issue. Again, the source was always in a safe position. At no time were personnel exposed to any reportable levels of radiation."

Kansas Item Number: KS130003

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Non-Agreement State Event Number: 48903
Rep Org: SAGINAW RADIATION ONCOLOGY CENTER
Licensee: MID MICHIGAN MEDICAL CENTER
Region: 3
City: SAGINAW State: MI
County:
License #: 21-01549-02
Agreement: N
Docket:
NRC Notified By: IAN REINECK
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2013
Notification Time: 14:56 [ET]
Event Date: 04/08/2013
Event Time: 10:30 [EDT]
Last Update Date: 04/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVE PASSEHL (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING A MIS-POSITIONED BRACHYTHERAPY SOURCE

On 04/08/13 at approximately 1030 EDT a female patient undergoing brachytherapy treatment for cervical/vaginal cancer received the first of three fractions. The prescribed dose for the first fraction was 400 cGy, however, the wrong length catheter was used. This placed the source 5 cm inferior to the intended treatment site. The actual dose received has not been determined at this time.

This error was discovered on 04/09/13 during a review by the Medical Physicist. Both the prescribing physician and patient have been informed. There are no adverse health consequences anticipated due to this error in treatment.

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.

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Power Reactor Event Number: 48922
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDY ROSE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/14/2013
Notification Time: 13:47 [ET]
Event Date: 04/14/2013
Event Time: 14:00 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVE PASSEHL (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 1400 EDT on Sunday, April 14, 2013, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems will be removed from service for scheduled maintenance.

"Under certain accident conditions, the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance and post maintenance testing is scheduled to be completed by 1400 EDT on Wednesday, April 17, 2013.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM GREGORY KANDA TO CHARLES TEAL AT 1456 EDT ON 4/17/13 * * *

"The Technical Support Center (TSC) air conditioning and filtration systems have been returned to service following maintenance. The TSC is fully functional.

"The NRC Resident Inspector has been notified. "

Notified R3DO (Orth).

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Power Reactor Event Number: 48926
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DARRIN GARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/16/2013
Notification Time: 08:55 [ET]
Event Date: 04/16/2013
Event Time: 00:37 [CDT]
Last Update Date: 04/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MALCOLM WIDMANN (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF MAIN CONTROL BOARD ANNUNCIATION DURING LOSS-OF-OFFSITE-POWER TEST

"This is an 8-hour report of a loss of emergency preparedness capabilities as required by 10CFR50.72(b)(3)(xiii).

"At 0037 CDT on 4/16/13, during the performance of an 'A' train loss-of-offsite-power test per procedure FNP-2-STP-80.14, Farley Unit 2 experienced a complete loss of main control board annunciation. Emergency Power Board annunciators are unaffected. No emergency action level criteria have been exceeded as a result of the loss of annunciation, however, annunciators normally relied upon for emergency assessment are not functional. Troubleshooting to identify the cause of the loss of annunciation is in progress. No estimate for restoring annunciator power is currently available. Compensatory measures for critical parameter monitoring have been established and implemented. Unit 2 plant conditions remain stable in mode 5. Unit 1 is unaffected by this event. There has been no release of radioactivity to the environment.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM DARRIN GARD TO CHARLES TEAL AT 1444 EDT ON 4/16/13 * * *

The Unit 2 main control room annunciators were restored at 0907 EDT on 4/16/13. The cause of the failure was determined to be a relay in the annunciator power supply circuit.

The licensee will notify the NRC Resident Inspector. Notified R2DO (Vias).

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Power Reactor Event Number: 48927
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: THOMAS YURKON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/16/2013
Notification Time: 10:17 [ET]
Event Date: 04/16/2013
Event Time: 08:45 [EDT]
Last Update Date: 04/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM COOK (R1DO)

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

INADVERTENT EMERGENCY SIREN ACTIVATION DURING WEEKLY TESTING DUE TO PERSONNEL ERROR

"The purpose of this report is to provide a telephone notification under 10CFR50.72(b)(2)(xi) to notify the NRC of the inadvertent actuation of the Oswego County emergency notification sirens at approximately 0845 [EDT] on 4/16/13. Oswego County was performing routine weekly testing and siren #17 was inadvertently actuated for approximately 2 minutes.

"The Oswego County Emergency Management Office issued a News Release identifying the inadvertent actuation of the emergency siren.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48928
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: MARK LEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/16/2013
Notification Time: 11:20 [ET]
Event Date: 04/16/2013
Event Time: 04:14 [EDT]
Last Update Date: 04/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN VIAS (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

TECHNICAL SUPPORT CENTER (TSC) UNAVAILABLE DUE TO PREPLANNED MAINTENANCE

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, based on LOSS of ASSESSMENT capability. This is a non-emergency notification. This condition does not affect the health and safety of the public or the operation of the facility. At approximately 0414 [EDT] on April 16, 2013, preplanned maintenance will be performed that will affect the Technical Support Center (TSC) ventilation system. The scope of the maintenance is to inspect and clean all Air Handler Units, Fans, and Outside Air Condensing Units that support TSC Ventilation. This maintenance is scheduled to be performed and completed within approximately 50 hours.

"TSC functionality requires all occupied areas of the TSC be maintained between 60.8 degrees F and 82.4 degrees F. Actual TSC area temperatures have been verified to be less than 78 degrees F. If an emergency condition should occur, the ventilation system will be restored, but potentially not within the time required for activation of the TSC. If the facility were activated with full staff, temperatures could rise above the 82.4 degrees F limit. Should the TSC need to be activated for an event, we have compensatory measures which would include relocating the TSC to the Alternate Emergency Facility per PEP-240. This decision would be based on the existing event conditions and coordinated with the Emergency Response Manager, Main Control Room - Site Emergency Coordinator, and Radiological Control Manager. The Alternate TSC has been verified to have electrical power, ventilation, and communication capability. The Technical Support Center - Site Emergency Coordinator has been notified.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48929
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JASON SAWYER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/16/2013
Notification Time: 11:32 [ET]
Event Date: 04/16/2013
Event Time: 09:14 [EDT]
Last Update Date: 04/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM COOK (R1DO)

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

Event Text

INADVERTENT EMERGENCY SIREN ACTIVATION DUE TO PERSONNEL ERROR

"On Tuesday April 16, 2013 at approximately 0914 EDT, the Oswego County Emergency Management Office notified Nine Mile Point via the Radiological Emergency Communications System RECS line of an inadvertent activation of Siren 17. The activation occurred during a normally scheduled Oswego County bi weekly test and was due to a human performance error. Activation occurred at approximately 0845 EDT and lasted for approximately 2 minutes.

"This notification is applicable to both NMP Unit 1 and 2 as well as the James A Fitzpatrick station, a separate notification will be communicated from JAF station. The Oswego County Emergency Management Office has issued a press release and the NRC resident inspector has been notified."

The licensee will also notify the State.

See related EN #48927.

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Power Reactor Event Number: 48932
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: MARK LEE
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/16/2013
Notification Time: 17:15 [ET]
Event Date: 04/16/2013
Event Time: 16:25 [EDT]
Last Update Date: 04/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
STEVEN VIAS (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

POTENTIAL CABLE SIZE AND BREAKER MISMATCH

"During investigation of a documentation discrepancy, a potential cable size and breaker mismatch was identified to exist in a non-safety related DC panel. Initial evaluation has shown that the cable may heat and be potentially damaged if exposed to a 'smart' high impedance fault for an extended period. This discovered condition has not been previously analyzed for NFPA [National Fire Protection Association] 805 common enclosure circuit coordination.

"Fire watches were established as a compensatory measure immediately following identification of the issue on April 8, 2013. An initial review of fire protection analysis was completed on April 16, 2013. Fire watches remain in place until a modification which will restore coordination is complete.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 48934
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHAEL CICCONE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/16/2013
Notification Time: 23:50 [ET]
Event Date: 04/16/2013
Event Time: 21:30 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
WILLIAM COOK (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

FITNESS FOR DUTY REPORT - LICENSED OPERATOR HAD A CONFIRMED POSITIVE FOR ALCOHOL

A licensed operator had a confirmed positive for alcohol during a for cause fitness-for-duty test. The employee's plant access has been revoked.

The licensee informed the NRC Resident Inspector and the State of Connecticut.

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Power Reactor Event Number: 48935
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JOSH CARROLL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/17/2013
Notification Time: 01:16 [ET]
Event Date: 04/16/2013
Event Time: 22:47 [CDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
STEVEN VIAS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED TO OFFSITE MEDICAL FACILITY

"Contract worker suffered a non-occupational medical emergency while working inside the Unit 2 Containment Building (105' elevation). The worker was working in a contaminated area when the event occurred. He was transported to Southeast Alabama Medical Center via ambulance. The worker is potentially contaminated. Health Physics provided escort in the ambulance.

"Farley Nuclear Plant [was] notified by Health Physics on 4/17/13 at 0028 [CDT] that [the] individual was surveyed and no contamination was found."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48936
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CHRIS GIAMBRONE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/17/2013
Notification Time: 02:11 [ET]
Event Date: 04/16/2013
Event Time: 21:42 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
WILLIAM COOK (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

SPECIFIED SYSTEM ACTUATION DURING TURBINE STOP VALVE LOGIC TESTING WHILE SHUTDOWN

"During outage main turbine stop valve RPS logic surveillance testing, an invalid RPS actuation occurred due to an error in executing main turbine surveillance testing procedures. A Turbine Stop Valve closure RPS signal occurred due to an error in the restoration sequence of restoring the RPS bypass signal and a subsequent manual trip of the main turbine. This resulted in a full scram and a trip of both reactor recirculation pumps.

"The site post-scram response procedure was entered, which required that the mode switch be placed in the locked SHUTDOWN position. This caused an expected but valid RPS actuation.

"No control rod motion occurred due to all control rods were inserted at the time of the invalid RPS actuation and subsequent valid RPS actuation."

The license has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48937
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: GLENDON BURNHAM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/17/2013
Notification Time: 05:20 [ET]
Event Date: 04/16/2013
Event Time: 23:23 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ORTH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

DEGRADED FLOW IN EMERGENCY SERVICE WATER SYSTEM 'A'

"The Perry Nuclear Power Plant is reporting an event or condition pursuant to 10 CFR 50.72(b)(3)(v)(D).

"On April 16, 2013, at 2323 EDT, it was identified that Emergency Service Water (ESW) pump 'A' was inoperable due to an inability to maintain minimum flow requirements. As a result, ESW 'A' and the supported Division 1 Emergency Diesel Generator (EDG) were declared inoperable. Coincident with this discovery, a test of the Division 2 emergency systems was in progress with the associated ESW 'B' pump and Division 2 EDG inoperable. Division 2 EDG was available to support the Shutdown Defense In-Depth Strategy. Division 3 EDG was operable and could supply High Pressure Core Spray system injection, if needed.

"Both EDGs were inoperable simultaneously and Technical Specification 3.8.2 'AC Sources-Shutdown' was entered and required actions taken. These actions included immediately suspending core alterations and immediately initiating actions to restore the required EDG. The test of Division 2 emergency systems was suspended and ESW 'B' and the Division 2 EDG were restored to operable status at 0135 EDT on April 17, 2013.

"The failure of ESW 'A' minimum flow is currently under investigation.

"The Resident Inspector has been notified."

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Research Reactor Event Number: 48938
Facility: PENNSYLVANIA STATE UNIVERSITY
RX Type: 1000 KW TRIGA MARK III
Comments:
Region: 1
City: UNIVERSITY PARK State: PA
County: CENTRE
License #: R-2
Agreement: N
Docket: 05000005
NRC Notified By: MARK TRUMP
HQ OPS Officer: VINCE KLCO
Notification Date: 04/17/2013
Notification Time: 15:53 [ET]
Event Date: 04/16/2013
Event Time: 17:01 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
WILLIAM COOK (R1DO)
XIAOSONG YIN (NRR)

Event Text

TEST REACTOR EXCEEDED LICENSED POWER LIMIT DURING A SCRAM

The following information was excerpted from an email from the licensee:

On April 16, 2013 at 1701 EDT, the research test reactor automatically shutdown from 100% power (1 MW) due to a valid high power condition. The duty Senior Reactor Operator removed a timed irradiation sample from the core that added positive reactivity. Both the digital (non-safety system) and the analog safety system acted on the high power condition and initiated the shutdown. All systems functioned as designed. The short duration power transient reached a peak power of about 1.3 MW. There was no increase in radiation levels, personnel radiation exposure, or release of radiation from the facility. No emergency event entry criteria were met. The plant was placed in a secured condition and an event review investigation was conducted.

The event is (potentially) reportable in that the Maximum Power Level observed during the short duration (< 1 second) transient exceeded the steady state power limit for non-pulse mode operation as described in Technical Specification(TS) 3.1.1 Non-pulse mode operation sub-section b. The maximum power level shall be no greater than 1.1 MW (thermal).

The reactor was returned to routine service at approximately 1300 EDT on April 17, 2013.

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Power Reactor Event Number: 48939
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: DAN SZUMSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/17/2013
Notification Time: 16:59 [ET]
Event Date: 04/17/2013
Event Time: 15:11 [CDT]
Last Update Date: 04/18/2013
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVE ORTH (R3DO)
JEFFERY GRANT (IRD)
DAVID SKEEN (NRR)
JENNIFER UHLE (NRR)
ANNE BOLAND (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown
2 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

NOTIFICATION OF UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER FROM A LIGHTNING STRIKE

"LaSalle Unit 1 and LaSalle Unit 2 have both experienced an automatic reactor scram, in conjunction with a loss of offsite power. This was caused by an apparent lightning strike in the main 345kV/138kV switchyard during a thunderstorm. 138kV line 0112 has been inspected in the field, and heavy damage has been noted on the insulators on two of the three phases on a line lightning arrestor line side.

"The plant systems have all responded as expected. All five diesel generators started, and have loaded on to their respective buses as designed. All rods went full in on both units during the respective scrams. HPCS [High Pressure Core Spray] system was started on each unit and automatically aligned for injection for initial level control."

The MSIVs [Main Steam Isolation Valves] are shut on both units with decay heat being removed via the safety relief valves. Suppression pool cooling is in progress.

The licensee will notify the NRC Resident Inspector and has notified the State.

Notified DHS, FEMA, USDA, HHS, DOE, NICC, EPA, and Nuclear SSA via email.

* * * UPDATE FROM DON PUCKETT TO VINCE KLCO AT 2113 EDT ON 4/17/2013 * * *

"In addition to information [previously provided], LaSalle Unit 2 received a high drywell pressure signal [1.77 psig] due to loss of containment cooling from the loss of power. At the time of this high drywell pressure signal, high pressure core spray pump and 2B residual heat removal [RHR] pump was already in operation, the low pressure core spray system and 2A residual heat removal system was secured and [placed] in pull to lock. When the signal was satisfied the ECCS [Emergency Core Cooling Systems] signal was processed but only the 2C RHR pump would have started. In this case, the 2C RHR pump tripped when the signal was received. There is no evidence of reactor coolant leakage. There was no additional ECCS systems discharging into the RCS [Reactor Coolant System]. As [initially stated], level was controlled using High Pressure Core Spray and level control is now being maintained using the Reactor Core Isolation Cooling [RCIC] systems. The 2C RHR pump trip is under investigation.

"Due to the initial loss of offsite power for both Unit 1 and Unit 2 reported at 1511 [CDT], multiple containment isolation valves isolated and closed as expected. Once initial containment isolations were verified, two Unit 2 primary containment vent and purge valves were opened to vent the Unit 2 containment. Once Unit Two containment pressure reached 1.77 [psig], these two vent valves isolated as expected.

"Due to the loss of offsite power, the Station Vent Stack Wide Range Gas Monitor (WRGM) and the Standby Gas Treatment Wide Range Gas Monitor (VGWRGM) also lost power. Manual sampling has been implemented and power is restored to the VGWRGM, however the VGWRGM has not been declared operable yet. Normal radiation levels have been reported from the manual sampling. [This is being reported in accordance with 10CFR50.72(b)(3)(xiii).]"

The licensee notified the NRC Resident Inspector and the State of Illinois.

Notified the R3 IRC, NRR EO(Skeen), IRD MOC (Grant).

* * * UPDATE AT 0057 EDT ON 04/18/13 FROM MIKE LAWRENCE TO S. SANDIN * * *

"After the Unit 2 primary containment vent and purge system isolated on the Unit 2 containment High Pressure signal, Venting of the Unit 1 primary containment was commenced. At 2005 CDT, Unit 1 primary containment pressure reached the Group 2 primary containment isolation system setpoint (1.77 PSIG) causing the primary containment vent and purge valves being used to vent the Unit 1 containment to isolate. Unit 1 primary containment venting was being performed through the Standby Gas Treatment system which is a filtered system.

"In addition to the primary containment isolation signal on high drywell pressure, an ECCS initiation on high drywell pressure also occurred. The ECCS signal resulted in an auto start of the 1C RHR system. The 1B RHR system was already running in suppression pool cooling mode. 1A RHR and LPCS had been secured to prevent overloading the common diesel generator for division 1. The common diesel generator supplies both Unit 1 and Unit 2 division 1 ESF busses."

The licensee informed the NRC Resident Inspector. Notified NRR EO (Skeen), IRD MOC (Grant) and R3IRC (Louden).

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Power Reactor Event Number: 48940
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: LEE KELLY
HQ OPS Officer: VINCE KLCO
Notification Date: 04/17/2013
Notification Time: 23:19 [ET]
Event Date: 04/17/2013
Event Time: 16:00 [EDT]
Last Update Date: 04/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
STEVEN VIAS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Defueled 0 Defueled

Event Text

DEGRADED CONDITION DUE TO SUSPECTED VALVE BODY LEAKAGE

"On April 17, 2013 at 1600 [EDT], while performing a valve inspection/repair of the Unit 2 'A' Reactor Coolant Loop Fill Valve (2- RC-HCV-2556A), the as-found inspection results identified evidence of a suspected flaw causing leakage from the valve body to the threads of a stud housing of the valve. This valve is a 2 [inch] 316 SS [Stainless Steel] cast ASME XI (Class 1) 1500 psi valve body of a globe style design. Due to this design and the installed orientation, the RCS pressure medium fills the upper portion of the valve bonnet where the leak is located during normal plant operations. Therefore, this leakage would be considered pressure boundary leakage. 2-RC-HCV-2556A is currently isolated from the Reactor Vessel and is at atmospheric pressure.

"This inspection was performed in response to dry discolored boric acid identified during the normal operating pressure boric acid accumulation inspection procedure during the Spring 2013 Unit 2 refueling outage shutdown. An engineering evaluation of the suspected defect will be performed and corrective actions implemented.

"This event is reportable in accordance to 10CFR50.72(b)(3)(ii)(A) for, 'Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded'."

The licensee notified the NRC Resident Inspector and local County Commissioners.

Page Last Reviewed/Updated Thursday, April 18, 2013
Thursday, April 18, 2013