Event Notification Report for May 21, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/20/2009 - 05/21/2009
Power Reactor
Event Number: 45087
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JEFF WILLIAMS
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JEFF WILLIAMS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/21/2009
Notification Time: 20:46 [ET]
Event Date: 05/21/2009
Event Time: 16:35 [CDT]
Last Update Date: 05/21/2009
Notification Time: 20:46 [ET]
Event Date: 05/21/2009
Event Time: 16:35 [CDT]
Last Update Date: 05/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
MICHAEL KUNOWSKI (R3DO)
| 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 |
RPS ACTUATION (SCRAM) DUE TO A MAIN POWER TRANSFORMER FAULT
"At 1635 CDT on May 21, 2009, LaSalle Unit 1 automatically scrammed due to a main power transformer fault. The transformer fault appears to have been caused by a failed bushing or lightning arrestor. The main power transformers deluged and other than the initial flash, there was no fire. Two safety relief valves actuated in the relief mode on the turbine trip. There were spurious non-valid isolation signals due to electrical power perturbations that were received on the reactor building ventilation system and reactor water cleanup. The plant is stable with reactor pressure control to the main condenser via the turbine bypass valves. The plant [will] remain in hot shutdown pending transformer inspection and repair."
All control rods fully inserted following the scram signal. Water level is being controlled via the motor driven reactor feedwater pump. Current reactor pressure is 927 psig and current reactor temperature is 532 degrees F. The plant is in a normal post-trip electrical lineup. No diesel generators started as a result of this event.
The licensee notified the NRC Resident Inspector.
"At 1635 CDT on May 21, 2009, LaSalle Unit 1 automatically scrammed due to a main power transformer fault. The transformer fault appears to have been caused by a failed bushing or lightning arrestor. The main power transformers deluged and other than the initial flash, there was no fire. Two safety relief valves actuated in the relief mode on the turbine trip. There were spurious non-valid isolation signals due to electrical power perturbations that were received on the reactor building ventilation system and reactor water cleanup. The plant is stable with reactor pressure control to the main condenser via the turbine bypass valves. The plant [will] remain in hot shutdown pending transformer inspection and repair."
All control rods fully inserted following the scram signal. Water level is being controlled via the motor driven reactor feedwater pump. Current reactor pressure is 927 psig and current reactor temperature is 532 degrees F. The plant is in a normal post-trip electrical lineup. No diesel generators started as a result of this event.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 45088
Facility: OCONEE
Region: 2 State: SC
Unit: [] [] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: STEPHEN NEWMAN
HQ OPS Officer: DONALD NORWOOD
Region: 2 State: SC
Unit: [] [] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: STEPHEN NEWMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/21/2009
Notification Time: 23:09 [ET]
Event Date: 05/21/2009
Event Time: 20:15 [EDT]
Last Update Date: 05/21/2009
Notification Time: 23:09 [ET]
Event Date: 05/21/2009
Event Time: 20:15 [EDT]
Last Update Date: 05/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ROBERT HAAG (R2DO)
ROBERT HAAG (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 42 | Power Operation | 0 | Hot Standby |
RPS ACTUATION (REACTOR TRIP) DUE TO GENERATOR PHASE DIFFERENTIAL LOCKOUT
"Event: Oconee Unit 3 Reactor Protection System (RPS) actuation due to Anticipatory Trip.
"At 2015 hrs on 5-21-2009, Oconee Nuclear Station Unit 3 experienced a RPS actuation due to an anticipatory trip caused by a generator phase differential lockout. At the time of the RPS actuation, Unit 3 was exiting a planned refueling outage and power was at 42%. Immediately after the trip, Operators entered the appropriate emergency operating procedure and post-trip response was determined to be normal. Operators transitioned to the normal shutdown procedure at 2056 hours. Unit 3 is currently in Mode 3 and stable.
"This event is being reported as a 4-Hour Non-Emergency per 10 CFR 50.72(b)(2)(iv)(B).
"Initial Safety Significance: No Emergency Action Limits (EALs) were met and there was no safety significance as a result of the Unit 3 trip. Units 1 and 2 remain at 100% power (Mode 1) and were unaffected by the Unit 3 trip.
"Corrective Actions(s): Planned corrective actions are to maintain Unit 3 in Mode 3 (Hot Standby) until completion of the post-trip evaluation. The NRC Resident Inspector has been notified."
All control rods fully inserted. The reactor is currently subcritical and shutdown margin within Technical Specification limits. RCS Inventory Control is via normal makeup. PORV and Pressurizer Code Safeties are closed. SG inventory control is being maintained via Main Feedwater. Heat is being removed from the Steam Generators to the Main Condenser via Turbine Bypass Valves.
"Event: Oconee Unit 3 Reactor Protection System (RPS) actuation due to Anticipatory Trip.
"At 2015 hrs on 5-21-2009, Oconee Nuclear Station Unit 3 experienced a RPS actuation due to an anticipatory trip caused by a generator phase differential lockout. At the time of the RPS actuation, Unit 3 was exiting a planned refueling outage and power was at 42%. Immediately after the trip, Operators entered the appropriate emergency operating procedure and post-trip response was determined to be normal. Operators transitioned to the normal shutdown procedure at 2056 hours. Unit 3 is currently in Mode 3 and stable.
"This event is being reported as a 4-Hour Non-Emergency per 10 CFR 50.72(b)(2)(iv)(B).
"Initial Safety Significance: No Emergency Action Limits (EALs) were met and there was no safety significance as a result of the Unit 3 trip. Units 1 and 2 remain at 100% power (Mode 1) and were unaffected by the Unit 3 trip.
"Corrective Actions(s): Planned corrective actions are to maintain Unit 3 in Mode 3 (Hot Standby) until completion of the post-trip evaluation. The NRC Resident Inspector has been notified."
All control rods fully inserted. The reactor is currently subcritical and shutdown margin within Technical Specification limits. RCS Inventory Control is via normal makeup. PORV and Pressurizer Code Safeties are closed. SG inventory control is being maintained via Main Feedwater. Heat is being removed from the Steam Generators to the Main Condenser via Turbine Bypass Valves.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 45089
Rep Org: ST. JOHNS MERCY MEDICAL CENTER
Licensee: ST. JOHNS MERCY MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County: ST. LOUIS
License #: 24-0079403
Agreement: N
Docket:
NRC Notified By: ROBERT TURCO
HQ OPS Officer: VINCE KLCO
Licensee: ST. JOHNS MERCY MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County: ST. LOUIS
License #: 24-0079403
Agreement: N
Docket:
NRC Notified By: ROBERT TURCO
HQ OPS Officer: VINCE KLCO
Notification Date: 05/22/2009
Notification Time: 09:51 [ET]
Event Date: 05/21/2009
Event Time: 15:30 [CDT]
Last Update Date: 05/22/2009
Notification Time: 09:51 [ET]
Event Date: 05/21/2009
Event Time: 15:30 [CDT]
Last Update Date: 05/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
ANGELA MCINTOSH (FSME)
RICHARD SKOKOWSKI (R3DO)
ANGELA MCINTOSH (FSME)
MEDICAL EVENT INVOLVING A DOSE THAT IS DIFFERENT THAN PRESCRIBED
The patient was undergoing brachytherapy treatment of the prostate. After 6 seeds were implanted, the procedure was aborted because of concerns in placing additional needles into the patient. The prescribed dose was 145 Gy. However, only 6 of 88 prescribed seeds were implanted. Each seed total activity is 0.288 mCi of I-125.
Family members were notified of the aborted procedure.
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.
* * * UPDATE FROM ROBERT TURCO TO JOHN KNOKE AT 1643 EDT ON 5/22/09 * * *
This event is being retracted because the physician made a choice to terminate the brachytherapy treatment of the prostate to the patient. The physician then rewrote the procedure to the patient to limit the prescribed number of seeds to 6. Having 6 seeds implanted into the patient the prescribed dose was now met under the new directive.
Notified R3DO (Richard Skokowski) , FSME(Lydia Chang)
The patient was undergoing brachytherapy treatment of the prostate. After 6 seeds were implanted, the procedure was aborted because of concerns in placing additional needles into the patient. The prescribed dose was 145 Gy. However, only 6 of 88 prescribed seeds were implanted. Each seed total activity is 0.288 mCi of I-125.
Family members were notified of the aborted procedure.
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.
* * * UPDATE FROM ROBERT TURCO TO JOHN KNOKE AT 1643 EDT ON 5/22/09 * * *
This event is being retracted because the physician made a choice to terminate the brachytherapy treatment of the prostate to the patient. The physician then rewrote the procedure to the patient to limit the prescribed number of seeds to 6. Having 6 seeds implanted into the patient the prescribed dose was now met under the new directive.
Notified R3DO (Richard Skokowski) , FSME(Lydia Chang)