Event Notification Report for July 07, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/06/2010 - 07/07/2010
Power Reactor
Event Number: 46077
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: BILL HARDIN
HQ OPS Officer: CHARLES TEAL
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: BILL HARDIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/08/2010
Notification Time: 12:23 [ET]
Event Date: 07/07/2010
Event Time: 14:00 [CDT]
Last Update Date: 07/08/2010
Notification Time: 12:23 [ET]
Event Date: 07/07/2010
Event Time: 14:00 [CDT]
Last Update Date: 07/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
CHUCK CAIN (R4DO)
CHUCK CAIN (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
ADMINISTRATIVE REVIEW REVEALED FITNESS FOR DUTY PROGRAM ISSUES
"Pursuant to Fitness For Duty and Fatigue Rule reporting requirements of 10CFR26.719(b)(2)(ii), Entergy is making this notification associated with violation of Waterford 3 working hour policy. This is a conservative report to proactively document the identified working hour issues.
"The site assembled a team for the purpose of reviewing working hours within the Waterford 3 Security Department to determine if the department is in compliance with procedure EN-OM-123 (Fatigue Management Program) and 10 CFR 26 Subpart I (Managing Fatigue). While this comprehensive review is still in progress, two examples have been identified associated with supervisory violations of the Fatigue Rule 'Working Hours.' This report is intended to capture these examples and to encompass any other examples that may be identified during this review process.
"The two examples of procedural violations are:
"Security supervisor had exceeded the 26 hours maximum in any 48 hour period by working 16 hours on 6/1/2010 and 11.5 hours on 6/2/2010 with no waiver in effect [10CFR26(d)(1)(ii)].
"Security supervisor had exceeded a 9 day period without a 34 hour break during the period of 5/16/2010 to 5/24/2010 with no waiver in effect [10CFR26(d)(2)(ii)].
"Security has verified the current watch bill meets the procedural and regulatory requirements. Security has implemented interim measures for the supervisors to perform a documented validation of work hour management system (PQ&S) data. Condition Report CR-WF3-2010-4156 has been initiated and entered into the Waterford 3 corrective action program. The ongoing comprehensive review will be completed.
"Waterford 3 has communicated this issue with the Waterford 3 NRC Senior Resident [Inspector], the NRC Region IV Security Branch Chief, and the NRC NRR Project Manager.
"[During] the week of July 26, a follow up call is planned with NRC Region IV associated with the working hour issues."
"Pursuant to Fitness For Duty and Fatigue Rule reporting requirements of 10CFR26.719(b)(2)(ii), Entergy is making this notification associated with violation of Waterford 3 working hour policy. This is a conservative report to proactively document the identified working hour issues.
"The site assembled a team for the purpose of reviewing working hours within the Waterford 3 Security Department to determine if the department is in compliance with procedure EN-OM-123 (Fatigue Management Program) and 10 CFR 26 Subpart I (Managing Fatigue). While this comprehensive review is still in progress, two examples have been identified associated with supervisory violations of the Fatigue Rule 'Working Hours.' This report is intended to capture these examples and to encompass any other examples that may be identified during this review process.
"The two examples of procedural violations are:
"Security supervisor had exceeded the 26 hours maximum in any 48 hour period by working 16 hours on 6/1/2010 and 11.5 hours on 6/2/2010 with no waiver in effect [10CFR26(d)(1)(ii)].
"Security supervisor had exceeded a 9 day period without a 34 hour break during the period of 5/16/2010 to 5/24/2010 with no waiver in effect [10CFR26(d)(2)(ii)].
"Security has verified the current watch bill meets the procedural and regulatory requirements. Security has implemented interim measures for the supervisors to perform a documented validation of work hour management system (PQ&S) data. Condition Report CR-WF3-2010-4156 has been initiated and entered into the Waterford 3 corrective action program. The ongoing comprehensive review will be completed.
"Waterford 3 has communicated this issue with the Waterford 3 NRC Senior Resident [Inspector], the NRC Region IV Security Branch Chief, and the NRC NRR Project Manager.
"[During] the week of July 26, a follow up call is planned with NRC Region IV associated with the working hour issues."
Power Reactor
Event Number: 46075
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC POWELL
HQ OPS Officer: DONG HWA PARK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC POWELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/07/2010
Notification Time: 13:22 [ET]
Event Date: 07/07/2010
Event Time: 11:17 [EDT]
Last Update Date: 07/08/2010
Notification Time: 13:22 [ET]
Event Date: 07/07/2010
Event Time: 11:17 [EDT]
Last Update Date: 07/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
JEFFERY GRANT (IRD)
MIKE CHEOK (NRR)
ANTHONY DIMITRIADIS (R1DO)
JEFFERY GRANT (IRD)
MIKE CHEOK (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP CAUSED BY MAIN GENERATOR AND TURBINE TRIP
"Salem Unit 1 experienced an automatic reactor trip at 1117 hours due to a trip of the main generator and turbine. The main generator tripped as a result of a fault on the B Main Power Transformer (MPT). The B MPT fire protection deluge system automatically actuated and extinguished a small fire that occurred on the B MPT. The fire existed for approximately 5 minutes prior to being extinguished.
"All control rods fully inserted on the trip and all systems responded as designed with decay heat being removed via the Steam Dump system with condenser vacuum maintained. All three AFW [Auxiliary Feed Water] Pumps auto started as expected due to low Steam Generator level. Following the trip, the Reactor Coolant Pump (RCP) thermal barrier supply valve 1CC131 automatically closed and was subsequently reopened with no issue.
"Salem Unit 1 is currently in mode 3. The Reactor Coolant System temperature is 547 degrees F with pressure at 2235 psig (NOT and NOP). All ECCS and ESF Systems are available and no ECCS [Emergency Core Cooling System] systems actuated during the event. The 13 AFW pump has not yet been reset following the trip, per the Emergency Operating Procedures and is unavailable.
"No personnel injuries occurred as a result of the trip. There is no primary to secondary leakage. There was no impact on Unit 2."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM ERIC POWELL TO CHARLES TEAL ON 7/8/10 AT 1535 * * *
"Based on additional reviews, the reactor trip occurred at 1118 hours following actuation of the B Main Power Transformer (MPT) fire protection deluge system at 1116 hours. Personnel in the area stated that an arc flash occurred on the high voltage bushing of the B MPT following the deluge system actuation and there was no fire present when the deluge system actuated."
Notified the R1DO (Dimitriadis).
"Salem Unit 1 experienced an automatic reactor trip at 1117 hours due to a trip of the main generator and turbine. The main generator tripped as a result of a fault on the B Main Power Transformer (MPT). The B MPT fire protection deluge system automatically actuated and extinguished a small fire that occurred on the B MPT. The fire existed for approximately 5 minutes prior to being extinguished.
"All control rods fully inserted on the trip and all systems responded as designed with decay heat being removed via the Steam Dump system with condenser vacuum maintained. All three AFW [Auxiliary Feed Water] Pumps auto started as expected due to low Steam Generator level. Following the trip, the Reactor Coolant Pump (RCP) thermal barrier supply valve 1CC131 automatically closed and was subsequently reopened with no issue.
"Salem Unit 1 is currently in mode 3. The Reactor Coolant System temperature is 547 degrees F with pressure at 2235 psig (NOT and NOP). All ECCS and ESF Systems are available and no ECCS [Emergency Core Cooling System] systems actuated during the event. The 13 AFW pump has not yet been reset following the trip, per the Emergency Operating Procedures and is unavailable.
"No personnel injuries occurred as a result of the trip. There is no primary to secondary leakage. There was no impact on Unit 2."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM ERIC POWELL TO CHARLES TEAL ON 7/8/10 AT 1535 * * *
"Based on additional reviews, the reactor trip occurred at 1118 hours following actuation of the B Main Power Transformer (MPT) fire protection deluge system at 1116 hours. Personnel in the area stated that an arc flash occurred on the high voltage bushing of the B MPT following the deluge system actuation and there was no fire present when the deluge system actuated."
Notified the R1DO (Dimitriadis).
General Information or Other
Event Number: 46101
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/16/2010
Notification Time: 15:44 [ET]
Event Date: 07/07/2010
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2010
Notification Time: 15:44 [ET]
Event Date: 07/07/2010
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERED FROM THE PRESCRIBED DOSE BY GREATER THAN 50%
The following was received via fax from the Pennsylvania Department of Environmental Protection:
"On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.
"It is believed the medical staff mis-identified the treatment location and the end of the treatment tube was placed 3.5cm short of its intended location. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.
"There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."
PA Report # PA100015
* * * UPDATE FROM DAVID ALLARD TO DONG PARK AT 0936 EDT ON 7/23/10 * * *
The following was received via fax from the Pennsylvania Department of Environmental Protection:
"Due to further information received from the licensee, an amendment is being made to the original sent July 16, 2010, the CAUSE OF THE EVENT has been modified to reflect updated information.
"Event Description: On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.
"CAUSE OF THE EVENT: The applicator was placed correctly by the medical staff as confirmed by MRI but moved 3.5 cm short of its intended location prior to treatment. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.
"ACTION: There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."
Notified R1DO (Doerflein) and FSME EO (Villamar).
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.
The following was received via fax from the Pennsylvania Department of Environmental Protection:
"On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.
"It is believed the medical staff mis-identified the treatment location and the end of the treatment tube was placed 3.5cm short of its intended location. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.
"There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."
PA Report # PA100015
* * * UPDATE FROM DAVID ALLARD TO DONG PARK AT 0936 EDT ON 7/23/10 * * *
The following was received via fax from the Pennsylvania Department of Environmental Protection:
"Due to further information received from the licensee, an amendment is being made to the original sent July 16, 2010, the CAUSE OF THE EVENT has been modified to reflect updated information.
"Event Description: On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.
"CAUSE OF THE EVENT: The applicator was placed correctly by the medical staff as confirmed by MRI but moved 3.5 cm short of its intended location prior to treatment. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.
"ACTION: There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."
Notified R1DO (Doerflein) and FSME EO (Villamar).
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.