Event Notification Report for September 30, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/29/2010 - 09/30/2010
EVENT NUMBERS
46300462974629846292
General Information or Other
Event Number: 46300
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAYLOR RADIOSURGERY CENTER
Region: 4
City: DALLAS State: TX
County: DALLAS
License #: 05842
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: ERIC SIMPSON
Licensee: BAYLOR RADIOSURGERY CENTER
Region: 4
City: DALLAS State: TX
County: DALLAS
License #: 05842
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 10/01/2010
Notification Time: 11:50 [ET]
Event Date: 09/30/2010
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2010
Notification Time: 11:50 [ET]
Event Date: 09/30/2010
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)
TEXAS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING GAMMA KNIFE THERAPY
The following was received from the State of Texas via e-mail:
"On October 1, 2010, the Agency [Texas Department of Health] received a phone call from the licensee's Radiation Safety Officer (RSO). The RSO stated that a medical event occurred on September 30, 2010, when, while conducting a single fraction exposure to a patient, the computer screen froze. The patient was immediately removed from the gamma knife device. Approximately five percent of the prescribed dose was delivered. The intended dose was 20 gray to one location, and 15 gray to a second location, both to be delivered simultaneously. The referring physician and patient have been notified of the event.
"The gamma knife is a Leksell Gamma Knife System, model number 24001 containing GE model 43047 sealed cobalt (Co) - 60 sources.
"Additional information will be provided as it is received in accordance with SA-300."
This is Texas Incident #: I-8790.
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 from the State of Texas via e-mail:
"On October 1, 2010, the Agency [Texas Department of Health] received a phone call from the licensee's Radiation Safety Officer (RSO). The RSO stated that a medical event occurred on September 30, 2010, when, while conducting a single fraction exposure to a patient, the computer screen froze. The patient was immediately removed from the gamma knife device. Approximately five percent of the prescribed dose was delivered. The intended dose was 20 gray to one location, and 15 gray to a second location, both to be delivered simultaneously. The referring physician and patient have been notified of the event.
"The gamma knife is a Leksell Gamma Knife System, model number 24001 containing GE model 43047 sealed cobalt (Co) - 60 sources.
"Additional information will be provided as it is received in accordance with SA-300."
This is Texas Incident #: I-8790.
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 46297
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: SCOTT LINDQUIST
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: SCOTT LINDQUIST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2010
Notification Time: 21:39 [ET]
Event Date: 09/30/2010
Event Time: 16:16 [CDT]
Last Update Date: 11/30/2010
Notification Time: 21:39 [ET]
Event Date: 09/30/2010
Event Time: 16:16 [CDT]
Last Update Date: 11/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (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 |
UNANALYZED CONDITION DUE TO POTENTIAL FLOODING VIA CONDENSATE DRAIN LINES
"USAR Section 2.7.1.2, River Stage and Flow, states flooding protection against the 1,014 foot flood in the auxiliary building is provided by removable flood barriers and sandbagging. When required, these flood barriers are installed in openings leading to safety related equipment on the 1,007 foot and 1,011 foot floor elevations.
"It has been identified that the condensation drains from the switchgear room's air handling units VA-87 and VA-88 (located in the auxiliary building), and the upper electrical penetration room's air handling units VA-85 and VA-86 (located in the auxiliary building), have no isolation valves or check valves to prevent backflow from the drain line's discharge in the turbine building basement. This means that flooding of the turbine building above approximately the 1011 foot elevation (floor level of the switchgear rooms) would result in water back-flowing via the drain lines into the switchgear rooms.
"River level is currently at the 999' 6" elevation and stable. Procedure changes are currently being developed to block the affected drain lines."
River level has never reached the 1011 foot elevation at the facility.
The licensee has notified the NRC Resident Inspector.
* * * RETRACTION FROM ERICK MATZKE TO ERIC SIMPSON AT 1307 EST ON 11/30/10 * * *
"A further evaluation of the reported flooding issue determined that the flow into the switchgear rooms would be insufficient to affect the operability of safety related equipment in the auxiliary building; therefore, the incident could not have prevented fulfillment of a safety function nor could it have caused the inoperability of independent trains of safety related equipment. The situation does not constitute an unanalyzed condition. Therefore, this event is being retracted."
The NRC Resident Inspector has been notified.
Notified R4DO (Powers).
"USAR Section 2.7.1.2, River Stage and Flow, states flooding protection against the 1,014 foot flood in the auxiliary building is provided by removable flood barriers and sandbagging. When required, these flood barriers are installed in openings leading to safety related equipment on the 1,007 foot and 1,011 foot floor elevations.
"It has been identified that the condensation drains from the switchgear room's air handling units VA-87 and VA-88 (located in the auxiliary building), and the upper electrical penetration room's air handling units VA-85 and VA-86 (located in the auxiliary building), have no isolation valves or check valves to prevent backflow from the drain line's discharge in the turbine building basement. This means that flooding of the turbine building above approximately the 1011 foot elevation (floor level of the switchgear rooms) would result in water back-flowing via the drain lines into the switchgear rooms.
"River level is currently at the 999' 6" elevation and stable. Procedure changes are currently being developed to block the affected drain lines."
River level has never reached the 1011 foot elevation at the facility.
The licensee has notified the NRC Resident Inspector.
* * * RETRACTION FROM ERICK MATZKE TO ERIC SIMPSON AT 1307 EST ON 11/30/10 * * *
"A further evaluation of the reported flooding issue determined that the flow into the switchgear rooms would be insufficient to affect the operability of safety related equipment in the auxiliary building; therefore, the incident could not have prevented fulfillment of a safety function nor could it have caused the inoperability of independent trains of safety related equipment. The situation does not constitute an unanalyzed condition. Therefore, this event is being retracted."
The NRC Resident Inspector has been notified.
Notified R4DO (Powers).
Power Reactor
Event Number: 46298
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: STEVE SANDIN
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/01/2010
Notification Time: 01:35 [ET]
Event Date: 09/30/2010
Event Time: 19:04 [CDT]
Last Update Date: 10/01/2010
Notification Time: 01:35 [ET]
Event Date: 09/30/2010
Event Time: 19:04 [CDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (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 |
STANDBY DIESEL GENERATOR AUTOSTART DUE TO LOSS OF A SWITCHYARD BUS DURING MAINTENANCE
"At 1904 [CDT] on 9/30/2010, the South Texas Project (STP) North switchyard bus was lost due to a Transmission & Distribution Service Provider (TDSP) human performance error that occurred while performing maintenance on breaker Y-0530. This resulted in a loss of power to Standby transformer 1 which was supplying power to the Unit 1 B Train Engineered Safety Features (ESF) 4160v bus. The B Train Standby Diesel Generator automatically started due to the Loss of Offsite Power (LOOP) on its associated bus. The Mode II (LOOP) ESF loads sequenced onto the bus. All safety related equipment responded as expected. Action (e) of Technical Specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was momentarily entered due to the loss of two independent offsite circuits while the North bus was de-energized. The North bus was de-energized for approximately 5 minutes. Action (a) of Technical specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was entered due to the loss of one independent offsite circuit. All Technical Specification Limiting Condition of operation have been exited at this time.
"An 8-hour notification is required for this event due to the valid actuation of safety related equipment as described in 10CFR50.72 (b) (3) (iv) (A). [A notification is required for] any event or condition that results in valid actuation of any of the systems listed in paragraph (b) (3) (iv) (B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.
"The NRC Resident Inspector has been notified."
Unit 2 briefly entered a Technical Specification Limiting Condition of Operation, while all electrical buses remained energized.
"At 1904 [CDT] on 9/30/2010, the South Texas Project (STP) North switchyard bus was lost due to a Transmission & Distribution Service Provider (TDSP) human performance error that occurred while performing maintenance on breaker Y-0530. This resulted in a loss of power to Standby transformer 1 which was supplying power to the Unit 1 B Train Engineered Safety Features (ESF) 4160v bus. The B Train Standby Diesel Generator automatically started due to the Loss of Offsite Power (LOOP) on its associated bus. The Mode II (LOOP) ESF loads sequenced onto the bus. All safety related equipment responded as expected. Action (e) of Technical Specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was momentarily entered due to the loss of two independent offsite circuits while the North bus was de-energized. The North bus was de-energized for approximately 5 minutes. Action (a) of Technical specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was entered due to the loss of one independent offsite circuit. All Technical Specification Limiting Condition of operation have been exited at this time.
"An 8-hour notification is required for this event due to the valid actuation of safety related equipment as described in 10CFR50.72 (b) (3) (iv) (A). [A notification is required for] any event or condition that results in valid actuation of any of the systems listed in paragraph (b) (3) (iv) (B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.
"The NRC Resident Inspector has been notified."
Unit 2 briefly entered a Technical Specification Limiting Condition of Operation, while all electrical buses remained energized.
Power Reactor
Event Number: 46292
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: KENT MILLS
HQ OPS Officer: STEVE SANDIN
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: KENT MILLS
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/30/2010
Notification Time: 09:39 [ET]
Event Date: 09/30/2010
Event Time: 06:50 [EDT]
Last Update Date: 09/30/2010
Notification Time: 09:39 [ET]
Event Date: 09/30/2010
Event Time: 06:50 [EDT]
Last Update Date: 09/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MEL GRAY (R1DO)
MEL GRAY (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION - INADVERTENT ALARM ACTUATION
"At 0650 [EDT] on September 30, 2010, site personnel were notified by multiple Calvert County residents of a single siren activation (Siren C21) at 0645 [EDT] for approximately 2-3 minutes.
"Following a detailed review of the site's Alert and Notification System, the site identified multiple activations of the siren in addition to the first inadvertent activation of the siren that occurred at 0645 [EDT]. The multiple siren activations were not related to any condition or event at Calvert Cliffs. The siren has experienced multiple losses of power as a result of the effects from heavy rain and wind associated with the passing of Tropical Storm Nicole. Each time the power had restored to the siren, it performed a full cycle test as opposed to the standard silent test.
"County Officials were notified and are taking actions to communicate to Calvert County residents concerning the inadvertent siren actuation.
"Site maintenance locally deactivated the siren at 0827 [EDT] and will further investigate the extent of issue with the siren once the Tropical Storm Nicole has passed. In response to deactivating the siren, Calvert County has implemented the back-up method of route alerting in the event that actual siren activation is required.
"The NRC Resident Inspector has been informed of the activations."
"At 0650 [EDT] on September 30, 2010, site personnel were notified by multiple Calvert County residents of a single siren activation (Siren C21) at 0645 [EDT] for approximately 2-3 minutes.
"Following a detailed review of the site's Alert and Notification System, the site identified multiple activations of the siren in addition to the first inadvertent activation of the siren that occurred at 0645 [EDT]. The multiple siren activations were not related to any condition or event at Calvert Cliffs. The siren has experienced multiple losses of power as a result of the effects from heavy rain and wind associated with the passing of Tropical Storm Nicole. Each time the power had restored to the siren, it performed a full cycle test as opposed to the standard silent test.
"County Officials were notified and are taking actions to communicate to Calvert County residents concerning the inadvertent siren actuation.
"Site maintenance locally deactivated the siren at 0827 [EDT] and will further investigate the extent of issue with the siren once the Tropical Storm Nicole has passed. In response to deactivating the siren, Calvert County has implemented the back-up method of route alerting in the event that actual siren activation is required.
"The NRC Resident Inspector has been informed of the activations."