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Event Notification Report for April 27, 2011

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/26/2011 - 04/27/2011

EVENT NUMBERS
467904679146792467934679546797

Power Reactor
Event Number: 46790
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM REED
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 13:06 [ET]
Event Date: 04/27/2011
Event Time: 10:30 [EDT]
Last Update Date: 04/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (R2DO)
Power Reactor Unit Info
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 92 Power Operation 92 Power Operation
Event Text
LOSS OF EMERGENCY SIRENS DUE TO LOSS OF ELECTRIC POWER

"At approximately 1030 EDT on April 27, 2011, [Sequoyah Nuclear Plant] received notification from TVAs Operations Duty Specialist that >30% of offsite sirens are not functional resulting in a 'major loss' of offsite [automatic] public notification [capabilities]. The loss of offsite sirens is due to loss of electrical power caused by severe thunderstorms and high winds in the area. Thirty five sirens are not functioning (32 sirens are considered 30%). Efforts are in place to restore offsite sirens to service.

"At 1044 EDT on April 27, 2011, power was restored to 2 offsite sirens leaving 33 offsite sirens not functional.

"At 1050 EDT on April 27, 2011, TVA's Operations Duty Specialist made a notification to Tennessee Emergency Management Agency (TEMA) and Hamilton County Emergency Response."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM JEFF EPPERSON TO DONG PARK ON 4/29/11 AT 0514 EDT * * *

Sequoyah Nuclear Plant reported that 28 of 108 sirens are not functional (26%) which is below the 'major loss' of offsite automatic public notification capabilities threshold.

The licensee has notified the Tennessee Emergency Management Agency (TEMA) and Hamilton County Emergency Response. The licensee will notify the NRC Resident Inspector.

Notified R2DO (Seymour).


Hospital
Event Number: 46791
Rep Org: BEAUMONT HOSPITALS
Licensee: BEAUMONT HOSPITALS
Region: 3
City: ROYAL OAK   State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: SHERYL SCHULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/27/2011
Notification Time: 16:05 [ET]
Event Date: 04/27/2011
Event Time: 10:45 [EDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANN MARIE STONE (R3DO)
JOSEPHINE PICCONE (FSME)
Event Text
PATIENT RECEIVED LESS THAN PRESCRIBED DOSE DUE TO AN OCCLUSION IN THE DELIVERY CATHETER

A patient received 14.8 Gray rather than the 63 Gray prescribed treatment to the upper portion of the liver using SIRSpheres manufactured by Sirtex. Only 0.7 GBq of the 3 GBq Y-90 microspheres were delivered to the treatment site due to an occlusion in the micro catheter. The treating physician terminated the dose administration after encountering difficulty in "pushing" the syringe contents through the micro catheter. While removing the catheter a small release of microspheres occurred due to the trapped pressure. The spill was contained and immediately cleaned up.

The Hospital contacted the manufacturer and will return the dose unit for analysis. Both the patient and the referring physician have been informed. There was no adverse impact to the patient who has been rescheduled for a compensatory dose next week.

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.


Agreement State
Event Number: 46792
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO   State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 17:30 [ET]
Event Date: 04/27/2011
Event Time: 00:00 [CDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
ANN MARIE STONE (R3DO)
JOSEPHINE PICCONE (FSME)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE DUE TO CLUMPING IN THE DELIVERY DEVICE

The following information was obtained from the State of Illinois via email:

"The Radiation Safety Officer at Northwestern Memorial Hospital contacted the Illinois Emergency Management Agency on April 26th and reported that a medical event involving radiolabled Theraspheres had occurred. The treating physician attempted to perform radioembolization by placing the Y-90 microspheres in the treatment site using the appropriate Nordion Microsphere Delivery Device. However, increased resistance was felt in the administration syringe and a clump of microspheres developed between the needle injector assembly and the microcatheter connection during the initial bolus flush. Administration was halted as soon as the microsphere flow was slowed and a clump was visualized. Following a second attempt to complete the flush, the microspheres began layering within the outlet tubing. Further flushing of the system with saline did not alter the position of the remaining microspheres. The procedure was halted. Analysis of the system showed that a significant amount of the original dose had not been delivered as intended to the right hepatic lobe of the liver. Approximately 80 percent of the dose was not administered as a result of the failure. The primary cause of this incident is due to the clumping of the microspheres. However, the reason for the clumping is unknown."

The intended dose of Y-90 was 59.4 mCi (2198.8 Mbq) for an exposure of 9750 rad (97.5 Gy).

The administered dose was 22.7 mCi (839.9 Mbq) for an exposure of 3760 rad (37.6 Gy).

Illinois Report Number: IL11049


Power Reactor
Event Number: 46793
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: BILL BAKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 18:23 [ET]
Event Date: 04/27/2011
Event Time: 17:01 [CDT]
Last Update Date: 05/02/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (R2DO)
ERIC LEEDS (NRR)
VICTOR MCCREE (R2RA)
DEBORAH SEYMOUR (R2DO)
JEFFERY GRANT (IRD)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 75 Power Operation 0 Hot Shutdown
2 A/R Y 75 Power Operation 0 Hot Shutdown
3 A/R Y 100 Power Operation 0 Hot Shutdown
Event Text
NOTIFICATION OF UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER

At 1701 CDT, the licensee declared a Notification of Unusual Event under Emergency Action Level 5.1U due to loss of offsite power for >15 minutes. The loss of offsite power occurred at 1635 CDT and was due to severe weather and winds in the vicinity. When offsite power was lost, all 3 units automatically scrammed. The units are currently stable in Mode 3 with their respective 4KV busses being supplied by the onsite Emergency Diesel Generators[EDG]. The 161KV Athens line is the only offsite power source energized. All onsite safe shutdown equipment is available with the exception of the Unit 3 "B" EDG which was out of service for planned maintenance.

* * * UPDATE FROM BILL BAKER TO HOWIE CROUCH AT 1942 EDT ON 4/27/11 * * *

The system actuations that occurred during the loss of offsite power were actuations of the Reactor Protection System, Primary Containment Isolation System (PCIS) and Emergency Diesel Generators. All primary containment valves actuated by the PCIS operated as expected. Unexpectedly, the Unit 3 "B" Main Steam Isolation Valve indicates intermediate.

Unit 1 High Pressure Coolant Injection actuated when reactor water level reached -45". Reactor Core Isolation Cooling (RCIC) was already initiated at the time.

* * * UPDATE FROM BILL BAKER TO S. SANDIN AT 2153 EDT ON 4/27/11 * * *

Following the loss of offsite power only 12 of the required 100 offsite emergency sirens are operable.

The licensee will inform both state/local agencies and the NRC Resident Inspector.

Notified R2IRC (Wert) of this update.

* * * UPDATE FROM BILL BAKER TO HOWIE CROUCH AT 2303 EDT ON 4/27/11 * * *

As a result of the loss of offsite power, the Diesel-driven Fire Pump auto-started. While the pump was running, the licensee discovered that approximately one quart of oil had leaked from the fire pump into the cold water channel which discharges into navigable waterways. The licensee confirmed this at 1950 CDT by visually identifying a sheen in the channel.

The licensee notified the National Response Center of the spill and, in accordance with their site discharge permit, notified the State of Alabama. This constitutes an Offsite Notification in accordance with 10CFR50.72(b)(2)(xi).

The licensee notified the NRC Resident Inspector. Notified NRC R2IRC (Wert).

* * * UPDATE FROM BILL BUTLER TO HOWIE CROUCH AT 2338 EDT ON 4/27/11 * * *

At 2120 CDT, operators on Unit 1 were controlling reactor water level between 2 and 51 inches when RCIC became sluggish and water level dropped to +2" causing a valid RPS Scram signal as well as PCIS signals 2, 3, 6, and 8. All valves operated as expected and all isolations were completed.

The licensee notified the NRC Resident Inspector. Notified NRC R2IRC (Wert).

* * * UPDATE FROM WILLIAM BAKER TO CHARLES TEAL AT 2338 EDT ON 4/28/11 * * *

"At 1635 CDT following offsite power grid oscillations (due to inclement weather), and a subsequent Unit 1 power reduction from 100% to 75% to attempt to correct the condition, BFNP experienced a complete loss of the 500kV offsite power system. This resulted in an automatic turbine trip and reactor scram of Units 1, 2 and 3. One 161 kV offsite power system (Athens) remains available. This condition is reportable IAW 10CFR50.72(b)(2)(iv)(B) - Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (4-hour notification). This notification was reported to NRC (Crouch) at 1723 CDT.

"At 1701 CDT, a NOUE was declared (EAL Designator 5.1-U) due to loss of normal and alternate voltage to all 4kV SD (Shutdown) Boards for greater than 15 minutes and at least two Diesel Generators supplying power to unit specific 4kV SD Boards. This condition is reportable IAW 10CFR 50.72(a)(1)(i) - The declaration of any of the emergency classes specified in the licensee's emergency plan (1-hour notification). This notification was reported to NRC (Crouch) at 1723 CDT.

"Following the initial scrams, there were valid actuation signals for RPS (U1/2/3), Containment Isolation Groups 2, 3, 6 and 8 (U1/2/3), HPCI (U1 only), and Emergency Diesel Generators A, B, C, D, 3A, 3C and 3D (EDG 3B is out of service for maintenance). MSIV's (U1 and 3) closed on loss of A and B RPS power, and the U3 B inboard MSIV is indicating 'double lit' (not fully closed) at this time. All other systems responded as expected. This condition is reportable IAW 10CFR50.72(b)(3)(iv)(A) - Any event or condition that results in the valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (8-hour notification). The systems with a valid actuation were RPS, Containment Isolation, HPCI and Emergency Diesel Generators. This was reported in an EN# 46793 update to NRC (Crouch) at 1842 CDT.

"At 1820 CDT a determination was made that offsite emergency notification sirens did not meet the minimum required number operable. Seventy of the one hundred sirens are required to be operable and twelve of the sirens are operable at this time. This condition is reportable IAW 10CFR50.72(b)(3)(xiii) - Any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, emergency notification system, or offsite notification system) (8-hour notification). This was reported in an EN# 46793 update to NRC (Crouch) at 2053 CDT.

"Following auto-start of the diesel driven fire pump, subsequent to the loss of offsite 500kV power system, approximately one quart of oil leaked from the drain plug in the diesel engine of the pump to the plant cold water channel (waters of the United States). This oil produced a "sheen" on the water (confirmed at 1950 CDT) that required a response to the National Response Center IAW 40CFR112.7(a)(4). This condition was reported to the National Response Center at 2055 CDT and assigned spill number 974232. In addition, IAW the BFNP NPDES (National Pollution Discharge Elimination System) permit, the State of Alabama was notified at 2100 CDT of the spill and subsequent notification of the National Response Center. The notification of these outside agencies is reportable IAW 10CFR50.72(b)(2)(xi) - Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification of other government agencies has been or will be made. Such an event may include an onsite fatality or inadvertent release of radioactive contaminated materials (4 hour notification). This was reported in an EN# 46793 update to NRC (Crouch) at 2203 CDT.

"At 2120 CDT, Unit 1 received a low reactor water level scram due to reactor water level lowering to +2 inches following sluggish RCIC response at low reactor pressure. At the time of this event RCIC and CRD were injecting to the vessel and the reactor level band specified was +2 to +51 inches. A valid Containment Isolation signal was received and groups 2, 3, 6 and 8 isolated as expected. Water level was immediately restored to within the specified band (RCIC). This condition is reportable IAW10CFR 50.72(b)(3)(iv)(A) - Any event or condition that results in the valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (8-hour notification). The systems with valid actuations were RPS and Containment Isolation. The Emergency Diesel Generators were already running at the time of the event. This was reported in an EN# 46793 update to NRC (Crouch) at 2238 CDT.

"The NRC resident has been notified of these 1, 4 and 8 hour reports and EN#46793 updates.

"These conditions and notifications will be captured in the licensee's Corrective Action Program."

* * * UPDATE FROM GIVENS TO HUFFMAN AT 2200 EDT ON 5/2/11 * * *

"At 2050 CDT, on 05/02/2011, the previously declared and reported NOUE (EAL Designator 5.1U) due to loss of normal and alternate voltage to all 4kV SD Boards for greater than 15 minutes and at least two Diesel Generators supplying power to unit specific 4kV SD Boards was terminated due to the conditions requiring entry being resolved. At this time, offsite power has been restored from two 161kV sources (Athens and Trinity), all eight 4kV SD boards are being powered from offsite sources, and six of eight Emergency Diesel Generators (B, C, D, 3A, 3C, 3D) are operable and in standby readiness. Emergency Diesel Generators A and 3B are not operable but are available at this time. All three units remain shutdown, in Mode 4, pending return of the 500 kV grid system. A timeline for return of the 500 kV grid system is yet to be finalized.

"In addition, the previous 8-hour notification of offsite emergency sirens not meeting the minimum required is being updated to reflect current conditions. As of 1015 CDT, on 05/02/2011, repair activities have resulted in 92 of 100 sirens being in operable status, thereby meeting the minimum requirement of 70 operable."

The licensee has notified the NRC Resident Inspector and the State of Alabama.

Notified R2DO (Seymour), NRR EO (Nelson), IRD (Grant), DHS (Daly), and FEMA (Dennis).


Power Reactor
Event Number: 46795
Facility: FORT CALHOUN
Region: 4     State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 19:05 [ET]
Event Date: 04/27/2011
Event Time: 18:00 [CDT]
Last Update Date: 04/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DALE POWERS (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
Event Text
EMERGENCY SIRENS INTERMITTENTLY INOPERABLE DUE TO UPGRADING

"Fort Calhoun Station is improving (upgrading) the emergency siren system. This evening during the upgrade the sirens will be inoperable for a short period between 1830 and 2400 today. Fort Calhoun will inform the HOO when the sirens are returned to operation following this evenings maintenance."

The licensee notified the states of Nebraska and Iowa and local authorities in both states of the siren outage.

* * * UPDATE FROM JOHN FICKLE TO DONG PARK AT 0210 EDT ON 4/28/11 * * *

The emergency siren system maintenance was complete and all sirens were restored to service at 0010 CDT on 4/28/11. The licensee notified the states and local authorities.

Notified R4DO (Powers).

* * * UPDATE FROM ERIK MATZKE TO CHARLES TEAL AT 1236 EDT ON 4/28/11 * * *

"Fort Calhoun Station is improving (upgrading) the emergency siren system. Today during the upgrade, the sirens will be inoperable for a short period between 1130 CDT and 1210 CDT today. Fort Calhoun will inform the HOO when the sirens are returned to operation following this maintenance."

Notified R4DO (Powers), State and local government.

* * * UPDATE FROM ERIK MATZKE TO CHARLES TEAL AT 1251 EDT ON 4/28/11 * * *

The emergency siren system maintenance was complete and all sirens were restored to service at 1150 CDT on 4/28/11. The licensee notified the states and local authorities.

* * * UPDATE FROM ERIK MATZKE TO CHARLES TEAL AT 1415 EDT ON 4/28/11 * * *

"Continuing maintenance on the sirens determined that they are not responding correctly. Troubleshooting is in progress. There is not an estimated time to return the sirens to service at this time. Emergency planning personnel have been contacted and contingency actions are in place. The station will contact the HOO when the issue is resolved."

Notified R4DO (Powers).

* * * UPDATE FROM ERIK MATZKE TO CHARLES TEAL AT 1529 EDT ON 4/28/11 * * *

The emergency siren system maintenance was complete and all sirens were restored to service at 1529 CDT on 4/28/11. The licensee notified the states and local authorities.

Notified R4DO (Powers).

* * * UPDATE FROM ERIK MATZKE TO DONG PARK AT 0848 EDT ON 4/29/11 * * *

"Fort Calhoun Station is improving (upgrading) the emergency siren system. Today during the upgrade, the sirens are anticipated to be inoperable for an hour or two during the period between 0755 [CDT] and 1000 [CDT] today. The emergency planning staff has been informed and compensatory measures are in place. Fort Calhoun will inform the HOO when the sirens are returned to operation following this maintenance."

The licensee notified the states and local authorities, as well as the NRC Resident Inspector.

Notified R4DO (Powers).

* * * UPDATE FROM ERIK MATZKE TO CHARLES TEAL AT 1201 EDT ON 4/29/11 * * *

The emergency siren system maintenance was complete and all sirens were restored to service at 1030 CDT on 4/29/11. The licensee notified the states and local authorities.

Notified R4DO (Powers).


Power Reactor
Event Number: 46797
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF EPPERSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/27/2011
Notification Time: 20:19 [ET]
Event Date: 04/27/2011
Event Time: 19:29 [EDT]
Last Update Date: 04/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
LEN WERT (R2IR)
Power Reactor Unit Info
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 92 Power Operation 92 Power Operation
Event Text
BOTH OFFSITE POWER SOURCES DECLARED INOPERABLE DUE TO EFFECTS OF INCLEMENT WEATHER

"At 1929 EDT, both off-site A.C. power sources to Sequoyah were declared inoperable due to the effects of inclement weather on the TVA transmission system. This determination was made after a review of grid conditions confirmed that pre-analyzed grid/offsite power requirements could not be met. Both Sequoyah Units have entered TS LCO 3.8.1.1, action d, for two inoperable offsite power sources. It has not been determined when this condition will no longer exist.

"Although inoperable, off-site A.C. sources remain connected to Sequoyah; emergency diesel generators are not running nor required to be at this time."

T.S. LCO 3.8.1.1, action d, requires verifying EDG operability within 8 hours and restoration of both offsite power sources within 24 hours or placing both Units in mode 3.

The licensee informed the NRC Resident Inspector.

* * * UPDATE FROM JEFF EPPERSON TO PETE SNYDER AT 0203 EDT ON 4/28/11 * * *

As of 0119 EDT the licensee has two operable offsite power sources qualified through transmission and reliability analysis. The licensee exited their LCO Condition. The grid condition is now yellow.

Notified R2IRC (Gody).