Event Notification Report for September 16, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/15/2011 - 09/16/2011
Power Reactor
Event Number: 47271
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: PAUL ADAMS
HQ OPS Officer: JOHN KNOKE
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: PAUL ADAMS
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/16/2011
Notification Time: 15:04 [ET]
Event Date: 09/16/2011
Event Time: 14:50 [EDT]
Last Update Date: 09/16/2011
Notification Time: 15:04 [ET]
Event Date: 09/16/2011
Event Time: 14:50 [EDT]
Last Update Date: 09/16/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
TAMARA BLOOMER (R3DO)
SCOTT MORRIS (IRD)
MARK KING (NRR)
ANNE BOLAND Acting (RA)
ERIC LEEDS (NRR)
TAMARA BLOOMER (R3DO)
SCOTT MORRIS (IRD)
MARK KING (NRR)
ANNE BOLAND Acting (RA)
ERIC LEEDS (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 79 | Power Operation | 0 | Hot Standby |
NOTIFICATION OF UNUSUAL EVENT DUE TO PRIMARY SYSTEM LEAKAGE GREATER THAN 10 GPM
The Licensee declared an Unusual Event for Palisades Unit 1 on 09/16/2011 at 1450 EDT based on EAL SU 8.1, RCS (Reactor Coolant System) leakage exceeding 10 gallons per minute (gpm). The licensee was monitoring an increase in RCS leakage, and at a rate of 3.5 gpm entered their off normal procedure and began shutting down the plant. Technical Specification requires the plant to be in Mode 3 within 6 hours. Leakage increased to greater than 10 gpm, and at 1454 EDT the reactor was manually tripped from 79% power. All control rods fully inserted, and the shutdown was described by the licensee as uncomplicated. Unit 1 is stable in Mode 3.
No safety injection was required since two charging pumps (B&C) were able to keep up with RCS leakage estimated to be between 14 and 15 gpm. Pressurizer level was restored to 43% and rising. RCS pressure was greater than 2000 psi and RCS temperature was being maintained at no load Tave of 535F on the turbine bypass valves. There is no indication of any primary-to-secondary leakage and all equipment is available except for charging pump 'A', which was tagged out of service for planned maintenance.
An entry into containment had been made and the licensee had identified the source of the RCS leakage as being in the vicinity of the 'A' pressurizer spray control valve #1057. This was based on a steam plume seen from below the pressurizer looking up through grating towards this valve.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM JAMES BYRD TO JOHN KNOKE AT 1952 EDT ON 09/16/11 * * *
At 1934 EDT the licensee terminated from their Unusual Event due to EAL SU 8.1. The plant is still in Mode 3 with a leak rate of 0.324 gpm..The licensee has confirmed that the leak is a result of the packing gland backing out of pressurizer spray valve #1057.
The licensee has notified the NRC Resident Inspector. The R3DO (Bloomer) was notified. Notified FEMA (Eiscoe) and DHS (Flinter).
The Licensee declared an Unusual Event for Palisades Unit 1 on 09/16/2011 at 1450 EDT based on EAL SU 8.1, RCS (Reactor Coolant System) leakage exceeding 10 gallons per minute (gpm). The licensee was monitoring an increase in RCS leakage, and at a rate of 3.5 gpm entered their off normal procedure and began shutting down the plant. Technical Specification requires the plant to be in Mode 3 within 6 hours. Leakage increased to greater than 10 gpm, and at 1454 EDT the reactor was manually tripped from 79% power. All control rods fully inserted, and the shutdown was described by the licensee as uncomplicated. Unit 1 is stable in Mode 3.
No safety injection was required since two charging pumps (B&C) were able to keep up with RCS leakage estimated to be between 14 and 15 gpm. Pressurizer level was restored to 43% and rising. RCS pressure was greater than 2000 psi and RCS temperature was being maintained at no load Tave of 535F on the turbine bypass valves. There is no indication of any primary-to-secondary leakage and all equipment is available except for charging pump 'A', which was tagged out of service for planned maintenance.
An entry into containment had been made and the licensee had identified the source of the RCS leakage as being in the vicinity of the 'A' pressurizer spray control valve #1057. This was based on a steam plume seen from below the pressurizer looking up through grating towards this valve.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM JAMES BYRD TO JOHN KNOKE AT 1952 EDT ON 09/16/11 * * *
At 1934 EDT the licensee terminated from their Unusual Event due to EAL SU 8.1. The plant is still in Mode 3 with a leak rate of 0.324 gpm..The licensee has confirmed that the leak is a result of the packing gland backing out of pressurizer spray valve #1057.
The licensee has notified the NRC Resident Inspector. The R3DO (Bloomer) was notified. Notified FEMA (Eiscoe) and DHS (Flinter).
Agreement State
Event Number: 47281
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/20/2011
Notification Time: 10:27 [ET]
Event Date: 09/16/2011
Event Time: 14:14 [EDT]
Last Update Date: 09/20/2011
Notification Time: 10:27 [ET]
Event Date: 09/16/2011
Event Time: 14:14 [EDT]
Last Update Date: 09/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
ANGELA MCINTOSH (FSME)
CHRISTOPHER NEWPORT (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 THERASPHERE UNDERDOSE
The following information was received from the Commonwealth of Pennsylvania via facsimile:
"Event Type: A medical event (ME) involving Y-90 Theraspheres where the patient received 51% of the intended dose, which is reportable under 10CFR35.3045(a)(1)(ii).
'Notifications: On September 16, 2011, at 1414 [EDT], the Department's Southeast Regional Office received notification via phone message about the ME.
"Event Description. The patient was being treated with MDS Nordion Y-90 glass Theraspheres for transarterial radioembolization. A suspected defective catheter caused 49% of the intended dose to clog up in the catheter. No harm to the patient is expected. The referring physician and patient have been notified. No more information is available at this time.
"Cause of the event: The cause of the event is suspected to be a defective catheter.
"Actions: After decay, the catheter will be returned to Nordion for inspection and may also be returned to the manufacturer, Terumo Medical, for a defect analysis. The licensee will be submitting a written report within 15 days. The [Pennsylvania] Department [of Environmental Protection] plans to do a reactive inspection."
PA Report ID: PA110025
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 information was received from the Commonwealth of Pennsylvania via facsimile:
"Event Type: A medical event (ME) involving Y-90 Theraspheres where the patient received 51% of the intended dose, which is reportable under 10CFR35.3045(a)(1)(ii).
'Notifications: On September 16, 2011, at 1414 [EDT], the Department's Southeast Regional Office received notification via phone message about the ME.
"Event Description. The patient was being treated with MDS Nordion Y-90 glass Theraspheres for transarterial radioembolization. A suspected defective catheter caused 49% of the intended dose to clog up in the catheter. No harm to the patient is expected. The referring physician and patient have been notified. No more information is available at this time.
"Cause of the event: The cause of the event is suspected to be a defective catheter.
"Actions: After decay, the catheter will be returned to Nordion for inspection and may also be returned to the manufacturer, Terumo Medical, for a defect analysis. The licensee will be submitting a written report within 15 days. The [Pennsylvania] Department [of Environmental Protection] plans to do a reactive inspection."
PA Report ID: PA110025
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.