Event Notification Report for August 21, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/20/2012 - 08/21/2012
EVENT NUMBERS
48214482184821948215
Power Reactor
Event Number: 48214
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: TERRY BRANDT
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: TERRY BRANDT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/21/2012
Notification Time: 06:14 [ET]
Event Date: 08/21/2012
Event Time: 04:07 [CDT]
Last Update Date: 08/23/2012
Notification Time: 06:14 [ET]
Event Date: 08/21/2012
Event Time: 04:07 [CDT]
Last Update Date: 08/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 94 | Power Operation | 94 | Power Operation |
TECHNICAL SUPPORT CENTER OUT OF SERVICE
"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the emergency power supply to the TSC from service. The TSC would be rendered non-functional with the loss of emergency power. The repair to the power supply is expected to last three days.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore the emergency power supply to service.
"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC emergency power supply has been restored to normal operation.
"NRC Resident has been notified."
* * * UPDATE FROM STEVE BREWER TO CHARLES TEAL ON 08/23/12 AT 1346 EDT * * *
Maintenance has been completed on the TSC. The TSC has been returned to service.
Notified R3DO (Duncan).
"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the emergency power supply to the TSC from service. The TSC would be rendered non-functional with the loss of emergency power. The repair to the power supply is expected to last three days.
"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore the emergency power supply to service.
"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC emergency power supply has been restored to normal operation.
"NRC Resident has been notified."
* * * UPDATE FROM STEVE BREWER TO CHARLES TEAL ON 08/23/12 AT 1346 EDT * * *
Maintenance has been completed on the TSC. The TSC has been returned to service.
Notified R3DO (Duncan).
Agreement State
Event Number: 48218
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/21/2012
Notification Time: 16:27 [ET]
Event Date: 08/21/2012
Event Time: 00:00 [EDT]
Last Update Date: 08/21/2012
Notification Time: 16:27 [ET]
Event Date: 08/21/2012
Event Time: 00:00 [EDT]
Last Update Date: 08/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM COOK (R1DO)
FSME_EVENTS RESOURCE (EMAI)
WILLIAM COOK (R1DO)
FSME_EVENTS RESOURCE (EMAI)
AGREEMENT STATE - RADIATION TREATMENT OVERDOSE RESULTING FROM A POTENTIAL GENERIC ISSUE
The following information was provided by the State of Pennsylvania via facsimile:
"On Monday, August 20, 2012, the licensee informed the Pennsylvania Department of Environmental Protection's Southcentral Regional Office of a medical event which occurred the same day. It is reportable within 24-hours under 10 CFR 35.3045(a)(1)(iii).
"During the first fraction of radiation therapy treatment, using a Nucletron Corporation microSelectron HDR (High Dose Rate) Model 106.990 remote afterloader, the unit's treatment planning software malfunctioned, resulting in an overdose to the patient of approximately 76.5%. Facility staff also failed to complete a required worksheet which may have alerted the Authorized User to the dosage difference prior to treatment. A total dose of 600 cGy (rad) was delivered instead of the prescribed 340 cGy (rad). The patient was notified on the same day, while the referring physician was notified the following day. The treating physician anticipates no effect to the patient, however, dose reconstruction is currently in progress. We believe this incident also qualifies the event as an Abnormal Occurrence.
"Cause of the event is equipment malfunction and human error.
"Licensee is contacting a service provider for the HDR unit to investigate the incident, and if needed, repair the equipment. The Pennsylvania Department of Environmental Protection will be evaluating possible generic implications and plans to do a reactive inspection as soon as possible."
PA Event Report No: PA120025
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 provided by the State of Pennsylvania via facsimile:
"On Monday, August 20, 2012, the licensee informed the Pennsylvania Department of Environmental Protection's Southcentral Regional Office of a medical event which occurred the same day. It is reportable within 24-hours under 10 CFR 35.3045(a)(1)(iii).
"During the first fraction of radiation therapy treatment, using a Nucletron Corporation microSelectron HDR (High Dose Rate) Model 106.990 remote afterloader, the unit's treatment planning software malfunctioned, resulting in an overdose to the patient of approximately 76.5%. Facility staff also failed to complete a required worksheet which may have alerted the Authorized User to the dosage difference prior to treatment. A total dose of 600 cGy (rad) was delivered instead of the prescribed 340 cGy (rad). The patient was notified on the same day, while the referring physician was notified the following day. The treating physician anticipates no effect to the patient, however, dose reconstruction is currently in progress. We believe this incident also qualifies the event as an Abnormal Occurrence.
"Cause of the event is equipment malfunction and human error.
"Licensee is contacting a service provider for the HDR unit to investigate the incident, and if needed, repair the equipment. The Pennsylvania Department of Environmental Protection will be evaluating possible generic implications and plans to do a reactive inspection as soon as possible."
PA Event Report No: PA120025
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.
Power Reactor
Event Number: 48219
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LEE GRZECK
HQ OPS Officer: JOHN SHOEMAKER
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LEE GRZECK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/21/2012
Notification Time: 20:13 [ET]
Event Date: 08/21/2012
Event Time: 19:30 [EDT]
Last Update Date: 08/21/2012
Notification Time: 20:13 [ET]
Event Date: 08/21/2012
Event Time: 19:30 [EDT]
Last Update Date: 08/21/2012
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):
ROBERT HAAG (R2DO)
ROBERT HAAG (R2DO)
| 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 |
DAMAGED PACKAGING CONTAINING RADIOACTIVE MATERIAL
"In accordance with 49 CFR 171.15, Duke Energy contacted the Department of Transportation National Response Center at 1930 [EDT] on August 21, 2012, Report Number 1021811, to inform them of a breach of a package containing a limited quantity of radioactive material. This breach was considered 'breakage' in accordance with Title 49 of the Code of Federal Regulations, Transportation. Although the packaging of the radioactive material was damaged during transportation, the radioactive material itself was not released, and the damage did not result in any external radioactive contamination or any radiation exposure. This event did not result in any adverse impact to the health and safety of the public. The State of North Carolina (NC) has also been notified of this event. Mecklenburg County, NC will be notified of this event.
"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi) as a result of the notification to another government agency.
"The safety significance of the breached package is minimal.
"The condition will be entered into the Corrective Action Program for evaluation. Corrective actions will be determined based on the results of this evaluation."
The container held a torque wrench calibration test tool and cable. The tools had penetrated the container, but no other damage to the tools was noted. The tools will be normally processed for use at the station.
The licensee has notified the NRC Resident Inspector.
"In accordance with 49 CFR 171.15, Duke Energy contacted the Department of Transportation National Response Center at 1930 [EDT] on August 21, 2012, Report Number 1021811, to inform them of a breach of a package containing a limited quantity of radioactive material. This breach was considered 'breakage' in accordance with Title 49 of the Code of Federal Regulations, Transportation. Although the packaging of the radioactive material was damaged during transportation, the radioactive material itself was not released, and the damage did not result in any external radioactive contamination or any radiation exposure. This event did not result in any adverse impact to the health and safety of the public. The State of North Carolina (NC) has also been notified of this event. Mecklenburg County, NC will be notified of this event.
"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi) as a result of the notification to another government agency.
"The safety significance of the breached package is minimal.
"The condition will be entered into the Corrective Action Program for evaluation. Corrective actions will be determined based on the results of this evaluation."
The container held a torque wrench calibration test tool and cable. The tools had penetrated the container, but no other damage to the tools was noted. The tools will be normally processed for use at the station.
The licensee has notified the NRC Resident Inspector.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 48215
Facility: MILLSTONE
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: KENNETH HAJNAL
HQ OPS Officer: STEVE SANDIN
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: KENNETH HAJNAL
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/21/2012
Notification Time: 07:50 [ET]
Event Date: 08/21/2012
Event Time: 00:38 [EDT]
Last Update Date: 09/04/2012
Notification Time: 07:50 [ET]
Event Date: 08/21/2012
Event Time: 00:38 [EDT]
Last Update Date: 09/04/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
WILLIAM COOK (R1DO)
WILLIAM COOK (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
BOTH EMERGENCY DIESEL GENERATORS INOPERABLE
At 0038 EDT on 08/21/12, EDG "A" was declared inoperable after the Engineered Safeguards Actuation System (ESFAS) fuse failed . EDG "B" had been inoperable for planned maintenance since 2223 EDT on 08/15/12. With both EDGs inoperable, Unit 2 entered Tech Spec LCO 3.8.1.2 which requires suspension of all operations involving core alteration and positive reactivity additions.
At 0713 EDT on 08/21/12, the licensee declared EDG "B" Operable exiting the Tech Spec LCO. The cause of the ESFAS fuse failure on EDG "A" is under investigation.
The licensee will notify state and local agencies and has informed the NRC Resident Inspector.
* * * RETRACTION FROM WAYNE WOOLERY TO DONG PARK AT 1027 EDT ON 9/4/12 * * *
"The purpose of this call is to retract the report made on 8/21/2012, Event Number 48215. Upon further review, the fuse failure did not render the 'A' Emergency Diesel Generator (EDG) inoperable in MODE 5. If called upon, the safety functions would have been met. The Engineered Safeguards Actuation System (ESFAS) was repaired prior to restart of the unit.
Notified R1DO (Conte).
At 0038 EDT on 08/21/12, EDG "A" was declared inoperable after the Engineered Safeguards Actuation System (ESFAS) fuse failed . EDG "B" had been inoperable for planned maintenance since 2223 EDT on 08/15/12. With both EDGs inoperable, Unit 2 entered Tech Spec LCO 3.8.1.2 which requires suspension of all operations involving core alteration and positive reactivity additions.
At 0713 EDT on 08/21/12, the licensee declared EDG "B" Operable exiting the Tech Spec LCO. The cause of the ESFAS fuse failure on EDG "A" is under investigation.
The licensee will notify state and local agencies and has informed the NRC Resident Inspector.
* * * RETRACTION FROM WAYNE WOOLERY TO DONG PARK AT 1027 EDT ON 9/4/12 * * *
"The purpose of this call is to retract the report made on 8/21/2012, Event Number 48215. Upon further review, the fuse failure did not render the 'A' Emergency Diesel Generator (EDG) inoperable in MODE 5. If called upon, the safety functions would have been met. The Engineered Safeguards Actuation System (ESFAS) was repaired prior to restart of the unit.
Notified R1DO (Conte).