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Event Notification Report for January 29, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2007 - 01/29/2007

** EVENT NUMBERS **


43112 43124 43125 43126 43127 43128

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General Information or Other Event Number: 43112
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SURGICAL CENTER OF CENTRAL FLORIDA
Region: 1
City: SEBRING State: FL
County:
License #: 3704-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/22/2007
Notification Time: 13:26 [ET]
Event Date: 06/13/2006
Event Time: 12:00 [EST]
Last Update Date: 01/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
MARIE MILLER (R1)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - MISADMINISTRATION OF BRACHTHERAPY SEEDS

The State of Florida was notified on 01/11/07 by Florida Agency for Health Care Administration that while performing an audit of the licensee it appeared a misadministration of brachytherapy seeds on June 13, 2006 was not reported to DOH-BRC, nor was there any documentation it was done. The State is planning to visit the licensee in the next few days to obtain details of this medical event from the Radiation Oncologist.

The auditor provide the following documentation to the State concerning a prostate seed implant procedure performed on June 13, 2006 at the Surgical Center of Central Florida:

"A review of preplanning, live planning and post planning documents was conducted on June 22, 2006, and a wrong site administration (as defined in Florida Administrative Code 64&5. 101, 88-6) was declared by the prescribing radiation oncologist and the Radiation Safety Officer associated with the Cancer Care Center of Sebring. Their conclusion was supported by diagnostic films and the physics calculations. Consistent with the Florida Radiation Safety Guidelines, the patient's referring physician was also contacted by the treating urologist on June 23, 2006 and [the] facility was advised within 24 hours of the finding. Both the patient and his wife have been informed of the post procedure evaluation results and the patient has undergone a diagnostic computed tomography exam and follow-up appointment at the Cancer Care Center in Sebring.

"As a result of further assessment, the apparent misadministration incident was determined to be reportable to the State of Florida pursuant to Florida Administrative Code Section 53E-5.345 4A by the license holder and its' Radiation Safety Officer. . . . "

The procedure involved the implant of sixty I-125 seeds totaling approximately 20 milliCuries.

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.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43124
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: KEVIN CRAVENS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/26/2007
Notification Time: 17:55 [ET]
Event Date: 01/26/2007
Event Time: 09:15 [CST]
Last Update Date: 01/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVE PASSEHL (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N Y 96 Power Operation 96 Power Operation

Event Text

CONTROL ROOM EMERGENCY VENTILATION AIR CONDITIONING (CREV AC) SYSTEM DECLARED INOPERABLE


On January 26, 2007 at 0915 hours, the Control Room Emergency Ventilation Air Conditioning (CREV AC) system was declared inoperable due to not meeting the surveillance acceptance criteria for the refrigeration condensing unit (RCU) during QCOS 5750-11 (Control Room Emergency Ventilation System Test - performed every 2 years). As result Technical Specification 3.7.5 Condition "A" was entered (30 day Limiting Condition of Operation).

"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) because the CREV system is a single train system, and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident.

"At this time, additional analysis is underway to determine the impact of the failure to meet the acceptance criteria on the CREV AC safety function."


The NRC Resident Inspector was notified of this event by the licensee.


* * * RETRACTION 01/28/07 AT 1651 EST FROM C. KRONICH TO MACKINNON * * *

"Further evaluation performed by Quad Cities Station confirms the CREV AC system would have performed its safety function. A revised surveillance (QCOS 5750-11, Control Room Emergency Ventilation System Test) was re-performed successfully, and the CREV AC system was declared operable on January 28, 2007 at 0911 hours.

"Based on the subsequent evaluation and surveillance testing, ENS report # 43124 is being retracted."

R3DO (Dave Passehl) notified.

The NRC Resident Inspector was notified of this retraction by the licensee.

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Power Reactor Event Number: 43125
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ERIC KELSEY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/26/2007
Notification Time: 19:26 [ET]
Event Date: 01/26/2007
Event Time: 13:54 [EST]
Last Update Date: 01/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL PERRY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

CAPABILITY TO DETERMINE STACK EFFLUENT RADIOACTIVITY RELEASE HAS BEEN LOST.

"At 1354 on 01/26/07, Nine Mile Point Unit 1 determined that the capability to determine effluent radioactivity going out the stack had been lost. It is postulated that this is likely due to moisture in both the primary and aux sample lines had frozen, blocking the flow of effluent to sample analysis equipment.

"Compensatory actions include; monitoring of alternate indications of increased radioactivity in the plant effluent stream and the development of procedures to quantify radioactivity release rate using existing operable instrumentation." The State of New York was notified of this event.


The NRC Resident Inspector was notified of this event by the licensee.

* * * UPDATE ON 01/26/07 AT 2137 EST BY ERIC KELSEY TO MACKINNON * * *

"The following action is intended to provide stack effluent release rates, temporarily replacing the non-operable stack sampling and analysis system. The method being developed will assess the significant rad and ventilation contributions of each of the plant systems that exhaust to the stack: specifically, the Off Gas, Reactor, Turbine and Radwaste Building ventilation. This summation will be equivalent to the rad release that was provided by the non-operable system. This method will be procedurally based and can be accomplished by the on-shift Chemistry Technician and can be directly input into the NMP dose computer.

"Repairs to the inoperable system will commence on day shift 1/27/07" R1DO (Neil Perry) notified.

The NRC Resident Inspector and the State of New York were notified of this update by the licensee.

* * * UPDATE ON 01/27/07 AT 1905 EST BY KIRSTY DANN TO SNYDER * * *

"The stack sample low flow issue has been corrected as of 1/27/07 at 14:55. Stack flow monitoring of stack effluent has been re-established to a normal lineup."

The licensee notified the NRC Resident Inspector.

Notified R1DO (Neil Perry).

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Power Reactor Event Number: 43126
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT CARTER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/26/2007
Notification Time: 22:52 [ET]
Event Date: 01/26/2007
Event Time: 17:15 [CST]
Last Update Date: 01/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVE PASSEHL (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

SAFETY PARAMETER DISPLAY SYSTEM (SPDS) DECLARED INOPERABLE.

"On January 26, 2007 at 0915 hours, the Clinton Power Station Plant Process Computer failed causing a loss of the Safety Parameter Display System. At 1715 hours, troubleshooting is ongoing and the failure has not been corrected and SPDS has not been restored. Since SPDS was not restored within eight hours, this event is reportable due to a major loss of emergency assessment capability per 10CFR50.72(b)(3)(xiii).

"The NRC Resident Inspector has been notified."

* * * UPDATE PROVIDED BY JERAMY ANDERSON TO JEFF ROTTON AT 0704 EST ON 01/27/07 * * *

"Plant process computer was restarted at 0405 CST and a 2 hour confidence run has been completed. The Safety Parameter Display System is now operable."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Passehl)

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Power Reactor Event Number: 43127
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: LEONARD WIEGAND
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/27/2007
Notification Time: 09:10 [ET]
Event Date: 01/27/2007
Event Time: 09:05 [EST]
Last Update Date: 01/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

ERFIS REMOVED FROM SERVICE FOR PLANNED MODIFICATION

"At 0905 hours EST, on January 27, 2007, the Emergency Response Facility Information System (ERFIS) computer system was removed from service to complete a planned modification of the ERFIS power supply system. The expected duration of ERFIS inoperability is approximately 2 hours. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, and the Inadequate Core Cooling Monitor (ICCM). The loss of ERFIS requires alternate methods, as described in plant procedures, to be used for the above described functions. Therefore, it is expected that appropriate assessment or plant conditions, notifications, and communications could still be made, if required, during the time that the ERFIS computer system is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As previously stated, alternate means remain available to assess plant conditions, make notifications, and accomplish required communications, as necessary. An update to this message will be provided when the ERFIS is restored.

"This message is similar to the January 6, 2007 event notification number 43081. At that time the ERFIS was being placed on an alternate power supply to allow modification of the normal power supply. This interruption of the ERFIS is due to the completion of that planned modification, which allows restoration of the ERFIS to the normal power supply."


The licensee notified the NRC Resident Inspector.


* * * UPDATE ON 01/27/07 AT 1347 EST FROM LEONARD WIEGAND TO MACKINNON * * *

Emergency Response Facility Information System (ERFIS) returned to service at 1150 EST.

The NRC Resident Inspector will be informed of this update by the licensee.

R2DO (Brian Bonser) notified

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Power Reactor Event Number: 43128
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: KEVIN McLAUGHLIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/28/2007
Notification Time: 00:02 [ET]
Event Date: 01/27/2007
Event Time: 20:40 [EST]
Last Update Date: 01/28/2007
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
Person (Organization):
NEIL PERRY (R1)

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

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOSS OF LOAD TRANSIENT CAUSED BY EHC PROBLEM

"On January 27, 2007 at approximately 2040 hours an automatic reactor trip occurred. The cause of the trip was Over Temperature Delta T (2/4). All systems functioned as designed. All control rods inserted on the trip. Decay heat removal is via condenser steam dump and Auxiliary Feedwater.

"The initial cause of the trip appears to be from a loss of load due to a turbine electro-hydraulic system issue. This is still under investigation.

"RCS Temperature is 547 Degrees F and stable
"RCS Pressure is 2235 psig and stable
"Both pressurizer PORVs momentarily opened and then closed during the transient.

"For 8Hr Non Emergency 10 CFR 50.72(b)(3)
"RPS actuation occurred.
"Auxiliary Feed Water actuation occurred."

There was no testing or maintenance in progress at the time of the transient.

The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012