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Event Notification Report for May 2, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/01/2007 - 05/02/2007

** EVENT NUMBERS **


43321 43331 43332 43333 43335

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General Information or Other Event Number: 43321
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: MEMORIAL MISSION HOSPITAL
Region: 1
City: ASHVILLE State: NC
County:
License #: 011-0091-6
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2007
Notification Time: 18:19 [ET]
Event Date: 04/24/2007
Event Time: [EDT]
Last Update Date: 04/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
ROBERT PIERSON (NMSS)

Event Text

AGREEMENT STATE REPORT - NORTH CAROLINA - MISADMINISTRATION OF IODINE-131

The State provided the following information via facsimile:

The State of North Carolina was notified on 4/26/07 of a misadministration of diagnostic Iodine-131. The event involved a "misdrawn and mislabeled dose from Shertech Pharmacy in Ashville NC (NC licensee 011-1203-1). The written directive [from the hospital] was for 30 microcuries for a diagnostic thyroid scan but 33.9 millicuries was delivered labeled as 33.9 microcuries. Nuclear Medical Technologist at Memorial Mission missed the error because they read the numbers (33.9) but not the units (millicuries vs. microcuries). Dose was administered on 4/24/07 and the error was found on 4/26/07. Patient and physician notified. Licensee is following up with Shertech." No information is available on any potential medical impact of the misadministration on the patient.


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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Power Reactor Event Number: 43331
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BRIAN HUPKE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/01/2007
Notification Time: 00:39 [ET]
Event Date: 04/30/2007
Event Time: 20:17 [CDT]
Last Update Date: 05/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTINE LIPA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

HPCI DECLARED INOPERABLE DUE TO PRIMARY CONTAINMENT NITROGEN LEAK

"At 1007 on the morning of 04/30/2007, operations personnel identified an adverse trend in Primary Containment Nitrogen makeup frequency. The subsequent investigation determined that Primary Containment Nitrogen was leaking backwards thru V22-0017 HPCI Turbine Exhaust Line Stop-Check Valve and V22-0016 HPCI Exhaust Check Valve, via the HPCI exhaust vacuum breakers and the environment of the HPCI room via the turbine seals.

"The degradation of V22-0016 and V22-0017 constitute a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. (50.72(b)(3)(v)(D)).

"At 2017 on the evening of 04/30/2007, V22-0017 HPCI Turbine Exhaust Line Stop-Check Valve and V22-0016 HPCI Exhaust Check Valve were declared inoperable due to Primary Containment Nitrogen leakage as described above.

"At 2032 on the evening of 04/30/2007, V22-0017 HPCI Turbine Steam Exhaust Line Isolation was shut to isolate Primary Containment Nitrogen leakage.

"With V22-0017 shut, HPCI is INOPERABLE and Unavailable."

The licensee is in a 14 day LCO under section 3.6.1.3 for Primary Containment Isolation Valves (PCIV). However, they are in a 72 hour LCO for having "A" core spray and HPCI inoperable, concurrently. The licensee expects to have "A" core spray restored during dayshift on 5/1/07. Additionally, the licensee is in a 7 day LCO for EDG OOS.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY E. VANN TO J. KOZAL ON 5/01/07 AT 1048 * * *

The licensee provided a correction to the TS LCO statement referenced in the initial report. The 14 day LCO is not under section 3.6.1.3 for Primary Containment Isolation Valves (PCIV). The correct LCO statement is 3.5.1 for ECCS Operating.

The licensee will notify the NRC Resident Inspector. R3DO (Lipa) notified.

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Power Reactor Event Number: 43332
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: JASON KOZAL
Notification Date: 05/01/2007
Notification Time: 11:23 [ET]
Event Date: 04/12/2007
Event Time: 06:20 [EDT]
Last Update Date: 05/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DANIEL HOLODY (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

PRIMARY CONTAINMENT ISOLATION DUE TO LOSS OF RPS POWER SUPPLY

"On April 12. 2007 at approximately 0620, with the James A Fitzpatrick Nuclear Power plant (JAF) operating at 100% reactor power, an equipment malfunction occurred, resulting in the tripping of one of the two 'B' Reactor Protection System (RPS) motor generator Electrical Protection Assembly (EPA) breakers. This caused a corresponding loss of power to the 'B' RPS bus, a half scram and primary containment isolation valve closures. Appropriate actions were taken in accordance with Abnormal Operating Procedure (AOP)-60, 'Loss of RPS Bus 'B' Power'. All equipment operated as designed as a result of the loss of power to the 'B' RPS bus.

"At 0629, the 'B' RPS bus was placed on the alternate power supply. At approximately 0658 the RPS half scram was reset and at approximately 0702 Primary Containment Isolation System (PCIS) isolation signal was reset. Restoration of the various isolated systems commenced shortly thereafter. The reactor remained at 100% power throughout the event and Technical Specifications (TS) Limiting Condition for Operation (LCO) Actions were entered for the affected equipment as required.

"The above event meets the reporting criteria of 10 CFR 50 73(a)(2)(iv)(a) since the loss of RPS bus resulted in primary containment isolation signals affecting containment isolation valves in more than one system. The following systems or components isolated as a result of the loss of 'B' RPS bus: Reactor Water Cleanup, Reactor Building Ventilation 'B' Containment Atmosphere Dilution, Torus Vent and Purge, Drywall Equipment and Floor Drain Sumps 'B' Drywall Containment Atmospheric Monitors, Recirculation System Sample Line Main Steam Line Drains, Residual Heat Removal drain valve to radwaste, Standby Gas Treatment (auto initiated).

"Since the signal was invalid (the result of loss of power vs. an actual containment isolation condition), this event meets the criteria in 10 CFR 50.73 (a)(1) for being reported as a 60 day telephone notification in lieu of a written LER.

"The loss of the 'B' RPS bus was caused by the tripping of one of the two in-series 'B' RPS motor generator EPA breakers. An apparent cause evaluation of the failure is in progress (Condition Report CR-JAF-2007-01422). At this time the failure is attributed to the failure of a subcomponent (capacitor) on the EPA breaker logic card. The logic card was replaced, restoring the 'B' RPS motor generator to service.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43333
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MATT LACROIX
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/01/2007
Notification Time: 13:17 [ET]
Event Date: 03/03/2007
Event Time: 08:14 [CDT]
Last Update Date: 05/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
CHRISTINE LIPA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

INVALID ECCS ACTUATION DURING REFUELING OUTAGE

"This telephone notification is provided in accordance with 10 CFR 50.73(a)(1), to report an invalid actuation reportable under 10 CER 50.73(a)(2)(iv)(A).

"On March 3, 2007, Unit 2 was in a refueling outage. Reactor penetration nozzles were being flushed to remove crud deposits. At 0814 CST, Low Reactor Vessel Level 1, Level 2, and Level 3 alarms were received in the Main Control Room, and the Division 1 Emergency Core Cooling System (ECCS) initiated. The Low Pressure Core Spray (LPCS) pump started on the ECCS initiation signal and injected into the Unit 2 reactor vessel. In addition, the '0' Diesel Generator auto-started, and the Low Pressure Coolant Injection valve (2E12-F042A) auto-opened.

"Operators verified that reactor vessel and reactor cavity water levels were normal, and then stopped the ECCS injection into the vessel by placing the LPCS pump control switch in pull-to-lock. ECCS is not required to be operable in Mode 5 with the spent fuel pool storage gates removed and water level greater than or equal to 22 feet above the Reactor Pressure Vessel (RPV) flange.

"Investigation determined that the low reactor vessel water level signal occurred when the flushing wand was inserted into instrument nozzle N14A, which is the reference leg tap for the reactor vessel level instruments. The transient in differential pressure sensed by the level instruments resulted in the invalid actuation.

"Corrective actions included a revision to the model work order for this task to clearly identify the nozzles that shall and shall not be flushed during this evolution.

"This event is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an invalid ECCS actuation and invalid system actuation."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43335
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MORGAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/01/2007
Notification Time: 17:51 [ET]
Event Date: 05/01/2007
Event Time: 17:00 [EDT]
Last Update Date: 05/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL HOLODY (R1)
JOHNSON (EPA)
WYATT (DOE)
TIMMONS (USDA)
MILLER (HHS)
BARDEN (FEMA)

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

Event Text

OFFSITE NOTIFICATION OF A SPILL OF ACIDIC WATER

The licensee made an offsite notification to the Maryland Department of the Environment based on the release of approximately 705 gallons of very acidic demineralized water (Ph of 1) to a storm drain. The drain is connected to a system that leads to the Chesapeake Bay. The acidic water is coming from a non-isolable leak from the 11 Waste Neutralizing Tank. The leakage is onto a gravel base below the tank which is about 5 feet from the storm drain. The leak rate is at a rate of about 1 GPM. The licensee has set up a system to divert some of the leakage from the storm drain and capture it in waste barrels but some of the water is still being spilled onto the ground. The long term remediation of this problem is to neutralize the tank with a caustic solution and then discharge the tank.

The licensee has also notified Calvert County and the NRC Resident Inspector.

* * * UPDATE FROM MORGAN TO HUFFMAN AT 1940 EDT ON 5/1/07 * * *

The licensee also made a report of this spill to the National Response Center (EPA). R1DO (Holoday) notified.

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