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Event Notification Report for May 22, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/21/2008 - 05/22/2008

** EVENT NUMBERS **


44219 44228 44229 44230 44231 44232

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Hospital Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 05/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."


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: 44228
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: SCOTT LINDQUIST
HQ OPS Officer: PETE SNYDER
Notification Date: 05/21/2008
Notification Time: 02:29 [ET]
Event Date: 05/20/2008
Event Time: 19:56 [CDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID PROULX (R4)

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

DECAY HEAT REMOVAL COOLING INTERUPTED DURING CORE RELOAD

"At 1956, during reactor core reload with a full refueling cavity, power was lost to the #2 non-vital instrument bus. This power loss resulted in closure of the shutdown cooling temperature control valve, HCV-341. The closure of HCV-341 interrupted the cooling capability of the in service shutdown cooling loop.

"While cycling a condenser motor operated valve a 480 volt ground occurred which resulted in tripping the feeder breaker to motor control center MCC-4B2. MCC-4B2 was supplying power to Instrument Bus 2 via the Inverter 2 test transformer. The test transformer was powering Instrument Bus 2 due to Inverter 2 replacement per plant modification. The loss of the #2 Instrument Bus resulted in HCV-341, the shutdown cooling heat exchangers temperature control valve, failing closed. HCV-341 was manually opened to restore cooling at 2019. At 2049 power was restored to Instrument Bus 2 and the shutdown cooling system was returned to automatic operation. Flow through the core was maintained throughout the event, as the shutdown cooling heat exchanger bypass valve responded by opening to maintain flow. At the time shutdown cooling was lost, 44 of 133 assemblies had been loaded into the vessel and shutdown cooling temperature was approximately 88 degrees F. Time to boil was conservatively calculated to be 22.5 hours per plant procedures which assume decay heat from all 133 assemblies. Shutdown cooling temperature rose approximately one degree during this event.

"Technical Specification 2.8.1(3)(1) was entered due to no Shutdown Cooling loop in Operation. No reactor coolant boron reductions were in progress. Irradiated fuel assembly loading into the reactor core was secured and actions to restore a Shutdown Cooling loop were been initiated. [Ft. Calhoun] enter[ed] a 4 hour LCO to close all containment penetrations providing direct access from the containment to the outside atmosphere."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44229
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: BRIAN JOHNSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/21/2008
Notification Time: 12:03 [ET]
Event Date: 05/21/2008
Event Time: 08:05 [CDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation
2 N Y 10 Power Operation 100 Power Operation

Event Text

INADVERTENT ACTUATION OF EMERGENCY SIRENS

"At approximately 0805 CDT, on May 21, 2008, a Dakota County Communications Center Shift Supervisor inadvertently activated the Dakota County sirens from the primary unit during conduct of a silent siren test. The licensee was notified of the siren activation by the activation signal received on the informer unit in the Technical Support Center (TSC) at 0805. Seven of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) were activated for less than one minute. No press release is planned by Xcel Energy."

The system has been restored to normal. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44230
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVE BAHNER
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/21/2008
Notification Time: 20:24 [ET]
Event Date: 05/21/2008
Event Time: 15:00 [PDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVID PROULX (R4)

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

MOBILE CRANE CAUSED DAMAGE TO MET TOWER

"During the performance of work activities in the vicinity of the Met Tower at 10 AM, a mobile crane made contact with a support wire causing damage to the tower. All instrumentation on the tower continues to function, but conservatively has been called inoperable. All instrumentation on the back up Met Tower continues to function. The backup Met Tower provides full assessment capability.

"Due to the structural damage to the tower, as a precaution the area around the tower including the simulator training building and the maintenance training building have been evacuated.

"Experts from Transmission and Distribution are assessing damage to the tower to determine what additional actions may be necessary.

"The local media requested information about this event at 1500. Information has been released to the media.

"The senior resident inspector has been notified."

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Power Reactor Event Number: 44231
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: WILLIE MARTIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/21/2008
Notification Time: 21:30 [ET]
Event Date: 05/21/2008
Event Time: 17:04 [EDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVEN VIAS (R2)

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 DIESEL GENERATOR SHIFTED TO EMERGENCY START DURING POST MAINTENANCE TEST

"At 1704, while performing post maintenance testing on the 'A' diesel, the automatic voltage regulator appeared to fail and was swapped from auto to manual. The 1DA bus voltage momentarily decreased causing the undervoltage relays to actuate. This actuation shifted the 'A' diesel to the emergency mode and restored bus voltage. The plant was in mode 5 at the time of the event. The 1DA bus remained energized throughout the event. Subsequently, the 1DA bus was paralleled to offsite power and the 'A' diesel generator was secured. The cause of the voltage regulator failure is being investigated."

The licensee notified the NRC Resident Inspector. The licensee will be notifying the State and local emergency response organizations.

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Power Reactor Event Number: 44232
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: RICKY GIVENS
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/21/2008
Notification Time: 21:41 [ET]
Event Date: 05/21/2008
Event Time: 15:15 [CDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN VIAS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 79 Power Operation 79 Power Operation
2 N Y 100 Power Operation 100 Power Operation
3 N Y 86 Power Operation 86 Power Operation

Event Text

LOSS OF CONTROL ROOM PHONE COMMUNICATIONS

"At 1515 hrs, the control room staff discovered that normal control room phone communications were not working. Additionally, the NRC emergency notification system (red phone) was not functional.

"The following communication systems were maintained: Satellite phone system, Chattanooga CECC ring down line, 2 lines in the Technical Support Center, Nextel mobile phone network, and site radio frequencies.

"Even though some communications capabilities were maintained, this condition was determined to be reportable as a major loss of communication capability via 10 CFR 50.72(b)(3)(xiii) given that normal control room phone lines and the NRC red phone were not available.

"All normal means of communication were returned to service at 1724 hrs by placing a spare battery charger in service to the communications system.

"The Browns Ferry NRC Resident Inspector was notified of this occurrence and restoration."

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