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Event Notification Report for June 13, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/12/2008 - 06/13/2008

** EVENT NUMBERS **


44275 44280 44287 44289 44290 44291 44292 44293

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Hospital Event Number: 44275
Rep Org: BON SECOURS VIRGINIA HEALTH SOURCE
Licensee: BON SECOURS VIRGINIA HEALTH SOURCE
Region: 1
City: RICHMOND State: VA
County:
License #: 45-25187-01
Agreement: N
Docket:
NRC Notified By: JUDY CHIN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/06/2008
Notification Time: 15:07 [ET]
Event Date: 05/01/2008
Event Time: 10:00 [EDT]
Last Update Date: 06/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAMELA HENDERSON (R1)
LYDIA CHANG (FSME)

Event Text

MEDICAL EVENT - EXCESS SKIN EXPOSURE DURING TREATMENT


A women was prescribed a breast cancer treatment using an HDR mammosite balloon brachytherapy. The dose was delivered in 10 fractions using Iridium - 192 seeds. During administration of the first fraction, the physicist received an alarm from the HDR computer, the alarm was overridden based on the judgment of the physicist at the time of the event and the treatment was completed. Additional fraction treatments were also completed as intended.

Subsequent review of the first treatment and the cause of the alarm indicated that a medical event may have occurred. The alarm was indicating that the seed placement was dislodged by 2 centimeters. The physicist thought at the time that the alarm was indicating the seed dislodged by only 2 millimeters. The treatment calculations were revisited and the dislodgment of the seed by 2 centimeters put the seed at the skin entry point of the application catheter. This resulted in an under dose to the target site and an overdose to the skin. Preliminary calculations estimate that the skin in a 7 mm diameter around the catheter entry point may have received a dose of 3700 centigrays based on the strength of the seed (4.47 curies) and the dwell time.

The patient will be notified of the event. The patient's doctor will continue to monitor the skin for any ill effects.



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: 44280
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JIM KONRAD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/10/2008
Notification Time: 01:52 [ET]
Event Date: 06/09/2008
Event Time: 20:07 [EDT]
Last Update Date: 06/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATTY PELKE (R3)

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

EMERGENCY OPERATIONS FACILITY POWER OUTAGE

"The Emergency Operations Facility (EOF) became unavailable when a storm took down the power line supplying the building that houses the EOF. The emergency diesel generator failed to start, leaving the EOF without power. Notification being made in accordance with 10CFR50.72(b)(3)(xiii). If EOF actuation is necessary, the alternate EOF will be utilized."

The licensee is investigating the failure of the backup emergency diesel generator to start.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 0335 ON 6/12/2008 FROM JIM KONRAD TO MARK ABRAMOVITZ * * *

Power had been restored to the EOF at the time of the initial notification. Power was unavailable on 6/9/2008 from 2007 to 2312, a period of three hours and five minutes.

The licensee notified the NRC Resident Inspector.

Notified the R3DO (Louden).

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Power Reactor Event Number: 44287
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEN JOHNSTON
HQ OPS Officer: PETE SNYDER
Notification Date: 06/11/2008
Notification Time: 23:48 [ET]
Event Date: 06/11/2008
Event Time: 14:05 [PDT]
Last Update Date: 06/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GEOFFREY MILLER (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

IDENTIFICATION OF A POTENTIAL ISSUE WITH ACCUMULATOR DRAIN VALVES

"On June 11, 2008 at 1405 PDT, licensed plant operators entered Technical Specification (TS) 3.0.3 on Units 1 and 2 due to identification of a potential ASCO solenoid valve failure that could initiate draining if the safety injection system accumulators following a small break Loss-of-Coolant-Accident (LOCA).

"ASCO Model 8316 and 8321 pilot-operated solenoid valves over 12 years old are susceptible to a potential shuttle ('insert' per vendor documentation) malfunction. The malfunction is that with greater than 12 years of service and a loss of minimum operating pressure differential (MPOD), the shuttle (or insert) could reposition and fail to return to the desired position. This MPOD related reposition could result following instrument air pressure loss and subsequent restoration to containment following a postulated small break LOCA. Diablo Canyon Power Plant (DCPP) Units 1 and 2 each have four susceptible ASCO solenoid valve locations used as drain valves for each of the four safety injection system accumulators per unit.

"DCPP is reviewing the performance of the ASCO solenoids based on a plant problem report and subsequent discussion with the vendor. The safety significance of this event is low as there was no actual accumulator drain valve failure. Although PG&E is still evaluating the potential degradation mechanism and failure mode of these valves, TS 3.03 was conservatively entered base on the potential for malfunction of these valves.

"On June 11, 2008, at 1610 PDT licensed plant operators exited TS 3.0.3 following isolation of the suspect accumulator drain lines. A licensee event report will be issued for this event.

"The NRC Resident Inspector has been notified."

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Research Reactor Event Number: 44289
Facility: KANSAS STATE UNIVERSITY
RX Type: 250 KW TRIGA MARK II
Comments:
Region: 4
City: MANHATTAN State: KS
County: RILEY
License #: R-88
Agreement: Y
Docket: 05000188
NRC Notified By: PAUL WHALEY
HQ OPS Officer: PETE SNYDER
Notification Date: 06/12/2008
Notification Time: 01:21 [ET]
Event Date: 06/12/2008
Event Time: 00:21 [CDT]
Last Update Date: 06/12/2008
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GEOFFREY MILLER (R4)
JOHN LUBINSKI (NRR)
WILLIAM GOTT (IRD)
ERIC LEEDS (NRR)
ELMO COLLINS (R4)
GOMEZ (DHS)
KEVIN BISCOE (FEMA)
JULIA MUSE (DOE)
DAVID TIMMONS (USDA)
LEE MILLER (HHS)

Event Text

ALERT DECLARED DUE TO TORNADO IMPACTING REACTOR BUILDING ONSITE

The research reactor building at the Kansas State University was damaged due to a tornado onsite. There is extensive damage to the building. The reactor was shutdown properly earlier in the day. There is no damage to the reactor. There is a loss of power onsite however, this type of reactor requires no active cooling. The reactor is shutdown and stable.

* * * UPDATE AT 0555 ON 6/12/08 FROM PAUL WHALEY TO PETE SNYDER * * *

The Alert condition at the site has been terminated. Conditions requiring entry into the Alert have been rectified.

Notified IRD (Gott), R4DO(Miller), EDO (Mallett), DHS (Jason Craig), FEMA (Mike LaForty), DOE (Thomas Yates), USDA (Rob Leadbetter), and HHS (Harry Peagler).

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Power Reactor Event Number: 44290
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BARRY BLEVINS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/12/2008
Notification Time: 05:48 [ET]
Event Date: 06/12/2008
Event Time: 00:40 [EDT]
Last Update Date: 06/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT SUMMERS (R1)

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

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM IDENTIFIED INOPERABLE DURING SURVEILLANCE

"Unit 2 HPCI was declared inoperable during the performance of a scheduled surveillance test. HPCI failed to develop the required discharge pressure to meet its design function."

Reactor Core Isolation Cooling (RCIC) is available.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44291
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DOUG PETERSON
HQ OPS Officer: KARL DIEDERICH
Notification Date: 06/12/2008
Notification Time: 15:19 [ET]
Event Date: 06/12/2008
Event Time: 11:30 [CDT]
Last Update Date: 06/12/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATRICK LOUDEN (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

UNUSUAL EVENT DECLARED DUE TO A MAJOR LOSS OF RESPONSE AND COMMUNICATIONS CAPABILITY

"At 1130CDT on 6/12/2008, the Duane Arnold Energy Center was informed due to flooding in the local area that access to the Joint Information Center (JIC), the Offsite Radiological Analytical Laboratory (ORAL), the Offsite Relocation and Reassembly Area (ORRA), and the Emergency Operations Facility (EOF) have been lost. This constitutes a reportable condition per 10CFR50.72(b)(3)(xiii) due to the major loss of offsite response capability. The ORAL function will be maintained by the Iowa State Hygienics Lab. At the present time the remaining facilities are being relocated or moved to the Linn County Emergency Operations Center (EOC) located at the Kirkwood Community College Campus. Also, although multiple roads in the area are closed due to high water level, evacuation capability in the EPZ is being maintained. Also, at 1256CDT on 6/12/2008, Duane Arnold Energy Center was informed that local commercial phone service through the Palo phone system has been lost. This service also includes our ability to fax and access the internet. We have also lost our FTS2001 ENS connection. Again, per 10CFR50.72(b)(3)(xiii) this represents a major loss of offsite communication capability. Offsite communications is being maintained currently thorough our microwave and cell phone systems. Onsite communications are possible through our in house PBX and page system. Contingency plans are in effect to setup a mobile satellite uplink that would include voice and data capability."

The NRC Resident Inspector has been informed.

* * * UPDATE AT 1629EDT ON 06/12/08 FROM DOUG PETERSON TO S. SANDIN * * *

"At 1430CDT on 6/12/2008, Duane Arnold Energy Center lost communications capability via commercial phone line, FT2001 ENS system and the microwave phone system. This meets the threshold criteria of an EAL classification of an Unusual Event. At 1440CDT the Shift Manager declared that Unusual Event and notifications were made to Linn County Emergency Management Agency, Benton County Emergency Management Agency and the Iowa Homeland Security Emergency Management Division. Currently, offsite communication is still possible via our installed cell phone and satellite systems and onsite communications remain possible via our PBX and page system."

The NRC Resident Inspector has been informed. Notified ET Member (B. Mallet), all IRD Management (B. McDermott, W. Gott, M. Leach), Commissioners' Staffs (D. Skeen, T. Hipschman, S. Baggett, J. Thoma, D. Coe), EDO Staff (J. Adams), PAO (E. Brenner), OCA (D. Decker), RDOs (R. Summers, B. Bonser, P. Louden, G. Miller), FEMA, DOE, USDA, and HHS.

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Power Reactor Event Number: 44292
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/12/2008
Notification Time: 17:06 [ET]
Event Date: 06/12/2008
Event Time: 13:45 [EDT]
Last Update Date: 06/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATRICK LOUDEN (R3)

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

UNAVAILABILITY OF EMERGENCY OPERATIONS FACILITY

"At 1345 on Thursday, June 12, 2008, the Cook Nuclear Plant (CNP) Buchanan Office Building was conservatively evacuated due to the presence of a solvent vapor in the building. The Buchanan Office Building houses both the Emergency Operations Facility (EOF) and Joint Information Center (JIC).

"The Buchanan Office Building has been ventilated and has been verified inhabitable by Safety and Health personnel. The Emergency Operations Facility and Joint Information Center access was restored at 1530 on Thursday, June 12, 2008. Further investigation concluded that the concentration of the solvent vapor was never at a level that would have mandated evacuation.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of offsite response capability. The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 44293
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: WILLIAM RICHARDS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/13/2008
Notification Time: 02:14 [ET]
Event Date: 06/13/2008
Event Time: 01:46 [EDT]
Last Update Date: 06/13/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
PATRICK LOUDEN (R3DO)
CALDWELL (R3)
STEVE YORK (DHS)
KEVIN BISCOE (FEMA)
STU BAILEY (DOE)
DAVID TIMMONS (USDA)
YVONNE MAMMARELLI (HHS)
LAURENCE COLLIGAN (CANA)

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

UNUSUAL EVENT DUE TO PARTIAL LOSS OF ANNUNCIATORS

The licensee is investigating a loss of greater than 75% of their annunciator indications. The annunciators lost include alarms for ECCS divisions 1 & 2, Reactor Control Panels, and electrical panels. "All normal methods of monitoring plant systems are available." Compensatory measures are being initiated. The plant is stable at 100% power and all maintenance has been stopped.

The licensee notified the NRC Resident Inspector.

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