United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2009 > January 2

Event Notification Report for January 2, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/31/2008 - 01/02/2009

** EVENT NUMBERS **


44624 44733 44742 44747 44748

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44624
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC BLOUGH
HQ OPS Officer: JOE O'HARA
Notification Date: 11/03/2008
Notification Time: 04:35 [ET]
Event Date: 11/03/2008
Event Time: 02:07 [EST]
Last Update Date: 12/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DEBORAH SEYMOUR (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R N 0 Cold Shutdown 0 Cold Shutdown

Event Text

MANUALLY OPENED REACTOR TRIP CIRCUIT BREAKERS TO INSERT CONTROL BANK "B"

"Manually opened reactor trip breakers in Mode 5 to insert control bank 'B' due to blown fuse in rod control cabinet."

Licensee was moving control rod bank "B" following I & C work, and the control rod bank failed to move as expected. All other control rod banks were inserted into the core at the time of the event. EDG's and offsite power sources are OPERABLE, and there is no increase in plant risk.

The licensee will inform the NRC Resident Inspector.

* * * RETRACTION ON 12/31/08 AT 1326 FROM RICK ABBOTT TO PETE SNYDER * * *

"Regarding the NRC Event Number 44624 conveyed November 3, 2008, McGuire Nuclear Station has determined that manually opening the reactor trip breakers was not reportable and hereby retracts this notification. Upon further consideration it was determined that manually opening the reactor trip breakers was a conservative decision to fully insert control rods based on the failure mechanism causing a single rod to drop to the fully inserted position. Manual actuation of the reactor trip breakers was not required by abnormal procedures and was performed only after consultation between operations, engineering and senior station management agreed that this was the preferred option. Therefore, the decision to manually open the reactor trip breakers is considered to be a preplanned actuation of the reactor protection system and is not reportable."

The licensee informed the NRC Resident Inspector. Notified R2DO (M. Lesser).

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44733
Rep Org: TRINITAS HOSPITAL
Licensee: TRINITAS HOSPITAL
Region: 1
City: ELIZABETH State: NJ
County:
License #: 29-04333-01
Agreement: N
Docket:
NRC Notified By: LINDA VELDKAMP
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/18/2008
Notification Time: 17:41 [ET]
Event Date: 12/17/2008
Event Time: 14:00 [EST]
Last Update Date: 12/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD BARKLEY (R1)
JIM LUEHMAN (FSME)

Event Text

MEDICAL DOSE LESS THAN 50 PERCENT OF PRESCRIBED DOSE

"Suspected movement of catheter during endobronchial high dose rate remote afterloading treatment procedure may have resulted in a single fraction of a multifraction treatment to differ from the prescribed dose by more than 50%. [35.3045(a)(1)(iii)].

"The intended dose was 500cGy to the Rt Bronchus (lung).

"Both the patient and the referring physician were notified by the authorized user of the possibility the intended treatment site did not receive full dose.

"1. Patient had endobronchial catheter placed in Rt Bronchus in the endoscopy department. Catheter was taped in place and position was marked.

"2. Patient was scanned in CT simulation room by therapist to determine catheter location and treatment dwell positions.

"3. Patient treatment plan was created by physicist and approved by the authorized user. Second calculation check was performed.

"4. Patient was monitored by nursing during the treatment planning process.

"5. Patient was brought into HDR treatment room by therapist.

"6. Authorized physicist and authorized user connected the treatment applicator to the HDR unit.

"7. Technologist monitored patient on the camera system.

"8. Treatment was administered as planned.

"9. Patient was disconnected from the HDR unit.

"10. Technologist removed catheter post treatment, noted the catheter she pulled out was relatively short compared to the planning scan.

"11. Technologist notified the authorized user and authorized physicist.

"12. Both individuals notified the RSO.

"13. RSO investigated and interviewed individuals involved.

"14. AU not sure at what point the catheter moved.

"Patient may have dislodged catheter when coughing or wiping mouth secretions.

"Actions to prevent re-occurrence:

"1. Authorized user will remove all endobronchial catheters post treatment in the future to prevent any ambiguity with regard to length of catheter in patient.

"2. Check marked position of the catheter at CT and both pre and post treatment prior to catheter removal.

"3. Measure catheter length outside the naries prior to planning CT, prior to treatment, and post treatment as a second check to the marked position.

"The Pulmonologist and Authorized user will perform a bronchoscopy in about 2 weeks [to determine if misadministration occurred]. Treatment reactions outside the planned treatment site will be evaluated and determination of treatment in an unintended area will be determined."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

* * * RETRACTION ON 12/31/2008 AT 1507 FROM LINDA VELDKAMP TO MARK ABRAMOVITZ * * *

"Basis for initial report: Basis for the initial report was the possibility that a medical event may have occurred. It was uncertain whether the endobronchial catheter moved before, during, or after the treatment. The patient's clinical response suggests that the catheter was correctly positioned during the treatment.

"Evidence supporting appropriate treatment administered: Authorized user (AU) continued to follow the patient closely since administration of treatment on 12/17/08. AU reported on 12/18/08 and 12/24/08 in patient follow-up no clinical evidence exists that would support a mistreatment. The AU reported, the patient was initially admitted with hemoptysis which resolved post treatment. In addition, the AU reported the patient has 'no treatment related toxicity, no pain, no discomfort and is feeling very well.' The AU stated she does not believe there was a medical event and based on the clinical evidence and follow-up there was 'no indication of a misadministration.' Based upon the aforementioned, the AU requests the medical event be retracted.

"Change in follow-up plan: Patient was discharged to another facility for treatment of an unrelated condition. AU reported based on patient improvement no additional treatment or bronchoscopy was required at this time. Subsequent treatment planned after discharge from other facility in several weeks.

"Process improvement steps identified and already implemented:
1. All endobronchial catheters will be removed by the AU post treatment.
2. Current procedures will be modified as follows: At the time of insertion the catheter will be securely taped in place. A physical measurement of the catheter length extended beyond the nares/securing tape in reference to an indexing mark on the catheter will be immediately conducted after catheter insertion by the AU and/or AMP, verified by the non-measuring party and recorded in the patient record. In accordance with standard operating procedure the catheter will continue to be marked with a permanent marker for visual check and recorded. These measurements will be rechecked and recorded prior to CT imaging for planning, just prior to treatment and post treatment. Significant deviations in measurement will be reported to the AU and will require re-imaging to verify catheter placement pre-treatment."

Notified the R1DO (Dentel) and FSME (Bubar).

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 44742
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: VINCE KLCO
Notification Date: 12/27/2008
Notification Time: 14:19 [ET]
Event Date: 12/26/2008
Event Time: 20:43 [CST]
Last Update Date: 12/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GEORGE HOPPER (R2)
ERIC BENNER (NMSS)

Event Text

PROCESS GAS LEAK DETECTION SYSTEM INOPERABLE

"At 2043 CST, on 12-26-08 the Plant Shift Superintendent (PSS) was notified that C-337 Unit 6 Cell 9 was above atmospheric pressure and the UF6 Release Detection (PGLD) System was inoperable. The cell had been running below atmosphere earlier in the day but a new gradient was put in and load movement caused pressure to go above atmosphere. The PGLD System for Unit 6 Cell 9 had been inoperable for an extended period of time due to wiring problems. TSR 2.4.4.1 requires that at least the minimum number of detector heads in the cell are operable during steady state operations above atmospheric pressure. Even though the increase in cell pressure was due to load movement which is transient in nature, it was determined that the pressure had been above atmosphere for about four and a half hours, which is longer than the typical transient. With the Unit 6 Cell 9 PGLD system inoperable, none of the required cell heads were operable. TSR LCO 2.4.4.1.B.1 was entered and a continuous smoke watch was put in place within one hour. This event is reportable as a 24 hour event in accordance with 10CFR76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Senior Resident Inspector has been notified of this event."

* * * RETRACTION ON 12/31/2008 AT 1716 FROM TONY HUDSON TO MARK ABRAMOVITZ * * *

"A subsequent review of the cell pressure proved that the cell pressures were below atmosphere at all times with the exception of one pressure spike of approximately 20 minutes. Since the cell was not operated above atmosphere and the TSR does not require PGLD systems to be operable during short term pressure transients, reporting under 10CFR76.120 is not required."

Notified the R2DO (Lesser) and NMSS (Lorson).

To top of page
Power Reactor Event Number: 44747
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: BILL HUFFMAN
Notification Date: 01/01/2009
Notification Time: 10:55 [ET]
Event Date: 01/01/2009
Event Time: 00:42 [EST]
Last Update Date: 01/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GLENN DENTEL (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

SAFETY PARAMETER DISPLAY SYSTEM INOPERABLE

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, off site response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or off site notification system)'.

"At 0430 ET on Thursday, January 01, 2009, Operators discovered that the Plant Process Computer (PPC) typer display output was not updating. In addition all keyboard control was lost. The Safety Parameter Display System (SPDS) Computer Display was updating, but the operators were not able to change the display to alternate views rendering the SPDS system degraded to the point of not being able to perform its monitoring function. This condition initially began at 0042 on 01 January 2009.

"All Control Room panel indicators and annunciators continued to respond properly providing operators with non-computer based emergency assessment capability. The PPC was secured for troubleshooting at 0746 on 01 January 2009."

"An update to this notification will be made after repairs are completed and the SPDS is returned to service."

The NRC Resident Inspector has been notified.

* * * UPDATE AT 1431 EST ON 01/01/09 FROM ERIC KELSEY TO S. SANDIN * * *

"On Thursday, January 01, 2009 at 1140 ET, the Plant Process Computer (PPC) was successfully restarted. The performance of the PPC and SPDS was monitored for approximately one hour. SPDS was declared operable at 1300, restoring full emergency assessment capability."

The licensee will inform the NRC Resident Inspector. Notified R1DO (Dentel).

To top of page
Power Reactor Event Number: 44748
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: C. DUNSMORE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/01/2009
Notification Time: 21:06 [ET]
Event Date: 01/01/2009
Event Time: 14:30 [EST]
Last Update Date: 01/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK LESSER (R2)

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

TWO EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE DUE TO COMPONENT FAILURE

"EVENT DESCRIPTION: During return to service testing for Emergency Diesel Generator (EDG) #3, it was noted that the fuel rack limiting cylinder was not returning to its non-limiting position. The fuel rack limiting cylinder is designed to limit the stroke distance of the fuel rack assembly during the initial EDG start sequence. Once the EDG is at rated speed, ~10 seconds, the fuel rack limiting cylinder should return to its non-limiting position. Failure of this component to operate as expected may have prevented EDG #3 from fulfilling its safety function during the postulated Loss of Off Site Power and/or Loss of Coolant Accident conditions. As a result, EDG #3 remains inoperable.

"During performance of subsequent surveillance testing on the remaining EDG's (#1, #2, and #4), in accordance with Technical Specifications, a similar condition as described above existed on EDG #4. EDG's #1 and #2 did not exhibit the same behavior and therefore, these EDG's remained operable during this sequence of events. Consequently, EDG #4 was declared inoperable at 1430 on 1/01/09. Failure of this component to operate as expected may have prevented EDG #4 from fulfilling its safety function during the postulated Loss of Off Site Power and/or Loss of Coolant Accident conditions. The concurrent failure of this component on EDG #3 and EDG #4 may have prevented on-site emergency power to Emergency busses 3 & 4 and thus the fulfillment of a safety function needed to mitigate the consequences of an accident.

"INITIAL SAFETY SIGNIFICANCE EVALUATION: Plant operation is being maintained within the limiting conditions of the license expected. However, transient analyses relating to accident mitigation could have been impacted due to the inability to ensure emergency on-site power supply to Emergency busses 3 & 4. Off-site power and the grid have been stable during the time period both EDG's were inoperable.

"CORRECTIVE ACTIONS: The fuel rack limiting cylinder for EDG #4 was repaired and EDG #4 was restored to Operable on January 1, 2009 at 1755 EST. Actions required per technical specifications for 2 EDG's were exited within the required time frame. Repair efforts are in progress for EDG #3."

The licensee informed the NRC Resident Inspector.

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