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Event Notification Report for September 23, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/22/2009 - 09/23/2009

** EVENT NUMBERS **


45227 45355 45358 45363 45376 45377

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45227
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIMOTHY D. BOLAND
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/24/2009
Notification Time: 18:50 [ET]
Event Date: 07/24/2009
Event Time: 14:15 [CDT]
Last Update Date: 09/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVEN VIAS (R2DO)

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

HPCI INOPERABLE DUE TO OIL LEAK IN MECHANICAL TRIP HOLD VALVE

"During performance of surveillance 1-SR-3.5.1.7, HPCI Main and Booster Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure, the HPCI Turbine Stop Valve Mechanical Trip Hold Valve, 1-PCV-73-18C, developed an oil leak of approximately 0.25 gpm. HPCI was INOPERABLE at the time of discovery due to performance of SR and continued to be INOPERABLE due to the oil leak that developed.

"This event is reportable within 8 hours in accordance with 10CFR 50.72(b)(3)(v) as an event or condition that at the time of discovery could have prevented the fulfillment of a safety function. It also requires a 60 day written report in accordance with 10CFR 50.73(a)(2)(vii)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 9/22/2009 AT 1700 EDT FROM RAYMOND SWAFFORD TO DONG PARK * * *

"On July 24, 2009, the High Pressure Coolant Injection (HPCI) Stop Valve Mechanical Trip Hold Valve (PCV-073-0018C) developed a ruptured diaphragm resulting an approximate 0.25 to 0.5 gallon per minute oil leak during scheduled performance of Surveillance Instruction, HPCI Main and Booster Pump Set Developed Head and Flow Rate at Rated Reactor Pressure. At the time BFN [Browns Ferry Nuclear] made [event] notification 45227, there were concerns regarding the ability of HPCI to fulfill its safety function, hence, BFN made an eight hour notification in accordance with 10CFR50.72(b)(3)(v)(B) and 10CFR50.72(b)(3)(v)(D).

"An evaluation performed in response to this notification concluded that the HPCI System was capable of performing its intended safety function with the oil leak. TVA Engineering evaluated the rate of oil loss considering a worse case failure of PCV-073-0018C diaphragm and determined that the turbine oil system capacity is such that the oil loss thru the failed diaphragm would not impact HPCI operation during its mission time for the Design Basis accidents and transients for which HPCI is credited.

"The circumstances discussed in the notification did not result in any condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or system that are needed to remove residual heat and mitigate the consequences of an accident. Therefore, this event is not reportable under 10CFR50.72(b)(3)(v)(B) and 10CFR50.72(b)(3)(v)(D).

"TVA documented the evaluation of this event notification in its corrective action program (PER 177206).

"The licensee has notified the NRC Resident Inspector."

Notified R2DO (Rudisail).

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General Information or Other Event Number: 45355
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: GREENVILLE MEMORIAL HOSPITAL
Region: 1
City: GREENVILLE State: SC
County:
License #: 257
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 12:11 [ET]
Event Date: 09/15/2009
Event Time: [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN WRONG DOSE

The following information was faxed in by the State:

"The South Carolina Department of Health and Environmental Control was notified on September 17, 2009, by the licensee, that a medical event occurred. A patient who was scheduled for a Yttrium-90 Microsphere therapy was given the wrong dose. The patient was scheduled for 25.38 millicuries but was administered 45.9 millicuries according to the initial report by the licensee.

"The event took place on the 15th and was verified by the licensee on the 17th of September. The referring physician has been notified as well as the patient. The licensee knew no additional details at this point. The licensee will provide additional information in a written report within 15 days. Updates to this event will be made through the NMED system as further information is received."


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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General Information or Other Event Number: 45358
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: LOCKHEED MARTIN CORPORATION
Region: 1
City: ORLANDO State: FL
County:
License #: 3137-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 16:03 [ET]
Event Date: 09/17/2009
Event Time: [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE OF TRITIUM

The following report was received from the State via facsimile:

"Leaking sealed source containing tritium was discovered by state inspector during routine inspection. Lab technician was bio assayed (urine) and an activity level of 1.25 E5 p/Ci per liter was reported. REAC/TS has been notified. [The device containing the tritium source] belongs to a company in Texas, BetaBatt, [whose] license number is L05961. This office [State] is still investigating."

Florida report number - FL09-064

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General Information or Other Event Number: 45363
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CARDINAL HEALTH
Region: 1
City: BELTSVILLE State: MD
County:
License #: 33-198-01
Agreement: Y
Docket:
NRC Notified By: AL JACOBSON
HQ OPS Officer: JASON KOZAL
Notification Date: 09/19/2009
Notification Time: 09:49 [ET]
Event Date: 07/21/2009
Event Time: [EDT]
Last Update Date: 09/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE - POTENTIAL EXTREMITY OVEREXPOSURE

A licensee radio-pharmacist was preparing Flourine-18 (F-18) doses for use, when a manipulator malfunction occurred. The radio-pharmacist continued to prepare the F-18 manually instead of securing the process. This led to a potential dose to the radio-pharmacist's right hand of greater than 50 rem. This dose is a rough estimate from whole body dose values and reconstruction of the event due to the fact the radio-pharmacist was not wearing any dosimetry on the extremity.

The State will continue to investigate this event and provide additional information as it become available.

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Power Reactor Event Number: 45376
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: ERIC NICHOLSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/22/2009
Notification Time: 13:46 [ET]
Event Date: 09/22/2009
Event Time: 05:11 [CDT]
Last Update Date: 09/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG WERNER (R4DO)

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 N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF POWER TO THE EMERGENCY OPERATIONS FACILITY

"The normal power supply to the Emergency Operations Facility (EOF) was lost due to thunderstorms in the area. Support personnel were dispatched to assess the EOF. The facility has a diesel generator that should supply power to the facility. However, electricians discovered the generator degraded and non-functional. By 0511, 9/22/2009, electricians determined that they were unsuccessful at immediately restoring the generator. It is estimated that the EOF was degraded for approximately 5 1/2 hours.

"Following restoration of normal power, Computer Support personnel discovered that the Safety Parameter Display System (SPDS) at the EOF was not functioning. SPDS is a computer based system designed to monitor and display a concise set of parameters from which the safety status of the plant can be readily and reliably determined.

"The normal power supply was eventually returned [to service] by Entergy Arkansas Transmission and the EOF was restored at 0420 and SPDS terminals were subsequently restored at 0815, 9/22/2009. Due to the time that the EOF was degraded, this is considered a major loss of assessment, communications, and response capability."

The licensee informed the Arkansas Department of Health.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 45377
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: CRYSTAL GARBE
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/22/2009
Notification Time: 15:11 [ET]
Event Date: 09/22/2009
Event Time: 13:29 [CDT]
Last Update Date: 09/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GREG WERNER (R4DO)

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

UNANALYZED CONDITION RESULTING FROM AN UNLATCHED DOOR SERVING AS A HIGH ENERGY LINE BREAK BARRIER

"Based on the results of a past operability evaluation completed on 1329 [CDT], 9/22/2009, it appears that an unanalyzed condition existed intermittently for short periods of time in which a door that serves as a High Energy Line Break (HELB) barrier may have been unlatched. With the door not latched, an engineering evaluation concluded that a critical crack (HELB) in the Main Feedwater pipe traversing the south penetration room would force the door (DR-19) open, creating a harsh environment in the adjoining Emergency Feedwater (EFW) pump room. Because the EFW pump room is not evaluated for harsh conditions, it must be conservatively assumed that both pumps may fail to operate following this HELB event. Therefore, this condition is being reported in accordance with 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety."

The licensee informed the Arkansas Department of Health.

The licensee will be notifying the NRC Resident Inspector.

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