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Event Notification Report for May 3, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/30/2010 - 05/03/2010

** EVENT NUMBERS **


45874 45876 45883 45888 45889 45890 45891 45893

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Power Reactor Event Number: 45874
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: ANDREW TEREZAKIS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2010
Notification Time: 11:51 [ET]
Event Date: 04/26/2010
Event Time: 08:37 [EDT]
Last Update Date: 05/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION TAKEN OUT OF SERVICE FOR MAINTENANCE

"On April 25, 2010, at 1130 EDT, the Control Room Emergency Ventilation system on St. Lucie Unit 1 was declared out of service due to removing both Control Room Booster fans from service in order to support charcoal absorber replacement in the common filtration train as part of scheduled outage maintenance. The Technical Support Center (TSC) ventilation system is part of the Unit 1 Control Room Emergency Ventilation system, therefore, the TSC ventilation system has been rendered non-functional during the course of the work activities. The TSC ventilation is expected to be returned to service on 4/26/10.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Should the TSC become uninhabitable, the TSC staff will relocate to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72 (b)(3)(xiii) due to the potential loss of an Emergency Response Facility (ERF). An update will be provided once the TSC ventilation system has been restored to normal operation. The NRC Resident Inspector has been notified."

* * * UPDATE FROM FRED POLLACK TO DONG PARK AT 0321 EDT ON 5/1/2010 * * *

"Charcoal absorber replacement and post maintenance testing has been completed satisfactorily and the Control Room Emergency Ventilation System, and thus the Technical Support Center Ventilation System, has been declared back in service at 0140 on 05/01/2010.

"The NRC Resident Inspector has been notified."

Notified R2DO (McCoy).

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General Information or Other Event Number: 45876
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MARY BIRD PERKINS CANCER CENTER
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2651-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/27/2010
Notification Time: 12:04 [ET]
Event Date: 03/15/2010
Event Time: 07:30 [CDT]
Last Update Date: 04/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

RADIATION UNDERDOSE AT PRESCRIBED LOCATION

The following information below is a summary of a facsimile provided by the State of Louisiana Department of Environmental Quality concerning a reported medical event:

"A medical event occurred involving a patient under treatment for adenocarcinoma of the prostate gland. The patient involved received a prostate brachytherapy implant on March 12, 2010, using radioactive iodine-125 seeds [95 seeds of I-125 were implanted at 0.322 mCi/seed].

"The radiation oncologist with the assistance of the urologist inserted the needles through the appropriate holes in the needle template. During the procedure, the radiation oncologist used the ultrasound to guide the needle placement. However, the radiation oncologist and ultrasound technologist had difficulty seeing the balloon location (indicating the prostate base) clearly on the sagittal view of the ultrasound during the dispensing of the seeds from the needles. It was felt that it was possible that the patient may have moved during the procedure which may have caused the balloon and ultimately the base plane to have shifted.

"A variance was suspected by the radiation oncologist after reviewing the post implant seed count x-ray. The patient was called to return for an early post-implant CT on March 22, 2010 to confirm the implanted seed locations. Using these images, a treatment plan was constructed using the treatment planning system's post-plan software. Based on this postoperative plan, it has been estimated that the entire implanted volume was shifted approximately 3.0-cm inferiorly, resulting in D90% of 12.88 Gy (dose that covers 90% of the prostate volume outlined on the post implant CT images). The prescription dose was 145.0 Gy. The post-implant planning results were referred to the Radiation Safety Committee (RSC) for review. After review, the RSC decided to interpret the implant as a medical event. This decision was made based on the fact that the V100 (volume of the prostate that received 100% of the prescribed dose) was less than 50% and the event classification was felt to be that of a wrong site.

"The information provided to the patient was that a treatment delivery inaccuracy occurred on March 15, 2010. The radiation oncologist explained to the patient that the dose delivered was not as planned and that supplemental treatment is recommended to treat his prostate cancer. A waiting period is recommended to allow the sources to decay and to determine any possible complications."

Louisiana Report # LA100003

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: 45883
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: CHRIS BUSH
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/30/2010
Notification Time: 05:26 [ET]
Event Date: 04/30/2010
Event Time: 03:00 [CDT]
Last Update Date: 04/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 65 Power Operation 65 Power Operation

Event Text

LOSS SAFETY PARAMETER DISPLAY SYSTEM (SPDS) DUE TO COMPUTER PROBLEMS

"At 0300 [CDT] on 04/30/2010, the Plant Computer Group identified that the SPDS stalled and was not updating data points as required. The SPDS also supplies data to several Emergency Response Data System (ERDS) points. Redundant, normal control room indications are still available to the operators. This is considered a Loss of Emergency Assessment Capability and therefore, reportable under 10CFR50.72(b)(3)(xiii).

"SPDS was restored at 0356 [CDT] on 4/30/2010.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 45888
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM TAYLOR
HQ OPS Officer: PETE SNYDER
Notification Date: 04/30/2010
Notification Time: 22:31 [ET]
Event Date: 04/30/2010
Event Time: 16:48 [CDT]
Last Update Date: 04/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GERALD MCCOY (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

LIGHT SOCKET SHORT CAUSES ISOLATION SYSTEMS TO ACTUATE

"At 1648 CDT, while the Control Bay AUO [Auxiliary Unit Operator] was attempting to change a light bulb for 1-IL-99-1AA, 1A [Reactor Protection System] RPS [Motor Generator] MG Set available light, the light socket shorted causing the loss of 1A RPS. The loss of 1A RPS resulted in Groups 2, 3, 6, and 8 primary containment isolations and initiated Standby Gas Treatment and Control Room Emergency Ventilation. All systems responded as designed. The Control Room operators entered the appropriate abnormal operating instruction, 1-AOI-99-1, to restore the affected systems. Operations entered TS LCO 3.3.1.1 conditions A.1 (place channel in Trip in 12 hours) and C.1 (restore RPS trip capability in 1 hr). At 1734 CDT, Operations exited TS LCO 3.3.1.1 upon restoration of 1A RPS per 1-AOI-99-1.

"This event is reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) 'Any event or condition that results in a valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) [b. General Containment Isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs)], except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' This event also requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 45889
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICK LULLING
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/01/2010
Notification Time: 02:01 [ET]
Event Date: 04/30/2010
Event Time: 21:00 [CDT]
Last Update Date: 05/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GERALD MCCOY (R2DO)

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

Event Text

INADVERTENT SYSTEM ACTUATION OCCURRED DURING A SURVEILLANCE TEST

"Unit 2 was performing a planned refueling outage surveillance test, FNP-2-STP-40.0, Safety Injection with Loss of Off-Site Power. The system was being returned to normal following the actuation portion of the test. When the B2F Sequencer was reset, a loss of off-site power (LOSP) occurred, which caused a loss of the 'A' Train 4kV busses, and an LOSP signal was generated. The 1-2A Diesel Generator was already running at normal speed, and voltage. Therefore, the diesel generator output breaker opened, and then reclosed which then allowed the LOSP loads to automatically start. This included the 2A Motor Driven Auxiliary Feedwater Pump, and the 2A High Head Safety Injection Pump. Therefore, during the test, the system actuated in a way that was not part of the planned evolution.

"The investigation indicated that a recent design change on the diesel generator output breaker circuitry had not been fully incorporated into the test procedure. The test procedure currently in progress was revised to provide guidance for operating the B2G Sequencer Test Trip Override switch. The restoration section for the 'B' Train was completed with no further complications when the B2G Sequencer Test Trip Override switch was operated before resetting the B2G Sequencer."

The licensee has notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 45890
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: ROD COOK
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/01/2010
Notification Time: 08:46 [ET]
Event Date: 04/30/2010
Event Time: 10:15 [CDT]
Last Update Date: 05/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GERALD MCCOY (R2DO)
TIM MCCARTIN (NMSS)

Event Text

TAR FOUND ON OVERPRESSURE RUPTURE DISCS POTENTIALLY CHANGING THE RELIEF SET POINT

"On 04/30/10 the Plant Shift Superintendent (PSS) was notified that while performing maintenance on C-337 Unit 2 Cell 4 Odd R-114 rupture disc replacement, roofing tar was discovered in the upper rupture disc. C-337 U/2 C/4 Odd system was not in a mode of applicability according to TSR [Technical Safety Requirement] 2.4.3.4. The presence of the roofing tar on an operable R-114 coolant overpressure control system rupture disc would not allow the rupture disc to perform its intended safety function as required by TSR 2.4.3.4. The R-114 rupture disc is the primary component of the R-114 coolant overpressure control system. The R-114 coolant overpressure control system prevents excess coolant pressure from rupturing the coolant system and releasing coolant into the UF6 primary system that could result in the subsequent release of UF6 due to over pressurization of the UF6 system. TSR 2.4.3.4 and 2.3.3.2 require that the R-114 coolant overpressure control system be operable. An extent of condition inspection of in use R-114 rupture discs is in progress. Roofing tar was discovered on R-114 coolant overpressure control system rupture discs in the following locations: C-337 cells U/3 C/2 Odd, U/1 C/5 Odd, U/1 C/6 Odd, U/6 C/4 Odd, U/2 C/5 Even, U/5 C/4 Odd, U/5 C/6 Even, U/5 C/8 Odd, U/4 C/7 Even (Not in an applicable mode), U/2 C/4 Odd (Not in an applicable mode). U/6 C/7 Odd (Not in an applicable mode). C-331 U/1 C/4 (Not in an applicable mode). Buildings C-310 and C-335 R-114 coolant overpressure control system rupture discs were inspected and were free of any foreign material. Systems that are in an applicable mode according to TSR 2.4.3.4 and were discovered to have roofing tar on the rupture discs were declared inoperable and an operator was stationed to continuously monitor the R-114 pressure in order to take action according to TSR 2.4.3.4.

"This event is reportable as a 24 hour event in accordance with 10 CFR 76.120(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 Resident Inspector has been notified of this event.

"PGDP Assessment and Tracking Report No. ATRC-l0-1131; PGDP Event Report No. PAD-2010-6"

* * * UPDATE FROM JOE BARLETTO TO HOWIE CROUCH @ 2254 EDT ON 5/1/10 * * *

"On 05-01-2010 at 2225 hours, extent of condition walk downs have been completed. Additional R-114 rupture disc locations were discovered with either roofing tar and/or shipping caps in the upper rupture disc. The presence of either would not allow the R-114 rupture disc to perform its intended safety function as required by TSR 2.4.3.4. Systems that are in an applicable mode according to TSR 2.4.3.4 and were discovered to have roofing tar and/or shipping caps on the upper rupture discs were declared inoperable and an operator was stationed to continuously monitor the R-114 pressure in order to take action according to TSR 2.4.3.4."

The licensee provided a list of 28 cells that had shipping caps installed and 13 cells with roofing tar on the discs.

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

* * * UPDATE FROM ROD COOK TO JOHN KNOKE @ 1737 EDT ON 5/2/10 * * *

"On 5/02/2010 at 0636 hours during a review of the extent of condition inspection notes, engineering identified that C-333 U/4 C/9 Even R-114 Over-pressurization system had been omitted from the report due to oversight. Engineering had identified a shipping cover with tar on it was present on the rupture disc.

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

"PGDP Assessment and Tracking Report No. ATRC-10-1141; PGDP Event Report No. PAD-2010-6. Responsible Division: Operations"

Notified R2 DO (Randy Musser) and NMSS EO (Tim McCartin)

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Other Nuclear Material Event Number: 45891
Rep Org: PARTICLE DRILLING TECHNOLOGIES
Licensee: PARTICLE DRILLING TECHNOLOGIES
Region: 4
City: PINEDALE State: WY
County:
License #: TEXAS #G02344
Agreement: N
Docket:
NRC Notified By: ROB O'DONEL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/01/2010
Notification Time: 16:28 [ET]
Event Date: 04/26/2010
Event Time: [MDT]
Last Update Date: 05/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JEFF CLARK (R4DO)
JAMES DANNA (FSME)

Event Text

GAUGE SHUTTERS STUCK OPEN

On April 26, 2010, while the licensee, Particle Drilling Technologies out of Houston, Texas was performing a scheduled shutter operation check, the shutter on a Ronan Model SA1 nuclear gauge failed to close. They were at a remote drilling site in the Pinedale, Wyoming when this occurred and was using the gauge as generally licensed material under its Texas license. The gauge contains 20 millicuries of Cesium (Cs) 137 (S/N #6198CN). The gauge is in its normal operating position and a radiation survey conducted by the licensee indicated that radiation levels are normal. The gauge was leak tested and the test sent for analysis. The licensee stated that there is no risk of additional exposure to their workers. The licensee is working with the manufacturer to schedule the repair of the gauge on May 18, 2010. The licensee reported this incident to the NRC Operations Center on April 27, 2010, and it was logged until it could be determined whether this incident should be reported to the State of Texas or the NRC. It was determined that since the event occurred in Wyoming, it is an NRC report.

On May 1, 2010, the licensee was performing shutter checks when they discovered two more shutters were stuck in the open position. These are also Ronan Model SA1 gauges that contain 20 mCi Cs-137 sources. Their serial numbers are 6115CN and 5808CN. The vendor is still scheduled for onsite repairs on May 18.

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Power Reactor Event Number: 45893
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD KRESS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/02/2010
Notification Time: 15:27 [ET]
Event Date: 05/02/2010
Event Time: 08:58 [EDT]
Last Update Date: 05/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID HILLS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 49 Power Operation

Event Text

MANUAL ACTUATION OF AUXILIARY FEEDWATER SYSTEM IN RESPONSE TO LOSS OF ONE MAIN FEEDWATER PUMP

"At 0858 [EDT] on Sunday, May 2, 2010, operators manually started all Auxiliary Feedwater (AFW) pumps in response to a loss of the East Main Feedwater Pump (EMFP).

"Operators were responding to high bearing temperatures on the EMFP, and had entered the Rapid Power Reduction Procedure, when they received EMFP Hi and Hi-Hi vibration alarms and reports of oil leaking from the EMFP. Operators entered the procedure for Loss of One Main Feed Pump, which directs starting the AFW pumps, and removed the EMFP from service. The plant was stabilized at approximately 49% power.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(iv)(A) due to the valid actuation of the AFW system in response to equipment failure."

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