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Event Notification Report for June 25, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/24/2010 - 06/25/2010

** EVENT NUMBERS **


46026 46031 46042 46043 46044 46045

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General Information or Other Event Number: 46026
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MOHAMED MEGAHY, M.D., Ltd
Region: 3
City: MARYVILLE State: IL
County:
License #: IL-02032-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 14:23 [ET]
Event Date: 05/01/2010
Event Time: [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL DOSE TO EMBRYO OR FETUS

The State of Illinois provided the following information via email:

"On June 17, 2009, the [Illinois Emergency Management] Agency was contacted with a request to make a dose estimate to a fetus as a result of administration of radioiodine to a patient who was later found to be pregnant. Subsequently when additional information was requested to determine the appropriate parameters, the [Illinois Emergency Management] Agency was advised that the administration had occurred 3 years earlier and that the child had been delivered after a full term pregnancy and was receiving thyroid hormone therapy. The physician indicated that on May 1, 2007 a patient was given 102.9 milliCi of I-131 as a treatment for recurrence of cancer associated with a previous thyroidectomy conducted in 2006. The physician had previously treated the patient with I-131 in 2006 following surgery and had conducted patient interviews/training regarding administration of I-131 at that time, so that when she represented herself for an additional treatment dose, he had been lead to believe she understood the contraindications. The doctor stated that he was told no when he asked if she was pregnant. No independent test was conducted. On June 11, 2007, he was contacted by the physician's obstetrician who advised that she was at 32 weeks gestation as of June 11, 2007. This would infer she was 25-27 weeks (6 month) pregnant at the time of the second administration a month earlier.

"Calculations were performed by the [Illinois Emergency Management] Agency for a thyroid patient following ANSI Std. N13.54-2008 which lead to an estimated dose to the fetus of 86 Rad. This event remains open pending submission of the required report from the physician and follow up by the [Illinois Emergency Management] Agency."

IL Event No.: IL 10044

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General Information or Other Event Number: 46031
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SUTTER HEALTH MEDICAL PHYSICS CENTER
Region: 4
City: SACRAMENTO State: CA
County:
License #: 2964
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 19:38 [ET]
Event Date: 06/17/2010
Event Time: [PDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE FROM GAMMA KNIFE TREATMENT

"A patient undergoing Gamma Knife treatment received less than the prescribed dose in the eighth of eight planned treatments. The undertreatment exceeded 50% of the planned treatment dose for the final fractional treatment (only approximately 12 rads of the prescribed approximately 162 rads for the final fractional dose was administered).

"The final treatment was terminated approximately 15 seconds into the planned 3.5 minute treatment due to apparent pain on the part of the patient. Upon investigation, it was determined that the head immobilizing bracket was not fully secured. Only approximately 12 rads dose had been administered in the approximately 15 seconds before the treatment was terminated. The planned total treatment dose was 1300 rads. Approximately 1150 rads were administered in the eight treatments.

"The licensee reported they likely will not give the patient the remaining 150 rads of the planned treatment."

CA Event No.: 061810

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: 46042
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/23/2010
Notification Time: 23:57 [ET]
Event Date: 06/23/2010
Event Time: 20:51 [EDT]
Last Update Date: 06/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM FOLLOWING LOSS OF BOTH RECIRCULATION PUMPS

"Limerick Unit 1 was manually scrammed from 100% power on 6/23/10 at 2051 hours in accordance with plant procedure OT-112 'Recirculation Pump Trip' when both 1A and 1B recirc pump MG set drive motor breakers were observed to have tripped, resulting in a loss of both reactor recirculation pumps. Preliminary indication is a loss of power to 114A Load Center, caused by 'A' phase overcurrent trip of 13.2 KV feeder breaker (11-BUS-07) to the 114A Transformer and Load Center. The cause of the MG set drive motor breaker trips is under investigation at this time.

"All Control Rods inserted as required.

"No ECCS or RCIC initiations occurred.

"No Primary or Secondary Containment Isolations were received.

"The plant is currently in Hot Shutdown maintaining normal reactor level with feedwater in service."

All systems functioned as required during the transient. The manual scram was characterized as uncomplicated. No PORVs or Safety Relief valves lifted during the transient. Decay heat is being discharged to the condenser via turbine bypass valves. The unit is in a normal shutdown electrical lineup and there was no impact on Unit 2.

The electrical supplies for the recirc pump MG sets has been walked down by the licensee and no indication of any damage or electrical faults has been found at this time.

The NRC Resident Inspector has been notified and the licensee indicated a media or press release will be made.

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General Information or Other Event Number: 46043
Rep Org: EXELON NUCLEAR CORPORATE
Licensee: EXELON NUCLEAR CORPORATE
Region: 3
City: CHICAGO State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PATRICK SIMPSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/24/2010
Notification Time: 11:32 [ET]
Event Date: 06/24/2010
Event Time: 09:55 [CDT]
Last Update Date: 06/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JULIO LARA (R3DO)

Event Text

EXELON DRUG TESTING CONTRACTOR TESTED POSITIVE DURING RANDOM FITNESS-FOR-DUTY TEST

A contractor used by Exelon Corporate for drug testing at six Exelon nuclear sites tested positive for an illegal substance during a random fitness-for-duty test. The individual has been denied unescorted access to Exelon facilities. Contact HOO for details.

The licensee will notify the NRC Resident Inspectors at each site.

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Power Reactor Event Number: 46044
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF GROFF
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/24/2010
Notification Time: 12:35 [ET]
Event Date: 06/24/2010
Event Time: 09:36 [EDT]
Last Update Date: 06/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JULIO LARA (R3DO)

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

FITNESS FOR DUTY - SUPERVISOR TESTED POSITIVE DURING RANDOM DRUG/ALCOHOL TEST

A non-licensed employee supervisor had a confirmed positive for alcohol during a random drug/alcohol test. Unescorted access has been suspended. Contact the HOO for further details.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46045
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: CURTIS CASTELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/24/2010
Notification Time: 21:34 [ET]
Event Date: 06/24/2010
Event Time: 14:34 [EDT]
Last Update Date: 06/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

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

Event Text

INSTRUMENT BUSES 3 AND 8 FAILED CAUSING CLOSURE OF RHR VALVES

"At 14:34 hours on June 24, 2010, with the unit in MODE 5, Cold Shutdown, with approximately 50% pressurizer level, during Refueling Outage 26, Instrument Buses 3 and 8 unexpectedly de-energized during performance of testing in accordance with procedure OST-163, 'Safety Injection Test and Emergency Diesel Generator Auto Start on Loss of Power and Safety Injection.' The loss of Instrument Buses 3 and 8 occurred during the loss of power and Safety Injection testing of the 'A' Train.

"Instrument Buses 3 and 8 are normally powered from Inverter 'B' which is normally supplied by the Train 'B' DC Bus. During the test, it was noted that the power supply to Instrument Buses 3 and 8 had tripped. The cause of the failure of Inverter 'B' is not currently known. The failure of Inverter 'B' caused the closure of the Residual Heat Removal (RHR) Heat Exchanger discharge valve (HCV-758) and the RHR Heat Exchanger bypass valve (FCV-605).

"Both trains of RHR continued to operate and reactor coolant system temperature remained in the range of approximately 93 to 96 degrees Fahrenheit. Abnormal Operating Procedure AOP-020, 'Loss of Residual Heat Removal (Shutdown Cooling)' was entered. Power was restored to Instrument Buses 3 and 8 by use of the alternate power supply at 14:49 hours. Normal configuration of the RHR system was restored and AOP-020 was exited at 14:51 hours.

"Currently Instrument Buses 3 and 8 are being powered from the alternate power supply which causes the associated 'B' EDG to be inoperable due to the inoperability of the automatic load sequencer that starts the associated Service Water and Component Cooling Water pumps. The 'A' EDG is inoperable due to the need to complete required post-maintenance testing. Therefore, both EDGs are currently inoperable.

"Both EDGs are currently considered available and are aligned for automatic starting. Both EDGs would be expected to automatically supply their respective buses if a loss of offsite power were to occur. Manual action would be required to start the required loads on the 'B' Train due to the current alignment of the Instrument Buses 3 and 8 on the alternate power supply.

"It is expected that the 'B' EDG will be restored to operable status when Inverter 'B' is restored to operable status and realigned to supply Instrument Buses 3 and 8.

"The Technical Specifications (TS) Action Statement currently in effect for loss of Inverter 'B' (TS 3.8.8 Condition A) requires initiation of action to restore AC instrument bus sources to OPERABLE status immediately. The actions to restore Inverter 'B' were initiated immediately and are continuing.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), for any event or condition that at the time of discovery could have prevented the fulfillment of structures or systems that are needed to mitigate the consequences of an accident."

The licensee has notified the NRC Resident Inspector.

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