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Event Notification Report for October 4, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/01/2010 - 10/04/2010

** EVENT NUMBERS **


46286 46291 46298 46299 46301 46302 46303 46304 46305

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General Information or Other Event Number: 46286
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: OH02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/28/2010
Notification Time: 15:01 [ET]
Event Date: 09/27/2010
Event Time: [EDT]
Last Update Date: 09/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
KEVIN HSUEH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - 95% MEDICAL UNDERDOSAGE DUE TO EQUIPMENT FAILURE

The following report was received from the State of Ohio via email:

"On September 27, 2010, the Gamma Knife gave a Fatal Error and terminated treatment to a patient. The error appears to be a failed computer disc drive. The safety system of the Gamma Knife functioned as designed, moving the patient out of the treatment machine and closing the Gamma Knife doors. The patient was safely removed from the treatment room. A service representative was immediately contacted and repair of the Gamma Knife is in progress.

"It is intended to give the remaining dose from the plan to the patient once the Gamma Knife is repaired."

The device in question is a Leksell, Model Perfexion Gamma Knife unit [S/N MV010], which contains a 13,824 Ci Co-60 source. The intended dose was 1400 rad. The delivered dose was 71.5 rad. The target organ was the brain. There is no effect on the patient.

Ohio report #: OH100021.

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: 46291
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSIAL WELL SERVICES, INC
Region: 1
City: MEADVILLE State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/29/2010
Notification Time: 21:15 [ET]
Event Date: 09/29/2010
Event Time: 07:50 [EDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE HOUSING ON DENSITOMETER DETACHED FROM EQUIPMENT

The following information was sent from the commonwealth via fax:

"Excessive equipment vibration while the licensee was working at a job site caused the source housing of the Berthold LB8010 densitometer (Ser. No. 10049) to dislodge itself from the base plate, and detach from the equipment it was mounted to. The source housing was not damaged, the shutter is fully functional, and current survey readings similarly match past surveys; approximately 200 microroentgen per hour (uR/h) being the highest reading at 1 meter, with the shutter was closed and beam pointed toward the ground. The SS&D sheet on this densitometer notes a [maximum] 50 milliCuries (mCi) of Cs-137 source. Exact current activity on this unit to be determined.

"CAUSE OF THE EVENT: Excessive vibration during use, and [perhaps] a design problem with how the source housing is bolted to a mounting plate.

"ACTIONS: To prevent this from happening in the future, the clamps will be switched out on all the licensee's inline densitometers. In the meantime, the device is being sent back to Berthold to be remounted using a new version clamp. They will try to send whatever they can of the old clamp that failed to Berthold so it can be inspected.

"PaDEP/BRP [state] will be performing an inspection of the device and equipment, as well as interviewing those involved with the source housing recovery for additional details.

"The licensee will also be providing a full report with their findings and corrective actions."

PA Event Report No: PA100023

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Power Reactor Event Number: 46298
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/01/2010
Notification Time: 01:35 [ET]
Event Date: 09/30/2010
Event Time: 19:04 [CDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
THOMAS FARNHOLTZ (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

STANDBY DIESEL GENERATOR AUTOSTART DUE TO LOSS OF A SWITCHYARD BUS DURING MAINTENANCE

"At 1904 [CDT] on 9/30/2010, the South Texas Project (STP) North switchyard bus was lost due to a Transmission & Distribution Service Provider (TDSP) human performance error that occurred while performing maintenance on breaker Y-0530. This resulted in a loss of power to Standby transformer 1 which was supplying power to the Unit 1 B Train Engineered Safety Features (ESF) 4160v bus. The B Train Standby Diesel Generator automatically started due to the Loss of Offsite Power (LOOP) on its associated bus. The Mode II (LOOP) ESF loads sequenced onto the bus. All safety related equipment responded as expected. Action (e) of Technical Specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was momentarily entered due to the loss of two independent offsite circuits while the North bus was de-energized. The North bus was de-energized for approximately 5 minutes. Action (a) of Technical specification (TS) 3.8.1.1, 'AC Electrical Power Sources', was entered due to the loss of one independent offsite circuit. All Technical Specification Limiting Condition of operation have been exited at this time.

"An 8-hour notification is required for this event due to the valid actuation of safety related equipment as described in 10CFR50.72 (b) (3) (iv) (A). [A notification is required for] any event or condition that results in valid actuation of any of the systems listed in paragraph (b) (3) (iv) (B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.

"The NRC Resident Inspector has been notified."

Unit 2 briefly entered a Technical Specification Limiting Condition of Operation, while all electrical buses remained energized.

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Power Reactor Event Number: 46299
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: ROSS MOONITZ
HQ OPS Officer: ERIC SIMPSON
Notification Date: 10/01/2010
Notification Time: 07:23 [ET]
Event Date: 10/01/2010
Event Time: 03:40 [EDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO A TURBINE BUILDING EVACUATION

"At 0340 EDT on Friday, October 1, 2010, the turbine building was evacuated as a precaution while station employees investigated the presence of a chemical odor. The source of the odor was identified as paint fumes from planned outage activities and air samples confirmed that no safety hazard existed. Workers were returned to the building approximately 45 minutes later. An Event of Potential Public Interest was issued to outside agencies."

State and local agencies were notified.

The NRC Resident Inspector has been notified.

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Hospital Event Number: 46301
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: AMARILLO State: TX
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: ERIC SIMPSON
Notification Date: 10/01/2010
Notification Time: 13:05 [ET]
Event Date: 10/01/2010
Event Time: 08:11 [CDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
STEVE ORTH (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

NON-FIXED RAD SURFACE CONTAMINATION GREATER THAN LIMITS

"[This report is being made] to report receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than reporting limits.

"The package was received today, October 1, 2010, at around 0811 CDT by the Amarillo Veterans Administration (VA) Health Care System, Amarillo, Texas.

"A wipe test performed on the external surface of the package indicated a removable contamination level of 1300 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2.

"The package was immediately bagged and secured within the VA nuclear medicine department where it will be stored for decay. Wipes were taken throughout the department with all readings being at background levels.

"The package contained 80 milliCuries of Tc-99m-labeled radiopharmaceuticals and was shipped from Panhandle Pharmacy, Amarillo, Texas. The vendor/shipper also serves as the delivery carrier. The VA nuclear medicine staff immediately notified the carrier before he left the nuclear medicine department and also contacted staff at Panhandle Pharmacy about the contaminated package at around 0825 CDT.

"We will notify our NRC Project Manager at NRC Region III of this event."

The VA facility RSO indicated that the VA staff offered to survey the carrier, but he declined.

The external exposure rate readings on the package were within limits: 0.4 mR/hr on contact.

The receiving facility was scanned for contamination. The results came back as reading background.

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Power Reactor Event Number: 46302
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: JEFF ERICKSON
HQ OPS Officer: ERIC SIMPSON
Notification Date: 10/01/2010
Notification Time: 15:31 [ET]
Event Date: 10/01/2010
Event Time: 13:25 [EDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
STEVE ORTH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 92 Power Operation 92 Power Operation

Event Text

UNANALYZED CONDITION - APPENDIX R NON-COMPLIANCE ISSUE IDENTIFIED

"At 1325 EDT on October 1, 2010, an Appendix R non-compliance issue was identified associated with a potential loss of safety related 2400 VAC Bus 1C and 1D due to specifically sequenced fires affecting control cables and power cables routed in common fire areas but different raceways. An extent of condition corrective action identified that three 2400 VAC breakers 152-103 (Bus 1 C Service Water Pump P-7B), 152-205 (Bus 1D Service Water Pump P-7C), and 152-208 (Bus 1D Component Cooling Water Pump P-52B) all have control cables routed in the same fire areas as the associated power cables.

"There are three fire areas, the 1C switchgear room 116A (Fire Area 4), screen house room 136 (Fire Area 9), and component cooling water room 123 (Fire Area16) that contain both control cables and power cables for the associated breakers. The concern is that a fire could first damage the control cable(s), resulting in the opening of the control power fuses which would disable the control power and render the breaker protection circuitry nonfunctional. The 2400 VAC breakers fail-as-is on loss of control power. As such if the breakers were closed they would remain closed until manually opened. If the same fire then damaged the power cable(s) on the same breaker, the loss of the breaker protection circuitry would prevent the individual breaker from automatically opening and the clearing of the cable fault would propagate upstream to the next coordinated breaker which would result in the associated 2400 VAC bus feeder breaker opening and a loss of the entire bus.

"Breaker 152-103 has the issue of both control and power cables present in the screen house room 136 (Fire Area 9) which has potential to result in the loss of the 1C bus for a fire in the screen house. The Appendix R safe shutdown analysis credits both 1C and 1D busses remaining available for a fire in Fire Area 9 and credits 1D bus remaining available for a fire in Fire Area 4.

"Breaker 152-205 has the issue of both control and power cables present in the screen house room 136 (Fire Area 9) and in the 1C Switchgear room 116A (Fire Area 4) which has potential to result in the loss of 1C and 1D busses for a fire in the screen house or the 1C switchgear room. The Appendix R safe shutdown analysis credits both 1C and 1D busses remaining available for a fire in Fire Area 9 and credits 1D bus remaining available for a fire in Fire Area 4.

"Breaker 152-208 has the issue of both control and power cables present in the component cooling water room 123 (Fire Area 16) which has the potential to result in the loss of 1D bus for a fire in the component cooling water room. The Appendix R safe shutdown analysis credits both 1C and 1D busses remaining available for a fire in Fire Area 16.

"The 1C and 1D busses are relied on to provide power to safety related equipment. The busses are normally supplied by offsite power. In the event that offsite power is lost, power is supplied to the busses by the emergency diesel generators. Existing hourly fire tours of the 1C switchgear room, the screen house room, and the component cooling water room are credited as initial compensatory measures.

"As a compensatory measure, existing hourly fire tours of the 1C switchgear room, the screen house room, and the component cooling water room are credited.

"This is considered to be an unanalyzed condition that significantly degrades plant safety."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46303
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MICHAEL COEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/01/2010
Notification Time: 17:56 [ET]
Event Date: 10/01/2010
Event Time: 09:51 [EDT]
Last Update Date: 10/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK LESSER (R2DO)

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

Event Text

HIGH HEAD SAFETY INJECTION REDUCED CAPABILITY

"This is an eight-hour non-emergency notification to the NRCOC for a condition that could have prevented the fulfillment of safety function of a system required to mitigate the consequences of an accident in accordance with 10 CFR 50.72(b)(3)(v)(D).

"Unit 4 High Head Safety Injection (SI) system was at reduced capability from approximately 0951[hrs. EDT] to 1027 [hrs.]. This was due to an open flowpath from the High Head Safely Injection Pump discharge to the Unit 3 Reactor Coolant System (RCS) and refueling cavity. This flow path was established during the execution of an Equipment Clearance Order for Unit 3 SI system when SI valves MOV-3-843A and MOV-3-843B were opened prior to closing SI lsolation Valve 3-867. This condition could have impacted the ability of the SI pumps to provide required flow to the RCS cold legs should the SI system have been required based on Engineering judgment. This condition was discovered at approximately 1005 [hrs.].

"Unit 3 is in Mode 6 for a planned refueling outage. Unit 4 is in Mode 1 at 100%"

Unit 3 and Unit 4 share a common High Head SI System discharge header. Unit 4 entered T.S. 3.0.3 from 0951[hrs.] to 1027 [hrs.] when SI Isolation Valve 3-867 was closed. The licensee has notified NRC Resident Inspector.

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Power Reactor Event Number: 46304
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVE GIBSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/02/2010
Notification Time: 15:38 [ET]
Event Date: 10/02/2010
Event Time: 10:11 [EDT]
Last Update Date: 10/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

RESIDUAL HEAT REMOVAL SYSTEM PIPING LEAK

"Approximately five hours after Beaver Valley Power Station Unit No. 1 was shutdown at 0011 hours [EDT] to enter a scheduled refueling outage, an approximate 5 drops per minute leak was identified from a drain valve on the Residual Heat Removal (RHR) System inside containment. This leak is downstream of the two series RHR isolation valves on a pipe which connects to both trains of RHR. The actual location of the leak on the valve was not immediately evident. An evaluation was requested. At 1011 hours, the evaluation reported a 270 degree circumferential crack in the socket weld on the RHR side of the valve. Without reasonable assurance of RHR System operability, both trains of RHR were declared inoperable. Both trains of the RHR System are currently in service, along with three steam generators/condenser remaining available for decay heat removal. Actions to address this condition are being pursued.

"This is being reported as a condition that at the time of discovery could have prevented the fulfillment of the safety function of systems needed to remove decay heat pursuant to 10 CFR 50.72(b)(3)(v)(B) since both trains of RHR were declared inoperable.

"Beaver Valley Power Station Unit No. 2 is unaffected by this event and remains at 100 percent power.

"The NRC Resident Inspector has been notified."

T.S. Action 3.4.7 requires that efforts be immediately initiated to restore RHR as soon as possible.

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Fuel Cycle Facility Event Number: 46305
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT P. MURRAY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/03/2010
Notification Time: 12:58 [ET]
Event Date: 10/02/2010
Event Time: 13:30 [EDT]
Last Update Date: 10/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
MARK LESSER (R2DO)
JAMES RUBENSTONE (NMSS)

Event Text

UNANALYZED CONDITION WHEN FUEL PELLET BOATS BECAME STACKED

"At approximately 1330 hours on October 2, 2010 it was discovered that boats of fuel pellets had become stacked in a UO2 sintering furnace located in the GNF-A Fuel Manufacturing Operation. The furnace had been shutdown due to an apparent boat jam, which was detected by an overload sensor on the equipment that pushes boats into the furnace. This sensor is designated as an IROFS [Item Relied On For Safety] in the ISA [Integrated Safety Analysis] Summary. The stacked boat condition was discovered after process engineering removed two boats of fuel from the entrance of the furnace as part of the boat jam investigation. With these boats removed the stacked boats could be clearly seen and proper notifications were made to management.

"The sintering furnace process has independent controls on geometry, which limit the process to a single layer of boats, and moderation, which prevent water and other forms of moderator from entering the process. In this event, the geometry control was compromised however the moderation control remained intact. The stacked boat condition has been analyzed as a process upset condition and is demonstrated safe in a documented safety analysis.

"The IROFS that were intended to detect a misalignment of boats functioned properly during the event as the misalignment was detected. The IROFS mitigated the severity of the boat jam and the furnace operation was shutdown due to the misalignment. This event did not result in an unsafe condition, however the declared IROFS did not prevent the loss of geometry and resulted in a failure to meet performance requirements.

"As a result, this event is being reported pursuant to 10CFR70 Appendix A (b)(1).

"SAFETY SIGNIFICANCE OF THE EVENT - Low Safety Significance - No unsafe conditions existed due to this event.

"SAFETY EQUIPMENT STATUS - Safety equipment associated with the sintering furnace operation is functional.

"STATUS OF CORRECTIVE ACTIONS - The sintering furnace operation remains shutdown pending investigation and implementation of corrective actions."

System design is such that boats cannot overturn and no spillage of fuel pellets has occurred. The furnace will have to cooldown before repairs can be completed. Applicable State and Local agencies will be notified by the facility. Marvin Sykes of NRC Region 2 has been notified by the facility.

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