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Event Notification Report for November 10, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/09/2010 - 11/10/2010

** EVENT NUMBERS **


46214 46286 46321 46332 46386 46389 46393 46407 46409 46410

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General Information or Other Event Number: 46214
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: BBC&M ENGINEERING, INC.
Region: 3
City: LIMA State: OH
County:
License #: OH31210250006
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Notification Date: 08/30/2010
Notification Time: 13:24 [ET]
Event Date: 08/26/2010
Event Time: [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following was received from the State of Ohio via e-mail:

"Ohio Department of Health (ODH) was informed on 8/27/10 of an incident involving a portable moisture density gauge. The incident occurred on 8/26/10 at a work site in Lima, Ohio. The incident occurred due to operator error on behalf of a BBC&M Engineering, Inc. (BBCM) employee - the employee backed over the gauge with a BBCM truck. BBCM staff followed established company emergency procedures - the area was cordoned off, all other site personnel were kept more than 20 feet away from area, and a BBCM employee stayed in the area until further notice.

"BBCM obtained a Radiation Alert Monitor and a lead 'pig' from CTS, Inc. and used the monitor at the project site in the area of the damaged gauge, truck, and original testing location of the gauge. The reading near the gauge (at 1 meter) was 2.0 mrem/hr. All other readings taken at the sire measured only background level readings. The gauge was damaged but the radiation sources were not comprised and/or leaking. As the source rod would not retract into the gauge, BBC&M installed a lead cap ('pig') over the rod tip/source end. The gauge was then transported to BBCM's Dublin, Ohio office to be stored until it can be transported to CTS, Inc. for further inspection."

The gauge contains 0.010 Ci Cs-137 and 0.050 Ci Am/Be sources.

Ohio incident #2010-051.


* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

"On 11/9/10 ODH inspected licensee and issued Notice of Violation for incident. Licensee has provided additional training for employees. Device was returned to manufacturer for repair."

Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: 0.010 Ci 0.37 GBq

Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Radionuclide or Voltage (kVp/MeV): AM-BE
Activity: 0.050 Ci 18.5 GBq

Device Number: 1
Device Name: PORTABLE GAUGE
Manufacturer: TROXLER
Model Number: 3430
Serial Number: 25983

Ohio Item Number: OH100011

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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: 11/09/2010
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.


* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

"On 11/9/10 the problem was diagnosed as faulty computer on unit. Computer was replaced and fully tested on 9/28/10. Patient remained in hospital overnight on 9/27/10 and received remainder of treatment on 9/28/10. No adverse effects anticipated due to delay in completing treatment. Licensee has contacted the manufacturer to review this incident for applicability to other units."

Ohio Item Number 100021

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: 46321
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL H. WILLIAMS, JR.
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/08/2010
Notification Time: 13:54 [ET]
Event Date: 10/08/2010
Event Time: 11:00 [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

INTEGRATED PLANT COMPUTER REMOVED FROM SERVICE FOR UPGRADE WORK

"At 1100, October 8, 2010, Unit 1 Integrated Plant Computer (IPC) was shutdown for upgrade work. This includes the SPDS [Safety Parameter Display System] system which is a function of the IPC. The IPC will be returned to service in approximately two weeks and SPDS function will be restored at that time. In addition, the ERDS [Emergency Response Data System] is out of service and will be restored in the same time frame. Per the 50.54.Q that was prepared by our Emergency Preparedness group, notification has been made to the NRC ERDS group of the unavailability of the ERDS system. While the IPC is out of service, control board indications are being utilized by the control room crew. In addition, the safety-related Plant Safety Monitoring System (PSMS) is OPERABLE. Restoration of SPDS and ERDS functions have been given the highest priority during restoration of the system. Both the NRC Ops Center and the NRC ERDS group will be notified when SPDS and ERDS capability have been restored."

The NRC Resident Inspector has been notified.

* * * UPDATE ON 11/9/2010 AT 1555 EST FROM CECIL WILLIAMS TO MARK ABRAMOVITZ * * *

"On Oct 8, 2010, EN# 46321 was made for notification that the Unit 1 Integrated Plant Computer (IPC) was shutdown for upgrade and that the SPDS function was out of service until the upgrade was completed. The IPC has been returned to service sufficiently to support SPDS Functionality. All data points have been verified and associated Control Room annunciator tested. Therefore, at this time SPDS is considered returned to service. The ERDS function has previously been tested with the NRC ERDS Group and returned to service."

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Blamey).

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General Information or Other Event Number: 46332
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: LEE TESTING & ENGINEERING, INC
Region: 3
City: HILLIARD State: OH
County:
License #: OH31210250011
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/14/2010
Notification Time: 13:43 [ET]
Event Date: 08/30/2010
Event Time: [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - ABANDONED MOISTURE DENSITY GAUGES

The following information was obtained from the State of Ohio via email:

"On August 11, 2010, the licensee submitted a request to [the State of Ohio to] terminate their portable gauge license. On September 9, 2010, the Ohio Department of Health (ODH) was notified by a third party that Lee Testing had vacated the premises at 3530 Parkway Lane and had left behind a total of seven (7) devices containing radioactive materials. Upon contacting the building owner, it was determined that the licensee had moved out of the building sometime during the prior week, and that the keys to the building and its contents were relinquished to the building owner.

"On September 13, 2010, representatives from ODH and a licensed service provider visited the 3530 Parkway Lane location and removed the seven devices present at that location. This removal was determined to be necessary as authorized under rule 3701:1-38-06(E) of the Ohio Administrative Code (OAC). The seven devices are currently in a safe and secure storage location pending a decision on final disposition.

"ODH is conducting an ongoing investigation.

"The NRC Registry of Radioactive Sealed Sources and Devices indicates that [three Troxler Model] 3411-B gauges contain a Cs-137 source with a maximum activity of 0.33 GBq (9 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi). The Registry indicates that [Troxler Model] 3241-C gauge contains an Am-Be source with a maximum activity of 11.1 GBq (300 mCi). The Registry also indicates that the [three Humboldt Scientific Model] 5001 gauges contain a Cs-137 source with a maximum activity of 0.41 GBq (11 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi)."

Ohio Report Number: OH100494

* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

The state of Ohio provided serial numbers for the following sources:

Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 47-2403
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 10
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 508801
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 11
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00192
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 12
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 5843GF
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 13
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00663
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 14
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 1195GH
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 00009159
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 3
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 475790
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 4
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 406594
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 5
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 477088
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 6
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 409291
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 7
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 8
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: Ci GBq

Source Number: 9
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: XX00166
Radionuclide or Voltage (kVp/MeV): AM-241

Ohio Item Number: OH100020

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General Information Event Number: 46386
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WARREN GENERAL HOSPITAL
Region: 1
City: WARREN State: PA
County:
License #: PA-0083
Agreement: Y
Docket:
NRC Notified By: JOE MALNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/03/2010
Notification Time: 09:43 [ET]
Event Date: 11/02/2010
Event Time: [EDT]
Last Update Date: 12/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT DUE TO A DOSAGE DIFFERING FROM THE PRESCRIBED DOSE

The following information was received via fax from the Commonwealth of Pennsylvania:

"Notifications: On November 2, 2010 PaDEP [Pennsylvania Department of Environmental Protection] Central Office was notified by the licensee of a medical event involving a dosage that differs from the prescribed dose by 20% as required under 10 CFR 35.3045. This event also meets the criteria for Abnormal Occurrence reporting.

"Event Description: On November 2, 2010 a patient was undergoing brachytherapy treatment for prostate cancer. A partial seed implant of 85 Gy was prescribed, however, the full treatment of 144 Gy was implanted. This event was discovered upon completion of the procedure.

"Cause of the Event: Human Error

"Actions: The Department is awaiting more event details at this time and plans to send regional staff to conduct a follow-up inspection. Final event details will be communicated in an NMED and Abnormal Occurrence report."

PA Report ID No.: PA100025

* * * UPDATE FROM DAVID ALLARD TO JOE O'HARA VIA FAX AT 1741 ON 12/28/10 * * *

"NOTIFICATIONS: The licensee called the PaDEP Bureau of Radiation Protection on the afternoon of November 2, 2010 to provide a 24-hour verbal notice of a Medical Event. The event involved a patient dosage that differed from the intended [written directive] dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(1)(i). Subsequently, the licensee provided a written report to PaDEP on November 5th.

"EVENT DESCRIPTION: On November 2, 2010 a patient was undergoing brachytherapy Cesium-131 seed implant treatment for prostate cancer. A partial seed implant of 85 gray (Gy) was directed, with a 45 Gy follow-up external [IMRT] beam therapy. However, the full seed treatment of 114 Gy was implanted. The event was discovered upon completion of the implants.

"CAUSE OF THE EVENT: Human error was the cause of the event. Specifically, the incorrect prescribed prostate dose was entered into the licensee's VariSeed planning system (i.e.114 Gy vs. 85 Gy), and an incorrect seed order was placed with the vendor. The error persisted because the licensee's staff did not directly compare the written directive to the printed treatment plan. Such a comparison would have alerted the staff to the error.

"ACTIONS: The PaDEP performed a reactive inspection at the hospital on 11/4/2010. Warren General also initiated the following changes: Their current Operating Room (OR) "time-out" procedure will be altered to include the expected prescription dose. A copy of the original written directive will be utilized in the OR for reference before and during the implant. Forms will be amended to have the physician's written directive and the planned dose on the same form for easy review and comparison. Lastly, the weekly physics chart review that involves a check of the written directive has been altered such that a summary sheet that is normally used for external beam patients will now also be used for seed implant patients. This event will be also communicated to NRC via NMED. However, there was an initial miscommunication between the licensee and PaDEP. The full treatment of 114 Gy was used, not 144 Gy. Thus, there will not be an Abnormal Occurrence report from PaDEP to NRC."

Notified R1DO(Hansell) and FSME EO(Watson)

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: 46389
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/03/2010
Notification Time: 13:43 [ET]
Event Date: 10/22/2010
Event Time: 14:45 [EDT]
Last Update Date: 11/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - DOSE ADMINISTERED IN WRONG LOCATION

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

"The patient has persistent small cell lung cancer after chemotherapy, in an area that has received prior external beam radiation therapy, and was symptomatic. Therefore, a course of endobronchial brachytherapy with a high-dose rate unit (HDR) was recommended to the left upper and left lower lobe bronchus where the tumor was present. The treatment prescription was 10 Gy x 2 fractions to the target volume as defined in the planning CT. The first treatment was delivered between 2 to 3 pm, on Oct 22, 2010. Unfortunately, due to errors in defining the starting dwelling positions of the source during the treatment planning, the actual dose was delivered to the wrong location along the catheters. Details of the process are described below.

"After two endobronchial catheters were placed under bronchoscopy in the OR [operating room], the patient was transferred to Radiation Oncology Department where a CT was obtained for treatment planning purposes. The two catheters were positioned correctly based on CT.

"In the first step of the treatment planning, the locations of the two endobronchial catheters were correctly identified in the CT images. The direction of the catheters was mistakenly reversed afterwards during the treatment planning, thereby changing the starting position of the HDR source. Therefore, instead of the patient being treated correctly to the identified tumor region in the left-sided airways, she was treated to a position more proximally along the path of the catheters (the larynx area). Although the plan was checked by a number of qualified physicists per operational protocol, the subtle orientation error was missed, both in the plan check and in the delivery check. The wrong treatment was delivered around 2:45 pm.

"The error was identified by the planning physicists when they were working on another patient case, about one hour after the patient's treatment. A computerized 3-D plan was generated to calculate the actual location and dose delivered due to this error. The estimated dose to the neck region was about 15-20 Gy. The plan delivered to the patient was also delivered on radiochromic film to confirm the location of the delivered dose.

"The attending physician, clinical director, and the director of physics were all notified immediately after the error was identified and confirmed. The Radiation Oncology Department chair was notified by the clinical director. The Radiation Safety Officer was notified also by the chief physicist.

"The attending physician reviewed the case and the dosimetry, and immediately tried to contact the patient. After several attempts the patient was reached around 6:00 PM and asked to come back to the hospital immediately for observation and prophylactic treatments. The patient was admitted to hospital around 9:00 PM on the same day (the time required for her to travel back to Duke from her home).

"Licensee's evaluation of why the event occurred:
a. Staff physicists were more focused on dose optimization and missed the catheter's orientation.
B The wrong orientation was again missed during the plan and delivery checks.
C. In addition to calculation checks, there was no experimental check, i.e. delivering dose to the film to verify the distance.

"The effect, if any, on the individual(s) who received the administration: The patient was admitted to Duke Hospital immediately after the error was discovered. She remained hospitalized for 4 days during which time she remained relatively asymptomatic. She did not develop increasing hoarseness, shortness of breath, or odynophagia. She underwent fiber optic laryngoscopy 36 hours after her treatment which showed minor edema of the supraglottic larynx but no airway compromise. She received the correct treatment while an inpatient, and after one additional day of observation was discharged home.

"What actions, if any, have been taken or are planned to prevent recurrence:
a. Conducted a root-cause analysis of the event among the physicists.
B. A new and more detailed standard operational procedure (SOP) for this type of treatment was generated by the members of the Brachytherapy team.
C. The existent HDR Patient QA form was edited to add extra check levels that will prevent this error from happening again.
D. A new verification procedure was added to the existent set of verification procedures. It involves the delivery of the treatment on Gafchromic film or alternative imaging device to verify the exact starting point of the treatment. This film will be compared with the plan and will have to be approved by two physicists and the attending for each case.

"Certification that the licensee notified the individual (or the individual's responsible relative or guardian) and if not, why not:
The patient was contacted, was returned to Duke and was admitted for evaluation and management."


Log # NC 10-47

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: 46393
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA BERKELEY
Region: 4
City: BERKELEY State: CA
County:
License #: 1333-01
Agreement: Y
Docket:
NRC Notified By: KAMANI HEWADIKARAM
HQ OPS Officer: PETE SNYDER
Notification Date: 11/04/2010
Notification Time: 14:25 [ET]
Event Date: 11/04/2010
Event Time: [PDT]
Last Update Date: 11/04/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was reported via e-mail by the State of California:

"On November 03, 2010, the RSO at UC Berkeley informed the [California] Radiologic Health Branch (RHB) that on 11/01/10 an Electron Capture Device (ECD), S/N F7737 containing 15 mCi of Ni-63, was determined to have leakage in excess of 0.005 microcurie criteria. The leaking source was installed in a Hewlett-Packard gas chromatography unit Mode 5890. Immediately after the leakage was found, the unit was taken out of service. Follow-up surveys performed did not show any area contamination. The maximum contamination found on the internal portion of the ECD outlet port was 0.007 microcuries. The extent of contamination was limited to the ECD and exhaust tubing. No personal contamination was expected since the leakage was limited to the internal parts of the gas chromatography unit and vent tubing.

"The unit was used for routine analysis of organic materials. The leakage may have been due to the routine use over many years (@ 16 years). The University will pursue disposal of this ECD."

California RHB 5010 - 110310.

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Power Reactor Event Number: 46407
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/09/2010
Notification Time: 15:13 [ET]
Event Date: 11/09/2010
Event Time: 11:39 [CST]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 47 Power Operation 47 Power Operation

Event Text

OFFSITE NOTIFICATION - VIOLATION OF THE DISCHARGE PERMIT

"The Minnesota Pollution Control Agency was notified [on 11/9/10] at 1139 hours [CST] today that at Monticello, the Circulating Water and Service Water Streams were simultaneously chlorinated for a duration of approximately one (1) hour. Simultaneous chlorination of these two water streams is a violation of the National Pollutant Discharge Elimination System (NPDES) Permit. Chapter 4, Section 2.3, states, 'The condenser cooling water and the service water shall not be chlorinated simultaneously.' Upon discovery of this event, both the Service Water and the Circulating Water bleach injection skids were secured.

"This event did not result in bleach discharge concentration in excess of the 0.038 ppm concentration set forth in the NPDES permit."

The licensee notified NRC Resident Inspector.

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Power Reactor Event Number: 46409
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BENJAMIN GEISS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/10/2010
Notification Time: 13:00 [ET]
Event Date: 11/10/2010
Event Time: 10:56 [EST]
Last Update Date: 11/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RONALD BELLAMY (R1DO)
THEODORE QUAY (NRR)
JANE MARSHALL (IRD)

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

Event Text

UNPLANNED AUTOMATIC SCRAM AND HIGH PRESSURE COOLANT INJECTION SYSTEM INITIATION DURING TESTING

"At 10:56 [EST] on Wednesday, November 10, 2010, Nine Mile Point Unit [1] One automatically scrammed from rated power. The cause of the scram was Main Steam Isolation Valve (MSIV) closure. The MSIV closure occurred during Instrument and Control Lo-Lo Level Surveillance Testing. The Lo-Lo Surveillance Test has been secured and all Reactor Protection System (RPS) Level Signals returned to normal. Two of four MSIVs went closed; troubleshooting to follow to determine the cause of the equipment malfunction [unexpected MSIV closure].

"Following the automatic scram, the High Pressure Coolant Injection (HPCI) System automatically initiated. At Nine Mile Point Unit One, a HPCI System actuation signal on low Reactor Pressure Vessel (RPV) level is normally received following a reactor scram, due to level shrink. At 10:58, RPV level was restored above the HPCI System low level actuation set point and the HPCI System initiation signal was reset. Pressure control was initially established on the Emergency Condensers (ECS). The MSIVs have been re-opened and the normal heat removal capability has been re-established [to the Main Condensers].

"All off-site power sources remain available [with a normal electrical alignment].

"10 CFR 50.72(b)(2)(iv)(B) requires reporting within 4 hours when a valid actuation of the Reactor Protection
System occurs.

"10 CFR 50.72(b)(3)(iv)(A) requires reporting within 8 hours when a valid actuation of the High Pressure Coolant
Injection System occurs.

"There are no other adverse impacts to the station based on this event."

All control rods inserted and the unit is stable in Mode 3 with reactor pressure and temperature approximately 600 psig and 480 degrees. All other safety systems operated as expected.

The licensee notified the NRC Resident Inspector and the New York State Public Service Commission.

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Power Reactor Event Number: 46410
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BOB MURRELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/10/2010
Notification Time: 13:49 [ET]
Event Date: 11/10/2010
Event Time: 05:18 [CST]
Last Update Date: 11/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
ANN MARIE STONE (R3DO)

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

Event Text

RHR PUMP TRIPPED WHILE OPERATING IN SHUTDOWN COOLING MODE

"On November 10, 2010, at approximately 0518 hours, with the plant in Mode 5 during Refueling Outage (RFO) 22, the 'A' Residual Heat Removal (RHR) pump tripped while operating in the shutdown cooling mode resulting in an interruption of the primary means of decay heat removal for approximately 30 minutes. During this period the maximum increase in reactor temperature was approximately 2 degrees Fahrenheit with a calculated time to boil of approximately 33.9 hours. There was no loss of decay heat removal due to the fact that both trains of Fuel Pool Cooling system and the Reactor Water Cleanup system remained in service. At the time of this event, the plant was in the process of restoring motive power to MO-1909, Outboard Shutdown Cooling Isolation valve. Motive power had previously been isolated to the valve as part of a preplanned evolution of transferring the power supply to 'B' Reactor Protection System (RPS). Due to a failure to isolate the control power to MO-1909 when RPS power had been transferred, MO-1909 automatically closed when motive power had been restored due the existence of a Primary Containment Isolation System (PCIS) signal that was initiated when 'B' RPS power had been transferred. The closure of MO-1909 resulted in the isolation of the common shutdown cooling pathway, and therefore prevented both the 'A' and the 'B' RHR systems from removing decay heat. Preliminary investigations into this event indicate that the failure to isolate control power to MO-1909 occurred due to an existing procedure deficiency for transferring RPS power supplies.

"As a result of the closure of MO-1909, Operations entered Abnormal Operating Procedure (AOP) 149, Loss of Decay Heat Removal, and Technical Specification (TS) Limiting Condition for Operations (LCO) 3.9.7 Condition A; Required RHR Shutdown Cooling Subsystem Inoperable and performed the required actions of the AOP and TS. At approximately 0547, shutdown cooling was restored when the 'C' RHR pump was placed in shutdown cooling. TS 3.9.7 and AOP 149 were subsequently exited at 0551. During the duration of this event adequate decay heat removal existed as part of the site's Shutdown Risk Management in that two loops of Fuel Pool Cooling were in-service and Feed and Bleed utilizing the Control Rod Drive pumps was available. Additionally, Reactor Water Cleanup was in service and remained in service for the duration of this event. Note that RHR shutdown cooling was considered available during this event due to the fact that there were no component failures associated with MO-1909 preventing it from being immediately re-opened.

"This event is being reported as an event or condition that at the time of discovery could have prevented fulfillment of a safety function of structures or systems that are needed to remove residual heat under 10 CFR 50.72 (b)(3)(v)(B).

"The [NRC] Resident Inspectors have been notified."

Page Last Reviewed/Updated Tuesday, August 11, 2015
Tuesday, August 11, 2015