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Event Notification Report for December 16, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/15/2010 - 12/16/2010

** EVENT NUMBERS **


46230 46470 46472 46475 46482 46483 46484

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General Information or Other Event Number: 46230
Rep Org: GE HITACHI NUCLEAR ENERGY
Licensee: GE HITACHI NUCLEAR ENERGY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DALE E. PORTER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/03/2010
Notification Time: 15:23 [ET]
Event Date: 09/03/2010
Event Time: [EDT]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RICHARD CONTE (R1DO)
EUGENE GUTHRIE (R2DO)
TAMARA BLOOMER (R3DO)
RICK DEESE (R4DO)
MIKE CHEOK (NRR)
PART 21 GP via email ()

Event Text

PART 21 - FAILURE TO INCLUDE SEISMIC INPUT IN REACTOR CONTROL BLADE CUSTOMER GUIDANCE

The following is text of a facsimile submitted by the vendor:

"GE Hitachi Nuclear Energy (GEH) has identified that engineering evaluations that support the guidance provided in SC 08-05, Revision 1, do not address the potential impact of a seismic event on the ability to scram as it relates to the channel-control blade interference issue. Note that the seismic loads are not a consideration in the scram timing, but rather the ability to insert the control blades. In other words, the control blades must be capable of inserting during the seismic event, but not to the timing requirements of the Technical Specifications. GEH is evaluating the impact of the seismic loads between the fuel channel and the control blade associated with an Operating Basis Earthquake (OBE), and a Safe Shutdown Earthquake (SSE) on BWR/2-5 plants. The scram capability is expected to be affected due to the added seismic loads at low reactor pressures in the BWR/2-5 plants. The ability to scram for the BWR/6 plants is not adversely affected by the seismic events. Additional evaluation is required to determine to what extent the maximum allowable friction limits specified for the BWR/2-5 plants in SC 08-05 Revision 1 is affected by the addition of seismic loads.

"GEH issues this 60-Day Interim Report in accordance with the requirements set forth in 10 CFR 21.21 (a)(2) to allow additional time to for this evaluation to be completed."

Affected US plants previously notified by vendor and recommended for surveillance program include: Nine Mile Point, Units 1 and 2; Fermi 2; Columbia; FitzPatrick; Pilgrim; Vermont Yankee; Grand Gulf; River Bend; Clinton; Oyster Creek; Dresden, Units 2 and 3; LaSalle, Units 1 and 2; Limerick, Units 1 and 2; Peach Bottom, Units 2 and 3; Quad Cities, Units 1 and 2; Perry, Unit 1; Duane Arnold; Cooper; Monticello; Brunswick, Units 1 and 2; Hope Creek; Hatch, Units 1 and 2; and Browns Ferry, Units 1and 2.

Affected US plants previously notified by vendor and provided information include: Susquehanna, Units 1 and 2 and Browns Ferry, Unit 3.

* * * UPDATE FROM DALE PORTER TO ERIC SIMPSON AT 1556 ON 09/27/2010 * * *

The following update was received via fax:

"This letter provides a revision to the information transmitted on September 2, 2010 in MFN 10-245 concerning an evaluation being performed by GE Hitachi Nuclear Energy (GEH) regarding the failure to include seismic input in channel-control blade interference customer guidance. Two changes have been made in Revision 1:

"1) A statement was added regarding the applicability of this issue to the ABWR and ESBWR design certification documentation.

"2) The original MFN 10-245 referenced the Safety Communication SC 08-05 R1 that was transmitted to the US NRC via MFN 08-420. The references to SC 08-05 were changed to MFN 08-420 to prevent possible confusion.

"As stated herein, GEH has not concluded that this is a reportable condition in accordance with the requirements of 10CFR 21.21(d) and continued evaluation is required to determine the impact of a seismic event on the guidance contained in MFN 08-420."

Notified the R1DO (Gray), R2DO (Hopper), R3DO (Orth), R4DO (Farnholtz), NRR EO (Lee) and Part 21 Group (via email).

* * * UPDATE FROM DALE PORTER TO MARK ABRAMOVITZ AT 1723 ON 12/15/2010 * * *

The following update was received via fax:

"This letter provides information concerning an on-going evaluation being performed by GE Hitachi Nuclear Energy (GEH) regarding the failure to include seismic loads in the guidance provided in MFN 08-420. As stated herein, GEH has not concluded that this is a reportable condition in accordance with the requirements of 10CFR21.21(d) and continued evaluation is required to determine the impact of a seismic event on the guidance contained in MFN 08-420.

"GEH has not completed the evaluation of the impact of the seismic loads between the fuel channel and the control blade associated with an Operating Basis Earthquake (OBE), and a Safe Shutdown Earthquake (SSE) on BWR/2-5 plants."

GEH expects the task to be completed by August 15, 2011.

Notified the R1DO (Holody), R2DO (Henson), R3DO (Kozak), R4DO (Werner), NRR EO (Evans) and Part 21 Group (via email).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 46470
Rep Org: PIPE COUNTY MEMORIAL HOSPITAL
Licensee: PIPE COUNTY MEMORIAL HOSPITAL
Region: 3
City: LOUISIANA State: MO
County:
License #: 24-32776-01
Agreement: N
Docket:
NRC Notified By: DOUG SONNENBERG
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/09/2010
Notification Time: 18:05 [ET]
Event Date: 12/09/2010
Event Time: 12:00 [CST]
Last Update Date: 12/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ROBERT DALEY (R3DO)
DIANA DIAZ-TORO (FSME)

Event Text

TWO DIFFERENT PATIENTS RECEIVED INCORRECT DIAGNOSIC DOSES DUE TO VIAL MIX-UP

A representative of the licensee (the hospital rad tech) reported that two patients were administered doses of diagnostic Technetium-99m (Tc-99m) for the wrong organs due to a mixed-up of the dose vials. Specifically:

Patient #1 received a 25 millicurie Tc-99m dose for a bone scan instead of the prescribed 10 millicurie Tc-99m dose for a Hida scan (to the gall bladder).

Shortly thereafter, Patient #2 received the 10 millicurie Tc-99m dose for a Hida scan instead of the prescribed 25 millicurie Tc-99m dose for a bone scan.

Both errors were discovered when the actual diagnostic scans were performed.

The patients, their physicians, and the RSO have been notified of this event. The licensee representative stated that there should be no harm to the patient from the incorrect administration. The cause of this event was reported to be insufficient verification that the proper vial had been selected for injection. Both vials were reported to be identical in appearance.

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.

* * * RETRACTION FROM JOEL HASSIEN TO HUFFMAN AT 1549 EST ON 12/10/10 * * *

After further review of the event described above, the licensee determined that the event was not reportable to the NRC Operations Center. The retraction is based on a determination that the dose to the organs involved did not exceed the reportability limits. The licensee will log the details of this event. R3DO (Daley) and FSME (Diaz-Torro) notified.

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Hospital Event Number: 46472
Rep Org: HENRY FORD MACOMB
Licensee: HENRY FORD MACOMB
Region: 3
City: CLINTON TOWNSHIP State: MI
County:
License #: 21-11850-01
Agreement: N
Docket:
NRC Notified By: BRETT MILLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/10/2010
Notification Time: 14:57 [ET]
Event Date: 12/10/2010
Event Time: 09:00 [EST]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT DALEY (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - TREATMENT AREA DIFFERENT FROM THE PRESCRIBED AREA

A High Dose Rate brachytherapy treatment with a 5.11 Ci source of Ir-192 was performed on a patient for vaginal cancer. The prescribed procedure was for a tube be inserted into the vaginal area for 120 cm, however, the treatment length of insertion was 132 cm. This was an out-patient procedure, so the patient went home after her treatment. The physician will be notifying the patient of the 12 cm insertion error.

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.

* * * UPDATE AT 1610 EST ON 12/15/2010 FROM BRETT MILLER TO MARK ABRAMOVITZ * * *

The brachytherapy exposure was received by four patients with the 12 cm insertion error. Three patients received three fractions each and the fourth received five fractions. The physicians have been notified except for the fourth patient's physician who will be notified.

Notified the R3DO (Kazak) and FSME (O'Sullivan).

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Power Reactor Event Number: 46475
Facility: POINT BEACH
Region: 3 State: WI
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KARL COSSEY
HQ OPS Officer: VINCE KLCO
Notification Date: 12/13/2010
Notification Time: 15:07 [ET]
Event Date: 12/13/2010
Event Time: 12:10 [CST]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
LAURA KOZAK (R3DO)
JANE MARSHALL (IRD)
MELANIE GALLOWAY (NRR)

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

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO NOT MEETING ROD GROUP ALLIGNMENT LIMITS

"On 12/13/10 at 1210 CST a Technical Specification (TS) required shutdown was initiated on Unit 2. TS Limiting Condition for Operation (LCO) 3.1.4, Rod Group Alignment Limits, was not met as a result of Surveillance Requirement (SR) 3.1.4.2 not being met. TS Action Condition (TSAC) 3.1.4.A was entered which requires the shutdown margin to be within the limits of the Core Operating Limits Report (COLR) or boration be initiated to restore shutdown margin to within the limits within one hour and that the reactor to be in MODE 3 within 6 hours. Shutdown margin has been verified to be within the limits specified in the COLR and a reactor shutdown has been initiated.

"On 12/10/10 at 1350 [CST], during performance of Technical Specification surveillance procedure TS-06 Rod Exercise Test, rod control urgent and non-urgent failure alarms occurred while stepping Control Bank B rods out. These alarms were verified locally in the Unit 2 rod drive room. On 12/10/10 at 2212 [CST], the test recommenced and control bank B was stepped out one step as procedurally required with no alarms. When control bank B was subsequently stepped inward one step, both rod control urgent and non-urgent failure alarms were received. Both of the times that Control Bank B rods failed to move, the movable gripper coil power supply fuse blew for control rod F-6. On 12/12/10 at 2143 CST, the surveillance procedure for Control Banks A, C, and D and Shutdown Banks A and B were completed satisfactorily, however, the failure of the Control Bank B rods to step in correctly resulted in the inability to satisfy SR 3.1.4.2, and entry into TSAC 3.1.4.A being required. During continuation of the surveillance on 12/12/10, it was not recognized that troubleshooting and repairs could not be conducted satisfactorily prior to the expiration of the surveillance interval. Therefore, a TS-required shutdown in accordance was not initiated.

"The likely cause of the failure is a damaged cable in the movable gripper circuitry for control rod F6. Troubleshooting is continuing and a repair plan has been developed.

"The NRC Senior Resident Inspector and Region III have been notified."

* * * UPDATE FROM PLESSAS TO KLCO ON 12/15/10 AT 1736 * * *

"On 12/13/10 at 1210 CST, a Technical Specifications (TS) required shutdown was initiated on the Unit 2 reactor. TS Limiting Condition for Operation (LCO) 3.1.4 Rod Group Alignment Limits was not met due to exceeding the specified Frequency and Grace Period for Surveillance Requirement (SR) 3.1.4.2, which required a verification of the freedom of movement (trippability) of each control rod not fully inserted into the core. TS LCO 3.1.4 is not met, and TS Action Condition 3.1.4.A was entered which requires the shutdown margin to be within the limits of the Core Operating Limits Report or boration be initiated to restore shutdown margin to within the limits within one hour as well as requiring that the reactor to be in Mode 3 within 6 hours. Shutdown margin has been verified to be within the limits specified in the Core Operating Limits Report and a reactor shutdown has been initiated.

"On 12/10/10 at 1350 CST, during performance of TS Surveillance-6 (TS-6) Rod Exercise Test, Rod Control Urgent and Non-Urgent failure alarms occurred while stepping Control Bank B rods out. These alarms were verified locally in the Unit 2 rod drive room. On 12/10/10 at 2212 CST, TS-6 recommenced and Control Bank B was stepped out one step as procedurally required with no alarms. When control bank B was subsequently stepped inward one step, both Rod Control Urgent and Non-Urgent failure alarms were received again. Both of the times that the Control Bank B rods failed to move, the movable gripper coil power supply fuse blew for control rod F-6. On 12/12/10 at 2143 CST, TS-6 for control banks A, C, & D and Shutdown Banks A & B was completed satisfactorily.

"Troubleshooting is continuing and a repair plan has been developed.

"The NRC Resident Inspector has been notified."

Notified R3DO (Kozak), IRD (Grant), NRR (Evans)

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Power Reactor Event Number: 46482
Facility: POINT BEACH
Region: 3 State: WI
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DUANE HOFSTRA
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/15/2010
Notification Time: 05:40 [ET]
Event Date: 12/15/2010
Event Time: 01:48 [CST]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R N 0 Startup 0 Hot Standby

Event Text

UNIT 2 MANUAL REACTOR TRIP DURING STARTUP

"On 12/15/10 at 0148 [CST] Control room personnel initiated a manual reactor trip in order to abort a startup in progress with the Unit 2 Reactor subcritical.

"During the performance of OP-1B, Reactor Startup for Unit 2 both Rod Control System Urgent and Non-Urgent alarms were received. Shortly after receiving the alarms multiple groups of control rods fell into the core as indicated by Individual Rod Position Indicators (IRPl's) and rod bottom lights. Based on these indications a manual reactor trip was initiated. All systems functioned as expected, with all control rods fully inserting. The plant is currently in Mode 3 and operating in accordance with normal plant procedures."

The cause of the control rod alarms is under investigation.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 46483
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN OSBORNE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/15/2010
Notification Time: 16:37 [ET]
Event Date: 12/15/2010
Event Time: 13:20 [EST]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL HOLODY (R1DO)

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

OFFSITE NOTIFICATION OF AN AMMONIA SPILL INTO THE DELAWARE RIVER

"A notification was made to the New Jersey Department of Environmental Protection of a discharge of approximately 500 gallons of water containing ammonia with a concentration of 1 ppm. The discharge occurred due to the U-1 FHB [Fuel Handling Building] Supply Fan HW coil rupture. The solution was discharged into the storm drain outside of the FHB Annex door. That storm drain leads to a permitted outfall that communicates with the Delaware River. The leak has been isolated and the downstream catch basin plugged. The remaining water in the discharge line upstream of the plugged catch basin will be removed by a contractor.

"There was no out-of service safely related equipment that contributed to this event. No one was injured as a result of this event."

The licensee notified the NRC Resident Inspector.

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Research Reactor Event Number: 46484
Facility: NORTH CAROLINA STATE UNIVERSITY
RX Type: 1000 KW PULSTAR POOL TYPE
Comments:
Region: 2
City: RALEIGH State: NC
County: WAKE
License #: R-120
Agreement: Y
Docket: 05000297
NRC Notified By: GERRY WICKS
HQ OPS Officer: VINCE KLCO
Notification Date: 12/15/2010
Notification Time: 16:24 [ET]
Event Date: 12/13/2010
Event Time: 15:00 [EST]
Last Update Date: 12/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
JAY HENSON (R2DO)
DUANE HARDESTY (NRR-)

Event Text

RESEARCH REACTOR RADIOGRAPHY INCIDENT

On 12/13/10 at 1500 EST, North Carolina State University [NCSU] was conducting routine radiography with the reactor at 1MW when unknown to the technician, the shutter stuck open. The technician entered the shielded room and noticed the shutter wasn't closed and immediately left the exposure room. After the technician left the room and secured the area, he notified other personnel including the control room. NCSU reports that the reactor was shut down by the operator because of this event. After the reactor was shut down, personnel entered the room and closed the shutter. The shutter door interlock had malfunctioned due to a mechanical interference. It was noted that the technician was not wearing personal dosimetry. NCSU estimates (based on cameras and a re-enactment conducted with the technician) that the technician was exposed for a maximum of 18 seconds with a resulting dose rate of about 150 mRem.

NCSU corrective actions include a research reactor shutdown, closing of the radiography shutter, installing interlocks to prevent shielded room access with the shutter not fully closed, and safety training of personnel related to use of the radiography facility.

NCSU is making this report in accordance with their research reactor technical specifications.

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