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Event Notification Report for January 20, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/19/2011 - 01/20/2011

** EVENT NUMBERS **


46543 46548 46551 46553 46554 46555 46556

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Agreement State Event Number: 46543
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2011
Notification Time: 15:49 [ET]
Event Date: 11/23/2010
Event Time: [CST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT

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

"On January 13 [2011], the licensee's Radiation Safety Officer contacted the Agency [Illinois Emergency Management] to report an apparent medical event that had been discovered during routine post surgery follow up. A patient had undergone treatment for prostate cancer utilizing permanent brachytherapy I-125 seed placement. A total of 102 seeds were inserted into the region in order to deliver a prescribed dose of 14,500 Rad. Manual insertion of the 0.4 milliCi I-125 seeds was done by ultrasound guided placement of the needle template. A C-arm x-ray scan was done post implant of the 0.4mm x 1mm seeds. Visualization of the seed placement was problematic in the post operation scan. Initial estimates were that the seeds may have been inferior to the ideal placement, but still acceptable. However, engorgement of the surrounding tissue and prostate due to the surgical procedure made visualization difficult and performance of additional dosimetry was deemed inappropriate and of little value. The patient was kept appraised of the situation beginning just prior to discharge and advised of the need for continued follow up. As the patient healed, additional scans were scheduled at the 4 week post treatment mark. Those scans suggested the seed placement to be 4-5 cm inferior of the treatment plan. Although the inferior placement of the seeds resulted in avoiding doses to the rectum and bladder as intended in the original treatment plan, as wells as the urethra, the dose to the prostate was suboptimal. Regions receiving elevated dose were the soft tissue at the base of the penis and the penile bulb. Dosimetry values for dose to the prostate provided by the licensee at this time are rough estimates, but are less than 80% of the intended dose.

"Currently, the patient is asymptomatic. No prediction of long term effects has been made at this time. Physicians are considering the application of external x-ray beam to provide a more effective treatment to the tumor site. This matter remains under investigation by the licensee and the Illinois Emergency Management Agency. The licensee is obliged to file a written report [to the Illinois Emergency Management Agency] in compliance with the rules within 15 days.

Given: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: ND
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 4400 rad 44 Gy

Intended: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: PROSTATE
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 14500 rad 145 Gy

% Dose Exceeds Prescribed: 0
% Dose is Less Than Prescribed: 70
Effect on Patient: UNKNOWN

The patient was informed of the underdose.

IL Report No.: IL11-004

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: 46548
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BRAD BISHOP
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2011
Notification Time: 10:48 [ET]
Event Date: 01/19/2011
Event Time: 02:00 [EST]
Last Update Date: 01/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (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
2 N N 0 Refueling 0 Refueling

Event Text

EMERGENCY RESPONSE DATA ACQUISITION AND DISPLAY SYSTEM (ERDADS) REMOVED FROM SERVICE FOR MAINTENANCE

"On 1/19/11, St Lucie Unit 1 and Unit 2 will lose the computer trains associated with Emergency Response Data Acquisition and Display System (ERDADS). Unit 1 will be removed for corrective maintenance, and Unit 2 will be removed for system modification. It is expected that Unit 1 will be restored by 1/21/11, and Unit 2 will be returned to a functional status prior to core reload and fully operational by March 20, 2011. Further, neither Unit 1 nor Unit 2 ERDADS will be removed from service until Unit 2 has defueled (currently scheduled for 1/19/2011 at 0200). This is an advance notification of a planned loss of emergency assessment capability, which will be reportable under 10CFR50.72(b)(3)(xiii). Other means to monitor critical data exists. Notification will be made when each unit is restored to available status."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM REESE KILIAN TO HOWIE CROUCH @ 0952 EST ON 1/19/11 * * *

"Unit 1 and 2 ERDADS have been removed from service at 0955 [EST]."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46551
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: TOM PHILLIPS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/19/2011
Notification Time: 03:10 [ET]
Event Date: 01/19/2011
Event Time: 02:32 [EST]
Last Update Date: 01/19/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
TAMARA BLOOMER (R3DO)
WILLIAM GOTT (IRD)
MARK SATORIUS (R3)
BRUCE BOGER (NRR)
TRIPP STRINGFIELD (DHS)
ERWIN CASTO (FEMA)

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

NOTIFICATION OF UNUSUAL EVENT DUE TO A FIRE AND EXPLOSIONS IN THE PROTECTED AREA

"An electrical fire and explosions were reported near the Containment Access Facility construction area. An Unusual Event was declared based on HU4. Temporary electrical power at service disconnect DSLM3-3 was isolated. The fire was out at 0243 EST. The fire was extinguished using dry chemical. The fire was reported at 0232 EST on 1/19/11. The cause of the fire has not been determined at this time."

The fire and explosions were initially reported by site security personnel. The licensee declared the NOUE at 0243 EST based on criteria HU4. The licensee initially called for offsite assistance in putting out the fire, however, the fire was extinguished by plant personnel and the offsite assistance was turned back. The licensee posted a reflash watch. The fire reportedly involved temporary cables and possibly a transformer supplying power to the construction area which is located inside the protected area outside the auxiliary building.

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM TOM PHILLIPS TO DONALD NORWOOD AT 0405 EST ON 1/19/2011 * * *

The licensee terminated the Notification of Unusual Event at 0358 EST. No additional information is available at this time.

Notified R3DO (Bloomer), NRR EO (Skeen), IRD (Gott), DHS (Stringfield), and FEMA (Casto).

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Hospital Event Number: 46553
Rep Org: BOTSFORD CANCER CENTER
Licensee: BOTSFORD CANCER CENTER
Region: 3
City: FARMINGTON HILLS State: MI
County:
License #: 21-08892-01
Agreement: N
Docket:
NRC Notified By: MARGARET SYRIAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/19/2011
Notification Time: 17:25 [ET]
Event Date: 01/19/2011
Event Time: 09:40 [EST]
Last Update Date: 01/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
TAMARA BLOOMER (R3DO)
BILL VON TILL (FSME)

Event Text

DOSE TO NON-RADIATION WORKER DURING MEDICAL TREATMENT

The licensee reported an event that occurred while using a HDR Afterloader brachytherapy device for prostate treatment with a 8.3 curie Ir-192 source. Following setup of the HDR Afterloader, the medical staff exited the treatment room and commenced the prostate irradiation. 1.8 minutes after the start of the treatment, the anesthesiologist technician was observed exiting the treatment room. The staff physicist completed the patient treatment and then conducted a review of the circumstances of the event. The anesthesiologist technician was unaware that the treatment was beginning and was crouched down and not visible when the rest of the staff left the treatment room. The technician was not wearing dosimetry (and not required to) so his exposure was estimated based on recreation of the event. His calculated exposure is believed to be approximately 5.6 millirem. The licensee is still evaluating corrective actions.

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Power Reactor Event Number: 46554
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [ ] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/19/2011
Notification Time: 17:44 [ET]
Event Date: 01/06/2011
Event Time: 17:02 [EST]
Last Update Date: 01/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MARVIN SYKES (R2DO)
PART 21 GRP EMAIL ()

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

Event Text

FOREIGN MATERIAL FOUND IN SPARE HEAT EXCHANGER

"Part 21 reportable defect foreign material (FM) was discovered in a spare heat exchanger (HX) when visually inspected on 10/19/10 as part of contingency planning for potential installation of the HX during the 3EOC25 refueling outage.

Visual inspections with a video probe (fiberscope) were being performed on the inlet/outlet channels and the tubes of a spare HX to verify that no FM was present. However, when performing these inspections, a problem was encountered in that maintenance was unable to disassemble and remove the bonnet from the lower (inlet) pressure seal connector on the HX.

"Subsequently, on 10/19/10 a fiberscope inspection was performed of the "back side" of the pressure seal bonnet by inserting a fiberscope thru the inlet nozzle access. A foreign object that appeared as a u-shaped piece of thin wire was seen just behind the pressure seal bonnet, laying in the bottom of the body. Due to the inability to disassemble the pressure seal connector, the affected HX was not installed,

"The FM was retrieved from the spare HX on December 27,2010 and its size and material type confirmed. The "U-shaped" material is type 304 stainless steel and appears to be a metal shaving. It is about 1-1/2" in length if the "u" was stretched out, 3/32" wide and less than 1/64" thick.

"The HX was intended for use as a Reactor Coolant System Letdown Cooler. It was ordered in 2006 and was supplied by Energy Steel Supply Company (ESSC), Catalog 10 350952, SIN N32389-1, Purchase Order No. DP 19279.

"Initial Safety Significance: This event has no actual significance since the issue was discovered prior to installation of the component and the component was not installed. However, Part 21 requires evaluation based on the assumption that the component was installed in the as-found condition. On 1/6/2011, Oconee Engineering concluded that, in some low probability scenarios, this FM could constitute a Substantial safety hazard. Per the postulated scenarios, the FM would be flushed out of the cooler when placed in service. A low potential exists that the FM could be trapped in a downstream valve and damage the seat, resulting in leakage. The cooler outlet valve and the next valve in series are containment isolation valves. If the FM caused leakage in one of those valves and the other was affected by a postulated single failure, any resultant leakage would constitute containment leakage. Also, in some event scenarios, unacceptable leakage past the cooler outlet valve seat could render the Oconee Standby Shutdown Facility (SSF) Reactor Coolant Make-up System inoperable. Therefore, Oconee concludes this issue meets the Part 21 definition as a reportable defect.

"Corrective Action(s): The affected spare cooler was not installed. Subsequently, the FM was removed. A second spare cooler was inspected, no similar FM was found, and the second cooler was installed."

The NRC Resident Inspector will be notified.

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Power Reactor Event Number: 46555
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: ALBET MARTIN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/19/2011
Notification Time: 22:50 [ET]
Event Date: 01/19/2011
Event Time: 20:58 [CST]
Last Update Date: 01/19/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
NEIL OKEEFE (R4DO)
WILLIAM GOTT (IRD)
LAURA PEARSON (ILTA)
DAVID SKEEN (NRR)
ELMO COLLINS (RA)
JACK GROBE (NRR)
STRANGFELD (DHS)
BARDEN (FEMA)

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

Event Text

NOTICE OF UNUSUAL EVENT DUE TO A SECURITY EVENT

The licensee declared an unusual event based upon a potential security incident at the site. Contact the Headquarters Operations Officer for additional details. The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46556
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROB WARNER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/20/2011
Notification Time: 00:08 [ET]
Event Date: 01/19/2011
Event Time: 18:41 [MST]
Last Update Date: 01/20/2011
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):
NEIL OKEEFE (R4DO)

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

Event Text

REACTOR TRIP DUE TO MAIN FEEDWATER PUMP TRIP

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On January 19, 2011, at approximately 1840 Mountain Standard Time (MST), Palo Verde Unit 3 received a Reactor Power Cutback (RPCB) due to the 'B' Main Feedwater Pump (MFP) tripping on low suction pressure in response to the 'A' MFP mini-flow valve failing open. Reactor power lowered to approximately 60% in response to the RPCB. Steam Generator levels continued to decrease and a Reactor Trip occurred on Low Steam Generator #1 level at 18:41. Unit 3 was at normal operating temperature and pressure prior to the trip. Following the automatic reactor trip all CEAs [Control Element Assemblies] inserted fully into the reactor core. No emergency classification was required per the Emergency Plan. An AFAS-2 [Auxiliary Feedwater Actuation Signal] occurred at 1844 on low Steam Generator #2 level. Safety related busses remained energized during and following the reactor trip. The Emergency Diesel Generators started in response to the AFAS-2 actuation but did not energize the class 4.16kV buses as they remained energized from off-site power. The offsite power grid is stable. No major equipment was inoperable prior to the event that contributed to the event.

"Unit 3 is stable at normal operating temperature and pressure in Mode 3 feeding the steam generators with Auxiliary Feedwater pump 'B'. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The [NRC] Senior Resident Inspector was informed of the Unit 3 reactor trip."

Unit 3 is in a normal post-trip electrical lineup. Decay heat is being removed via the turbine bypass valves to the main condenser. No safety valves on the secondary or primary side opened.

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Thursday, March 29, 2012