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Event Notification Report for January 21, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/20/2011 - 01/21/2011

** EVENT NUMBERS **


46414 46543 46556 46557 46558 46559

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46414
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE DEBOARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/12/2010
Notification Time: 15:44 [ET]
Event Date: 11/12/2010
Event Time: 08:18 [CST]
Last Update Date: 01/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANN MARIE STONE (R3DO)

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

CONTROL ROOM OUTSIDE AIR INTAKE NOBLE GAS CHANNEL SETPOINTS NON-CONSERVATIVE

"At 0818 CST, 11/12/10, Radiation Protection determined that the setpoints for the Control Room Outside Air Intake Noble Gas channels are non-conservative. This affects Tech Spec 3.3.7 required monitors 0PR31B, 0PR32B, 0PR33B and 0PR34B (Noble gas channels). The current setpoints for 0PR31B, 0PR32B, 0PR33B and 0PR34B are High Alarm 9.55E-05 microCi/cc and Alert Alarm 9.55E-06 microCi/ml. The calculated required setpoints are High Alarm 6.61E-05 microCi/cc and Alert Alarm 6.61E-06 microCi/cc. This is approximately a 30% decrease in setpoints from the current setpoints. LCO 3.3.7 conditions A and B were entered at 0818, 11/12/10. LCO 3.3.7 conditions A and B required actions completion time is 1 hour. All required actions were complete at 0900 11/12/10, less than 1 hour.

"This report is being made per 10 CFR 50.72(b)(3)(v), Event or condition that could have prevented fulfillment of a safety function, 8 hour non-emergency notification.

"Both trains of radiation monitor setpoints were non-conservative and actuate control room ventilation in emergency mode. The margin available in the control room dose analysis will be reviewed to confirm impact on safety function. The setpoints have been non-conservative since 1999."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM BART KELLER TO JOHN SHOEMAKER AT 1414 EST ON 01/20/11 * * *

"At 0818 CST, 11/12/2010, Radiation Protection determined that the setpoints for the Control Room Outside Air Intake Noble Gas channels are non-conservative. This affects Tech Spec 3.3.7 required monitors 0PR31B, 0PR32B, 0PR33B, 0PR34B (Noble Gas channels). ENS notification was made under ENS 46414 under 10 CFR 50.72(b)(3)(v)(D).

"The design basis accidents do not credit automatic actuation of the Control Room Outside Air Intake system to the Emergency mode from a high radiation signal. Therefore, the high radiation signal is not needed to mitigate the consequences of an accident and this event did not result in a safety system functional failure.

"Therefore, ENS notification 46414 is being retracted."

The licensee notified the NRC resident inspector. Notified R3DO (Bloomer)

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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: 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 A/R 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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Power Reactor Event Number: 46557
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TERESA PUTNAM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/20/2011
Notification Time: 12:46 [ET]
Event Date: 01/20/2011
Event Time: 11:10 [EST]
Last Update Date: 01/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MARVIN SYKES (R2DO)
JOHN THORP (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 90 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS

"The 1B and 2B trains of Nuclear Service Water Systems (Raw Water Nuclear RN) were declared inoperable on 1/18/11 at 0423 EST due to fouling of the respective suction strainers when aligned to the Standby Nuclear Service Water Pond (SNSWP).

"Tech. Spec. 3.0.3 was entered at 1110 EST on 1/20/11 due to the lack of reasonable assurance of operability pertaining to 1A and 2A RN trains in the event of a potential realignment to the SNSWP due to a seismic event."

The licensee plans to reduce power and place both Units in Mode 5. Unit 1 has been reduced to 90% and Unit 2 is holding at 100% and will begin reducing power later. The fouling is being caused by fish being sucked into the RN train suction strainers. The licensee has been back-flushing the strainers to clear the fouling. The pond was chemically treated approximately 1 year ago to eliminate the fish.

The NRC Resident Inspectors have been notified.

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Power Reactor Event Number: 46558
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: JIM DAVIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2011
Notification Time: 15:25 [ET]
Event Date: 01/19/2011
Event Time: 19:00 [EST]
Last Update Date: 01/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MARVIN SYKES (R2DO)
ALAN BLAMEY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 0

Event Text

FITNESS FOR DUTY REPORT INVOLVING FFD PROGRAM VULNERABILITY

A discovered vulnerability in the Fitness-For-Duty (FFD) program has resulted in contractor personnel being granted unescorted access to Vogtle 3&4 construction site without meeting all the requirements of the FFD Program. Contact the Headquarters Operations Officer for more details.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46559
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TERESA PUTNAM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/20/2011
Notification Time: 16:12 [ET]
Event Date: 01/20/2011
Event Time: 15:18 [EST]
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):
MARVIN SYKES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 28 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF BOTH MAIN FEED PUMPS DURING SHUTDOWN

"Unit 1 performed a manual reactor trip (from 28% power) due to the trip of the 1B main feedwater pump trip concurrent with the 1A main feedwater pump having been previously tripped per the shutdown procedure. Reactor power was below the setpoint for an automatic reactor trip from a turbine trip."

All rods fully inserted, heat removal is from auxiliary feedwater and condenser steam dumps, and the electrical system is in a normal alignment. The plant has stabilized at normal RCS pressure and temperature.

Both Units 1 and 2 are being shutdown as per Tech Spec 3.0.3 associated with an inoperable Nuclear Service Water System. Unit 2 is at 40% and decreasing power due to the Tech Spec action and was not effected by the Unit 1 reactor trip. Both units will be placed in Mode 5.

The licensee has notified the NRC Resident Inspector.

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