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Event Notification Report for May 25, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/24/2011 - 05/25/2011

** EVENT NUMBERS **


46858 46859 46860 46861 46862 46864 46865 46869 46875 46876 46877 46879
46880 46881 46882

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Agreement State Event Number: 46858
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EXXON MOBIL OIL CORPORATION
Region: 4
City: BEAUMONT State: TX
County:
License #: L00603
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 12:00 [ET]
Event Date: 05/18/2011
Event Time: 14:00 [CDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - STUCK OPEN GAUGE SHUTTER

"On May 19, 2011, the Agency [State of Texas] was notified by the licensee that the shutter on an Ohmart/Vega model SH- F2 containing 1.6 curies of Cesium (Cs) - 137 would not close. The licensee stated that they were making preparations to enter a steel vessel that is 12 inches thick to perform maintenance. The gauge shutter was to be closed before maintenance was started. Open is the normal position for the shutter therefore the gauge does not pose any additional exposure hazard. Access to the tank has been secured and will not be granted until the gauge is repaired. The licensee has contacted a service provider to make the repairs. The gauge was installed in October 2009. The cause for the failure is under investigation. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: I - 8852

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Agreement State Event Number: 46859
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: JOE O'HARA
Notification Date: 05/19/2011
Notification Time: 13:03 [ET]
Event Date: 07/02/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION USING HDR AFTERLOADER

The following was received from the State of New York via fax:

"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee called on 7/2/07 to report an event involving HDR unit. Patient did not get incorrect treatment. In fact patient did not receive any therapeutic dose on this session. Here is what happened.

"A patient was receiving mammosite therapy with the Nucletron HDR unit. During this session, the therapist went into the treatment room, and placed the transfer tube on the patient (across from right superior to left inferior) but did not connect it to the catheter in the patient's breast. Then she went out to get the doctor. Neither of them checked to make sure that the catheter was connected to the transfer tube through the connector. Then they delivered the treatment. Since the mammosite connector (closed end) was attached to the transfer tube tune, there was no interlock. But there was no sensor or interlock to inform them that there was nothing connected to the other end of this connector. So the source proceeded as programmed and stuck out 16 cm from the end of the transfer tube in the connector tube. They saw this only when they went in to disconnect after treatment. According to their calculations, the source was at distance of 38 cm from the patient's left leg. Notice that the transfer tube is part of Nucletron equipment. The connector that connects from the transfer tube to the catheter is part of mammosite (Cytec) equipment. There was no sensor to ensure that this connection was made. It appears that the connector's closed end was sticking out in the air by the patient's leg and the programmed positions for treatment resulted in the source being in the connector in air about 16 cm from the patient's left leg. Physician/RSO admitted over the phone that the treating physician did not check the applicator and connection prior to treatment. The patient received the correct treatment later.

"Policy and procedure reviewed. 'The physician will log into the treatment system to initiate treatment delivery and he will be responsible to ensure that all treatment parameters and connections are satisfied'. A copy of the Cytec and Medwatch correspondence was included with the documentation.

"This case can now be closed."

HDR Brachytherapy event (NYS DOH Internal Tracking No. 553). NY Event Report Number: NY-11-02.

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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Agreement State Event Number: 46860
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: JOE O'HARA
Notification Date: 05/19/2011
Notification Time: 14:36 [ET]
Event Date: 06/20/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION USING HDR AFTERLOADER

The following was received from the State of New York via fax:

"New York law prohibits the release of any identifiers In cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee telephoned [the State of New York] on 6/20/07, to report misadministration on 6/19/07. Patient was a 73 year old woman receiving the second of her 5 fractions of HDR for cancer of the cervix. It was a ring and tandem setup. 600 cGy prescribed to point A in the cervix. Patient moved about halfway through the treatment and with the applicator about 6 cm inferior to the cervix, the cervix received about 382 cGy while the vagina received about 218 cGy.

"During a conference call between Bureau staff and facility staff including radiation oncologist, physicist, and administrator, it was learned that the patient had had 10 children and muscles were not tight. Prior to the start of the treatment, she complained of discomfort from the foley catheter due to bladder distention and the clamp was loosened a bit. She continued to be uncomfortable and moved during the treatment of 644 seconds. Therapists reassured her and completed the treatment, despite the movement. It was discovered later that the applicator had slid inferior by about 6 cm.

"The radiation oncologist believes that the 218 cGy to the vagina will not impact the patient adversely because there is some disease in that area. The patient and the referring physician have been informed. The physician does not plan to make up for the deficit dose to point A in the cervix. Facility submitted an RCA and to prevent recurrence, they have implemented the following measures. (1) Minimize time between applicator insertion and treatment. (2) Use of stabilizing devices at the time of insertion to minimize applicator movement (3) Use anatomical markings at the time of device insertion to help verify applicator position just prior to and during treatment (4) Expand patient instruction with increased emphasis on need to remain still and (5) Staff education on patient monitoring prior to and during treatment, with applicator position verification added to physics checklist.

"These are sufficient.

"As of 5/13/09, the patient is free of disease and complications.

"This event may be closed."

HDR Brachytherapy misadministration (NYS DOH Internal Tracking No. 548). New York Event Number NY-11-01.

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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Agreement State Event Number: 46861
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City: NONE PROVIDED State: NY
County:
License #: NONE PROVIDED
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 14:03 [ET]
Event Date: 10/02/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED TWICE THE PRESCRIBED DOSE

The following report was received via fax.

"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee reported on 10/3/2007 that on 10/2/2007, a patient received 4 mCi 131 Iodine for a whole body scan instead of the 2 mCi that was ordered. The error was discovered after the radiopharmacy tried to reconcile their orders and shipments and found that a vial with 4 mCi [milliCurie] of 131 Iodine was missing and called the hospital. The nuclear medicine department staff inspected the waste sent from the department to the environmental services section of the hospital and found that the box they had sent did trigger an alarm and had been isolated. On closer inspection, they found one vial containing 2 mCi Iodine 131. An extra vial of Iodine 131 of 4 mCi (meant for another order) had been placed by the nuclear pharmacy in the box and sent along with the 2 vials of 2 mCi each. The technologist retrieved this mCi vial and one 2 mCi vial and gave the 4 mCi iodine capsule to the patient.

"The NM [Nuclear Medicine] technologist had retrieved 2 vials from the box on 10/2/2007. The order was for 2 vials, one for the patient dose and the other the standard. Failures: 1. She failed to verify that the labels on the dose vials matched the labels on the shipping box. 2. She failed to read the label on the vial containing the capsule that she gave to the patient. 3. She failed to assay the patient dose using the dose calibrator. 4. She failed to survey the box before sending it to the environmental services for disposal. All 4 failures are in violation of the licensee's protocol for the use of radioactive materials.

"The authorized user physician believes that the dose of 4 mCi for a whole body scan is still within the range in use at the facility and does not expect any harm to the patient as result of this event. A health physicist was consulted and doses to various organs were estimated and documented. To prevent a recurrence, they have implemented a TlME OUT protocol for administration of RAM [radioactive material], which requires that 2 technologists must agree on the correctness of the activity, assay and document it on both a hard copy log and the computer in the hot lab.

"These steps are adequate.

"This event is closed."

New York Event Number: NY-11-03
New York State DOH Internal Tracking Number 566


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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Agreement State Event Number: 46862
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS A&M UNIVERSITY
Region: 4
City: COLLEGE STATION State: TX
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 16:40 [ET]
Event Date: 05/19/2011
Event Time: 15:15 [CDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
CHRISTIAN EINBERG (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

On May 19, 2011, the Agency [State of Texas] received notification from Texas A & M University's Radiation Safety Officer [RSO] that while removing all tritium exit signs (TES) from a dormitory prior to its demolition, they noted that a TES was missing. The RSO could not provide any additional information at this time. Additional information will be provided as it is received.

Texas Event Number: I-8853

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

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Agreement State Event Number: 46864
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FEDERAL EXPRESS
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 20:22 [ET]
Event Date: 05/18/2011
Event Time: 09:00 [CDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
CHRISTIAN EINBERG (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE SHIPMENT LOST IN TRANSIT

"On May 19, 2011, the Agency [State of Texas] was notified by a shipper that on May 18, 2011, a package carrying a 297 Giga Becquerel Iridium (Ir) 192 source manufactured by Alpha-Omega Laboratory and shipped from Vinton, Louisiana was lost near the intersection of Rankin and Albine Westfield Roads in Houston, Texas. The source is used in a high dose afterloader. The source was being transported to DHL in Houston, Texas for shipment to the country of Brazil. The shipper stated that the door on the back of the truck popped opened and the driver could not see it open or any of the contents from the truck fall onto the road. The truck is a large truck with doors that swing open in the back. A member of the general public (MGP) saw several letters setting on the road and stopped to pick them up. He stated that he saw the small drum the source was packaged in across the road in a church parking lot and did not indicate that he saw any damage to the drum. He could not retrieve the drum because of the traffic and he was taking his wife to a doctor's appointment. On his way back from the doctor office about an hour later the MGP went back by the location where the drum had been and it was gone. He took the letters by a FedEx office and told them what had happened. FedEx responded by driving to the location and searching for the source. They also traced the path traveled by the truck three times, but they did not locate the source. The package the source is contained in is a Type A package, 34 cm in length, 34 cm wide, and 37 cm high and is similar to a 5 gallon paint bucket. The shipper stated that there was a locking device on the container. The container is labeled with a Yellow III label with a transport index of 1.3. Additional information will be provided as it is received in accordance with SA-300."

Later, the state reported that the source has been located at a Houston Area Fire Department. The state will provide additional information as it is received.

Texas Incident #: I - 8854

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event.

Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3"

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Agreement State Event Number: 46865
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: S&ME INC.
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0922-4
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/20/2011
Notification Time: 11:32 [ET]
Event Date: 05/18/2011
Event Time: [EDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AND SUBSEQUENTLY RECOVERED TROXLER GAUGE

The following information was received from the North Carolina Radiation Protection Section via e-mail:

"On May 18, 2011, an employee of S&ME parked a company truck at his house. The truck had a Troxler 3411B Portable Nuclear Gauge double locked in an aluminum box in the bed of the truck.

"The next morning, he discovered the truck missing. Company management was notified, who in turn notified Local Law Enforcement and the agency [State of North Carolina]. About 15 minutes after the Agency notification. the police determined that the vehicle had been towed. The explanation for the towing of the vehicle was that the vehicle, which was in front of the employees residence, had its wheels on the grass.

"The vehicle was retrieved from the towing company. The gauge was still locked in its storage box and appeared untouched."

"Device/Material Info:

Troxler 3411B S/N 13772
Cs-137 S/N 50-2590 9 mCi
Am-241 S/N 47-9185 44 mCi"

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 46869
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: URSINUS COLLEGE
Region: 1
City: COLLEGEVILLE State: PA
County:
License #: PA-0952
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2011
Notification Time: 23:27 [ET]
Event Date: 05/20/2011
Event Time: 12:00 [EDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
CHRISTIAN EINBERG (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TRITIUM EXIT SIGN

The following report was received via fax:

"On 5/20/2011, the PA DEP [Pennsylvania Department of Environmental Protection] Bureau of Radiation Protection (BRP) was notified by the Safety Manager from Ursinus College, explaining that during their dormitory inspection performed this morning, a tritium exit sign with perhaps 10 to 20 curies of H-3 is missing and presumed stolen."

Pennsylvania Event: PA110011

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 46875
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: SCOTT MOECK
HQ OPS Officer: VINCE KLCO
Notification Date: 05/23/2011
Notification Time: 23:41 [ET]
Event Date: 05/23/2011
Event Time: 22:00 [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DALE POWERS (R4DO)
DOMINIC PALAZZOLO (EPA)

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

Event Text

OFFSITE NOTIFICATION DUE TO AN OIL SPILL

"On May 23, 2011, at 2200 CDT, the station needed to notify the State of Nebraska, Department of Environmental Quality and the National Response Center due to an oil leak from the stations lube oil system. A quantity of oil spilled into the turbine building basement and an undetermined amount drained to the turbine building sump which discharges to the Missouri River. Some amount of oil was discharged to the river, which resulted in discoloration and a visible sheen noted on river sampling. Per Fort Calhoun Nuclear Station's National Pollutant Discharge Elimination System (NPDES) permit, the notifications will be made and samples will be taken for off site analysis to determine the quantity discharged involved. Also, the oil quantity in the turbine building sump (out fall L02) is expected to have exceeded 20 ppm oil and grease which does violate the State NPDES permit NE00000418.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi), 4 hour non-emergency notification due to a notifications being made to Government [Agencies] (State of Nebraska, Department of Environmental Quality and the National Response Center)."

The licensee notified the NRC Resident Inspector.

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Non-Agreement State Event Number: 46876
Rep Org: ECS CAROLINAS, LLP
Licensee: ECS CAROLINAS, LLP
Region: 1
City: CAMP LEJEUNE State: NC
County:
License #: 32-31294-01
Agreement: Y
Docket:
NRC Notified By: HARRY SLATER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/24/2011
Notification Time: 13:24 [ET]
Event Date: 05/24/2011
Event Time: 12:30 [EDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)
LAURA PEARSON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TROXLER MOISTURE DENSITY GAUGE STOLEN

At approximately 1230 EDT on 5/24/11, a Troxler Moisture Density Gauge, Model #3440, S/N 20641, with 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen from a truck at Camp Lejeune Marine Corps Base. The RSO reported the theft to the Base Safety Officer.

* * * UPDATE FROM HARRY SLATER TO HOWIE CROUCH ON 5/24/11 @ 1431 EDT * * *

The Troxler Moisture Density Gauge was located on the job site off the side of the road in a ditch. There was no damage to the gauge, and the gauge was placed back into service.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 46877
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JEREMIAH STRAHM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/24/2011
Notification Time: 13:40 [ET]
Event Date: 05/24/2011
Event Time: 11:20 [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARK HAIRE (R4DO)

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

Event Text

LO-LO LEVEL IN STEAM GENERATOR RESULTS IN SPECIFIED SYSTEM ACTUATIONS

"At 11:20 [CDT] on 5/24/11, the unit, while in Mode 4, had a reactor trip and Aux Feedwater actuation/Feedwater Isolation Signal due to lo-lo level on 'B' Steam Generator. Reactor Trip breakers were closed to support DRPI [Digital Rod Position Indication] testing. Steam Generator levels were being maintained approximately 30% to support Aux Feedwater pump full flow testing."

The trip occurred at 23.5% level in the steam generator. Reactor trip breakers opened and the motor-driven auxiliary feedwater pump fed the steam generators. The feedwater isolation valves fully closed. No other actuations occurred. Operators are in the process of resetting plant conditions to support completion of the testing in progress at the time of the trip.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46879
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RICKY GIVENS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/24/2011
Notification Time: 17:56 [ET]
Event Date: 05/24/2011
Event Time: 09:18 [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 19 Power Operation 19 Power Operation
2 N Y 18 Power Operation 18 Power Operation
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF POWER TO THIRTY-TWO EMERGENCY SIRENS

"This 8-hour notification is being made per the reporting requirements specified by 10 CFR 50.72(b)(3)xiii.

"At 0946 CDT on May 24, 2011, the TVA Corporate Operations Duty Specialist notified the Nuclear Power Group Emergency Duty Officer that the fifteen minute communication test for Lawrence County indicated a loss of communications with the Lawrence County siren activation system.

"At 0958 CDT, Lawrence County Alabama Emergency Management Agency (EMA) staff reported that a transformer had de-energized at 0918 CDT and that both the primary siren activation point (Lawrence County EMA office) and the backup activation point (Moulton, Alabama Fire Department) were without power. The EMA offices normally have backup power supplied by a diesel generator. However, the generator had failed during EMA operations associated with the April 27, 2011 tornadoes. The State of Alabama had supplied a generator for temporary use but this generator required manual actions for making connections in order for it to be placed into service.

"At 1003 CDT, electrical power was restored and the primary and backup siren activation points were returned to service.

"Browns Ferry has 100 ANS sirens and 32 are located in Lawrence County. All of the 32 Lawrence County sirens were affected. The duration of the condition was estimated to be approximately 45 minutes (0918 CDT through 1003 CDT). (Note that the polling system that provides the out of service times polls the system every 15 minutes so the timeframe by necessity is an approximation.)

"Both primary and backup activation systems were operable at 1003 CDT. A silent test was performed from the Lawrence County EMA office at 1159 CDT with all 32 Lawrence County sirens satisfactorily responding."

The licensee has notified the State of Alabama, the Lawrence County EMA and the NRC Resident Inspector of this report.

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Power Reactor Event Number: 46880
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RICKY GIVENS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/24/2011
Notification Time: 18:03 [ET]
Event Date: 03/30/2011
Event Time: 14:43 [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

60-DAY TELEPHONIC NOTIFICATION OF INVALID RPS SIGNAL DUE TO LOSS OF VARIABLE LEG OF LEVEL TRANSMITTER

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv) and 10 CFR 50.73(a)(1) to describe an invalid RPS (SCRAM) actuation.

"On March 30, 2011, at 1443 hours Central Daylight Time (CDT), during a refueling outage, Browns Ferry Unit 2 received an invalid Common Accident Signal (CAS) as a result of maintenance activities.

"The CAS caused a full Unit 2 Reactor SCRAM and associated system initiations. The CAS was initiated due to invalid indications on both Channels A and B of low-low-low reactor water level, which did not exist; therefore, the actuation was invalid.

"The affected equipment responded as designed. All four Unit 1/2 Emergency Diesel Generators auto started and all four Unit 3 Emergency Diesel Generators auto started. Unit 2 received a full Reactor SCRAM and Core Spray Pumps A, B, C, and D auto started and injected into the reactor. Unit 2 Division I Residual Heat Removal (RHR) System was in Shutdown Cooling with only the C pump in service. The 'A' RHR pump auto started and Shutdown Cooling flow increased, as expected. Unit 2 Division II RHR System had been tagged out for maintenance and did not respond. High Pressure Coolant Injection and Reactor Core Isolation Cooling received auto initiation signals; however, their steam isolation valves were tagged closed and the systems did not start. The Inboard Main Steam Isolation Valves (MSIVs) isolated as a result of the CAS signal. The outboard MSIVs had been previously closed and tagged for refueling outage purposes.

"This event was entered in the Corrective Action Program as Service Request (SR) 346544, which generated Problem Evaluation Report (PER) 346568.

"There were no safety consequences or impact on the health and safety of the public as a result of these events.

"The NRC Senior Resident Inspector has been notified."

The shutdown reactor water level transmitters share a common variable leg. When maintenance unrelated to the transmitters was performed, the variable leg was lost causing the low-low-low reactor water level SCRAM signal to be generated.

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Power Reactor Event Number: 46881
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RICKY GIVENS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/24/2011
Notification Time: 18:09 [ET]
Event Date: 03/26/2011
Event Time: 20:05 [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

60-DAY TELEPHONIC NOTIFICATION OF INVALID PRIMARY CONTAINMENT ISOLATION SIGNAL DUE TO MAINTENANCE

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv) and 10 CFR 50.73(a)(1) to describe an invalid actuation of multiple secondary containment isolation signals affecting more than one system.

"On March 26, 2011, at 2005 hours Central Daylight Time (CDT), following planned maintenance activities, an unplanned actuation of secondary containment isolation signals affecting containment isolation valves in more than one system occurred and resulted in a partial Primary Containment Isolation System (PCIS) (Group 6, Secondary Containment) isolation and receipt of a Unit 2 Reactor Building Ventilation Abnormal Alarm. Unit 2 was in Mode 4, in a refueling outage, and at 0 percent power (0 MWT). Units 1 and 3 were both in Mode 1 and operating at approximately 100 percent power.

"Plant Conditions, which initiate PCIS (Group 6, Secondary Containment) actuations, are Low Reactor Vessel Water Level, High Drywell Pressure, High Reactor Zone Exhaust Radiation, or High Refueling Floor Exhaust Radiation. At the time of the event, these conditions did not exist; therefore, the partial actuations were invalid.

"For this occurrence, equipment normally affected by a complete Group 6 isolation responded as follows. Trains 'B' and 'C' of Standby Gas Treatment (SGT) System started while Train 'A' did not. Train 'B' of the Control Room Emergency Ventilation System (CREVS) started while Train 'A' did not. Secondary containment (Unit 1, 2, and 3 Reactor and Refuel Zones) normal ventilation isolated - fans stopped and dampers closed. Suppression Chamber Exhaust Inboard Isolation Valve 2-FSV-64-32 and Drywell Exhaust Inboard Isolation Valve 2-FCV-64-29 did not close. Because only a partial (B part of the logic) PCIS isolation was relayed, only the affected Group 6 equipment received the isolation demand. All equipment that received the isolation demand responded and performed as designed.

"Control Room personnel commenced actions of the applicable Alarm Response Procedure and the Group 6 Ventilation System Isolation Abnormal Operations Procedure. Train 'A' of the SGT System was later started.

"This event was entered in the Corrective Action Program as Service Request (SR) 344609 and Problem Evaluation Report (PER) 344680.

"There were no safety consequences or impact on the health and safety of the public as a result of these events.

"The NRC Resident Inspector has been notified of this event."

Although Group 6 PCIS testing occurred earlier that day, the licensee could not determine the signal initiator and considered it spurious.

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Power Reactor Event Number: 46882
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LEON RAFNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/24/2011
Notification Time: 19:31 [ET]
Event Date: 05/24/2011
Event Time: 08:20 [PDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MARK HAIRE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 98 Power Operation 98 Power Operation

Event Text

FITNESS FOR DUTY REPORT INVOLVING A MAINTENANCE SUPERVISOR

A maintenance supervisor had a confirmed positive for alcohol during a for cause fitness-for-duty test. The employee's access has been revoked. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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