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Event Notification Report for May 27, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/26/2011 - 05/27/2011

** EVENT NUMBERS **


46715 46867 46871 46893 46894 46897

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46715
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MICAH BENNINGFIELD
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/31/2011
Notification Time: 20:50 [ET]
Event Date: 03/31/2011
Event Time: 14:32 [CDT]
Last Update Date: 05/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RYAN LANTZ (R4DO)

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

UNANALYZED CONDITION IDENTIFIED FOR INOPERABLE RWST LEVEL

"In response to a condition identified in late 2010 concerning the control and removal of hazard barriers in the plant, a review of the basis and analysis for high energy line breaks (HELBs) and the barriers for protecting against such events has been underway at Callaway in accordance with the plant's corrective action program. While following up on a question from the NRC Resident Inspector, and as a result of an additional question from the Nuclear Oversight organization at Callaway, it was identified that non-safety piping located in the valve room associated with the Refueling Water Storage Tank (RWST) could potentially [make] all four RWST low water level pressure transmitters inoperable in the event of a malfunction of the non-safety piping concurrent with a design-basis loss-of-coolant accident (LOCA) and/or following a seismic event. The RWST water level transmitters (which are located in the RWST valve room) perform a safety-related function for the emergency core cooling system (ECCS) by automatically swapping suction sources for the ECCS during a LOCA from the RWST to the containment sumps when a low water level condition is reached in the RWST. These instrument channels are required to be OPERABLE in Modes 1, 2, 3 and 4 per Callaway Technical Specification 3.3.2, 'Engineered Safety Feature Actuation System (ESFAS) Instrumentation.'

"The subject non-safety piping delivers steam supplied by the Auxiliary Steam system to (and from) heaters surrounding the RWST for maintaining RWST contents above the minimum required temperature during winter conditions. The piping passes through the RWST valve room containing the noted RWST water level transmitters which were designed only for a mild environment. It has been identified, however, that the non-safety Auxiliary Steam piping constitutes a high energy line and that its failure could create harsh (hot and wet) conditions in the valve room to which the RWST water level instrumentation was not designed.

"Per the Callaway FSAR, where non-safety piping interfaces with safety-related piping or systems, the design must be such that failure of the non-safety piping does not adversely affect the safety function(s) of the interfacing safety-related piping or system (since non-safety piping may be assumed to malfunction in conjunction with a design-basis accident). In this case, and based on a conservative interpretation of the FSAR, if the non-safety piping in the RWST valve room is assumed to malfunction (i.e., break), a failure of the RWST instrumentation could occur, thereby preventing the ECCS suction swap over from occurring as required or assumed for LOCA mitigation.

"This condition required declaring all four RWST water level channels inoperable. In light of recognizing that the RWST water level instruments could be subject to a harsh environment when they were only designed for a mild environment, and could thus fail as a result, this condition represents an unanalyzed condition that significantly degrades plant safety. With regard to the impact on the required ECCS suction swap over function that requires the RWST water level channels to be operable, the inoperability of all four instrument channels is a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to shutdown the reactor and maintain it in a safe condition, remove residual heat, control the release of radioactive material, and mitigate the consequences of an accident.

"Upon declaring the RWST water level instrument channels inoperable, TS Limiting Condition for Operation (LCO) 3.0.3 was entered at time 1432 CDT on 3/31/2011. At 1634 CDT, the Auxiliary Steam system was isolated and depressurized. This removed the energy that could be released from a break in the non-safety piping, thereby restoring Operability for the RWST water level instruments.

"The NRC Senior Resident Inspector was notified."

* * * RETRACTION FROM ADAM SCHNITZ TO HOWIE CROUCH AT 1511 EDT ON 05/26/11 * * *

"On March 31, 2011, event notification EN 46715 documented that a harsh environment from a postulated High Energy Line Break (HELB) in the Refueling Water Storage Tank (RWST) valve room could affect RWST level transmitters. These level transmitters provide RWST water level indication in the main control room, which is identified as a safe shutdown function in the Callaway FSAR. They also provide low RWST water level signals for effecting automatic swap over of suction sources for the Emergency Core Cooling System in the event of a loss-of-coolant accident (LOCA). This break may be postulated to occur on non-safety related auxiliary steam lines that run through the RWST valve room and on to the RWST heaters. This condition was initially reported both as an unanalyzed condition that significantly degraded plant safety and as a condition that could have prevented fulfillment of a safety function.

"When EN 46715 was reported, it was assumed that breaks were required to be postulated at any intermediate fitting, welded attachment, or valve on the subject auxiliary steam lines. Subsequent analysis shows that the sections of auxiliary steam piping in the RWST valve room are able to withstand safe shutdown earthquake (SSE) loadings and rupture loadings. For piping of this qualification, breaks at all intermediate fittings, welded attachments, and valves do not need to be postulated. Instead, line breaks are only required to be assumed at the terminal ends of the lines and at the locations specified for ASME Class 2 and 3 piping. None of these postulated break locations are located inside the RWST valve room, and a postulated auxiliary steam line break outside of the room would not adversely affect the RWST level transmitters.

"Since none of the postulated break locations are located inside the RWST valve room, there exists reasonable assurance that the RWST level transmitters would have remained capable of performing their safe shutdown function following a postulated break of the subject auxiliary steam lines. Further, there is no adverse effect on the assumed response to a postulated design basis LOCA since a hazard (such as a break in an auxiliary steam line) is not assumed to occur concurrently with the LOCA. Therefore, this condition does not meet the reporting requirements for an unanalyzed condition that significantly degraded plant safety or a condition that could have prevented fulfillment of a safety function.

"Event notification 46715 is hereby retracted.

"The NRC Senior Resident Inspector has been notified."

Notified R4DO (Haire).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 46867
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHRIST HOSPITAL AND MEDICAL CENTER
Region: 3
City: OAK LAWN State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2011
Notification Time: 16:36 [ET]
Event Date: 05/13/2011
Event Time: [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - EARLY TERMINATION OF RADIATION THERAPY BECAUSE OF POWER SUPPLY VOLTAGE VARIATION

"On Wednesday May 18th, the licensee's radiation safety officer contacted the agency [Illinois Emergency Management Agency] to advise that a medical event had likely occurred the prior Friday. Based on their initial evaluation, 1 of the 10 fractions prescribed for a patient was not delivered as intended such that less than 50% of the expected dose was delivered during a fraction.

"The written directive indicates that the patient was scheduled to undergo 10 treatments to her breast twice a day over a period of 5 days. Each treatment involved 340 centiGy for a total written directive prescription of 3,400 centiGy. During the 6th fraction after completion of treatments in channels 1 and 2, the unit experienced a power supply error. Sensing the power variation, the device automatically withdrew the source and did not complete the treatment for channel 3. Although additional attempts were made to clear the error and continue the treatment, none of the remaining 4 channels could be finished. The licensee had experienced similar problems with the device the previous week which had resulted in a service call on May 10. At that time the power supply was adjusted to ensure operation within specifications. The unit operated normally following the repair until the event on the 13th. The power supply as well as main controller board was subsequently replaced by the manufacturer Saturday morning and the patient returned that afternoon to complete the remaining portion of the 6th fraction. All the remaining fractions were delivered without incident. The fraction which finished the overall treatment was completed Tuesday. There have been no errors or incidents noted since the replacement of the above components.

"The licensee is still investigating this incident with the manufacturer to conduct an engineering evaluation of the power supply failure, however the 'fail safe' design of the system operated as expected. The licensee's initial estimate was that the patient received 133 centiGy of the 340 centiGy intended fractional dose. The patient and the referring physician were advised of the event but since the remaining fractions of the treatment were completed under the revised treatment plan, no adverse affect on the patient is expected and no other additional action is anticipated."

The intended dose for this fraction was 3.4 Gy. The dose received was 1.3 Gy.

Illinois Report Number: 11058

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 DAREN PERRERO TO VINCE KLCO ON 5/24/11 @ 0902 EDT * * *

The following information was received via email:

"On May 23, 2011 the licensee's medical physicist provided information to the agency [Illinois Emergency Management Agency] which demonstrated that the target volume involved in the interrupted fraction received a dose of 217 cGy of the prescribed 340 cGy rather than the conservatively estimated 130 cGy. This dose to the patient treatment volume represents 63% of the prescribed dose and therefore does NOT constitute a medical event as identified in regulations."

Notified R3DO (Cameron) and FSME EO (McIntosh)

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Agreement State Event Number: 46871
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/21/2011
Notification Time: 16:33 [ET]
Event Date: 04/04/2011
Event Time: 09:00 [PDT]
Last Update Date: 05/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT MISADMINISTRATION OF PROSTATE SEEDS

The following was received via e-mail:

"The patient underwent a permanent seed prostate implant in the UCLA 200 Medical Plaza outpatient surgery suite on 4/4/2011. The patient returned to the UCLA Department of Radiation Oncology on 5/3/2011 for a follow-up visit and a post-implant CT scan. A post-implant treatment plan was performed to verify seed placement and final dosimetry endpoints. The post-implant dosimetry plan indicated a significant number of seeds were implanted outside of the prostate.

"A detailed dosimetry analysis is being performed but is unavailable at the time of this report. This report will provide the details of the intended dose versus the received dose, as well as other supplemental information. This report will be included in the final investigation packet.

"UCLA has notified CDPH RHB [California Department of Public Health Radiologic Health Branch] that the permanent seed implant program has been placed on temporary hold pending review of this procedure. No further procedures have been performed since this discovery.

"This investigation is ongoing."

CA Report Number: 052011

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: 46893
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/26/2011
Notification Time: 06:24 [ET]
Event Date: 05/26/2011
Event Time: 00:15 [CDT]
Last Update Date: 05/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK HAIRE (R4DO)

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

Event Text

POTENTIAL FLOODING PATH DISCOVERED

"Operations identified a potential flooding issue in the Intake Structure 1007' 6" level. The areas of concern are the holes in the floor at the 1007' 6" level where the screen wash header penetrates the ceiling of the Raw Water Vault. There are five of these penetrations of concern. Flooding through the penetrations could have impacted the ability of the station's Raw Water (RW) pumps to perform their design accident mitigation functions.

"This eight-hour notification is being made pursuant to 10 CFR 50.72 (b)(3)(v).

"A one foot sandbag berm has been placed around each penetration of concern."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46894
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL WHITING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/26/2011
Notification Time: 12:57 [ET]
Event Date: 05/26/2011
Event Time: 02:26 [PDT]
Last Update Date: 05/26/2011
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 Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF STARTUP POWER DUE TO FAULT IN SWITCHYARD CAUSES ALL EDGS TO START

"At 0226 PDT on May 26, 2011, Unit 1 startup power was lost following actuation of the 230 KV line pilot wire differential relay 287X. Loss of power to the Unit 1 12 KV startup bus produced an undervoltage signal that caused all Unit 1 emergency diesel generators (EDGs) to start in a standby mode. The EDGs started as designed with no problems observed. No vital loads were affected as a result of the 12 KV bus loss and subsequent undervoltage. The cause of actuation of the differential relay 287X is under investigation at this time.

"At 0255 PDT on May 26, 2011, all Unit 1 EDGs were shutdown and returned to their normal at-power standby configuration.

"Unit 2 startup power was cleared at this time and there was no effect on Unit 2.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 46897
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: LISA WILLIAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/26/2011
Notification Time: 19:55 [ET]
Event Date: 03/31/2011
Event Time: 21:28 [PDT]
Last Update Date: 05/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
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

Event Text

60-DAY TELEPHONIC NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION

"This event is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an automatic actuation of general containment isolation signals affecting containment isolation valves in more than one system. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73(a)(2)(iv)(A). This actuation was invalid since it was caused by a loss of power to the Reactor Protection System (RPS) power system bus and not by any actual plant condition warranting containment isolation. The RPS power system provides 120 VAC power to logic and system components including the RPS and the containment isolation system.

"On March 31, 2011, at 2128 hours [PDT], normal power was lost to RPS Bus 'A' resulting in a half scram and actuation of the Groups 2, 5, 6 and 7 primary containment outboard isolation valves. The immediate investigation found that the associated RPS motor generator (MG) set was running with normal 120 VAC output and that the two electrical protective assemblies between the MG set and RPS Bus 'A' were closed with no abnormal indications. A visual inspection of the RPS power panel revealed a cleared fuse for the normal feed. The RPS Bus 'A' was subsequently transferred to the alternate supply at 2135 hours. The actuations and isolations were reset at 2154 hours.

"The RPS power system is supplied from either of two sources: the normal power source from the MG set or the alternate source from a non-Class 1E distribution panel. Transfer between the normal and alternate power supplies is manually initiated by the control room operator. Troubleshooting activities determined that the cleared fuse was due to an internal short in the windings of the 120 VAC coil on the RPS Bus 'A' normal feed contactor. The cause of the internal short was attributed to a random isolated occurrence. The contactor was subsequently replaced and RPS Bus 'A' was returned to the normal power supply.

"There were no actual safety consequences associated with this event. The affected equipment responded as designed. Valves affected by the invalid signal fulfilled their isolation function by successfully closing.

"The NRC Resident Inspectors have been notified."

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