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Event Notification Report for June 17, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/16/2011 - 06/17/2011

** EVENT NUMBERS **


46949 46952 46964 46965 46966

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Agreement State Event Number: 46949
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: GREENBAY State: WI
County:
License #: 009-1303-01
Agreement: Y
Docket:
NRC Notified By: MARK PAULSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/10/2011
Notification Time: 17:17 [ET]
Event Date: 05/15/2011
Event Time: [CDT]
Last Update Date: 06/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENTS INVOLVING USE OF SAVI BRACHYTHERAPY APPLICATORS

The following information was provided by the State via facsimile:

"On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED.

"The State of Wisconsin Department of Health Services will conduct a special inspection at the licensee's location."

Wisconsin Report No: WI 110006

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: 46952
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: AMERICAN ORDNANCE, LLC
Region: 3
City: MIDDLETOWN State: IA
County:
License #: 0290129SM1
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/13/2011
Notification Time: 13:01 [ET]
Event Date: 05/19/2011
Event Time: [CDT]
Last Update Date: 06/13/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received via e-mail:

"The Iowa Department of Public Health (IDPH) received a telephone notification on May 19, 2011 from the licensee concerning the loss of two tritium exit signs. They stated that during a remodeling process that the signs were taken down and mistakenly placed with the construction trash and sent to a landfill in Pike County, Illinois. The licensee stated that the signs were not retrievable. At the time of the notification, the licensee was not aware of the manufacturer, model number or activity of the signs. IDPH notified the Illinois Emergency Management Agency on May 20, 2011 regarding the exit signs in an Illinois landfill. IDPH was notified by the licensee on June 13, 2011 of the manufacturer, model number, serial number and activity of the sources."

Manufacturer: EvenLite, Inc.
Activity: 20 Ci each
Model: LEX Series
Serial Numbers: Z34957 and Z34946

Iowa event: IA110003

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: 46964
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: EUGENE DORMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 06/16/2011
Notification Time: 12:14 [ET]
Event Date: 06/15/2011
Event Time: 14:00 [EDT]
Last Update Date: 06/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JUDY JOUSTRA (R1DO)
PART 21 GROUP (EMAI)

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

ROSEMOUNT MODEL 710 TRIP UNITS WOULD NOT TURN ON DURING TESTING

"On June 15, 2011, the Site Vice President was notified that the 10 CFR 21 evaluation of Rosemount Model 710 trip units supplied under purchase order 10174727 determined that the reporting criteria of 10 CFR 21.21 (d)(1) are met.

"During pre-installation testing, it was found that 3 of 4 Rosemount Model 710 trip units would not turn on. The units were returned to Rosemount for failure analysis and it was determined that a resistor in the start-up circuit for the trip unit was failed. This prevented the trip unit from starting. Based on engineering analysis, some of the applications for the trip unit require it to energize to perform the associated safety functions. Therefore, the identified failure mechanism could have represented a substantial safety hazard if the components had been installed, and the condition is reportable.

"The condition had no actual safety consequences as the deficiency was identified during pre-installation testing and if installed without pre-installation testing, the system could not have passed post maintenance testing. The three failed units were returned to Rosemount. This notification is made pursuant to 10 CFR 21(d)(ii)(3)(i)."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46965
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: SCOTT MOECK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/16/2011
Notification Time: 14:46 [ET]
Event Date: 06/16/2011
Event Time: 12:30 [CDT]
Last Update Date: 06/16/2011
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):
GREG WERNER (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

ADDITIONAL PENETRATION IDENTIFIED FOR MITIGATION DURING WALKDOWN

"Operations identified a potential flooding issue in the Intake Structure 1007 ft. 6 in. level. The area of concern is a the hole in the floor at the 1007 ft. 6 in. level where the relief valve from FP-1A discharge pipe goes through the raw pump bay and discharges into the intake cell. There is one penetration of concern. Flooding through this penetration could have impacted the ability of the station's Raw Water (RW) pumps to perform their design accident mitigation functions.

"Efforts are in progress to seal the penetration.

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

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46966
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: RON FELLOWS
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/16/2011
Notification Time: 15:25 [ET]
Event Date: 04/24/2011
Event Time: 21:44 [EDT]
Last Update Date: 06/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JUDY JOUSTRA (R1DO)

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

60 DAY OPTIONAL NOTIFICATION OF INVALID START OF EMERGENCY DIESEL GENERATOR.

"This report is being made per paragraphs 50.73(a)(1) and 50.73(a)(2)(iv)(A) to address an actuation of the 'B' Emergency Diesel Generator on 4/24/11 while performing a test of the diesel generator load and safeguard sequence. Emergency AC Electrical Power system including Emergency Diesel Generators is a system named in 50.73(a)(2)(iv)(6).

"On 4/24/11, at 2144, [hrs. EDT] while testing the continuity of relay SI-20X that is part of the test of diesel generator load and safeguard sequence, an unexpected partial Safety Injection signal occurred. The initiating action was the testing of the continuity of relay SI-20X while the 'B' train Safety Injection DC breaker was closed. Once the testing of relay SI-20X was completed, the partial Safety Injection signal ceased and all the equipment that had started, or had been repositioned, was returned to its pre-test condition. The unexpected partial Safety Injection signal was the result of the improper sequencing of a separate test of process radiation monitors that was being performed concurrently with the test of the diesel generator load and safeguard sequence.

"Specific information required per NUREG-1022:

"a. The specific train(s) and system(s) that were actuated: The 'B' Diesel Generator actuated. In addition, (a) equipment that started, or was repositioned, were the 'D' Service Water pump, the 'B' Control Room Emergency Air Treatment System (CREATS), and Emergency Core Cooling System (ECCS) valves 871B and 852B; and (b) equipment that stopped was the containment purge supply and exhaust fans, and Control Room Air Handling Unit supply and return fans.

"b. Whether each train actuation was complete or partial: The actuation was partial.

"c. Whether or not the system started and functioned successfully: The 'B' Emergency Diesel Generator started and operated successfully. It was later secured by Operations personnel.

"The licensee has notified the NRC Resident Inspector."

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Thursday, March 29, 2012