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Event Notification Report for August 3, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/02/2011 - 08/03/2011

** EVENT NUMBERS **


47057 47114 47116 47118 47119 47120

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 47057
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HEALTH NETWORK
Region: 1
City:  State: PA
County:
License #: PA-0232
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/15/2011
Notification Time: 11:33 [ET]
Event Date: 07/12/2011
Event Time: [EDT]
Last Update Date: 08/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING TREATMENT DOSE ADMINISTERED TO WRONG SITE

The following event report was received from the Pennsylvania Bureau of Radiation Protection:

"The licensee called the PA Department of Environment Protection (PaDEP) Southeast Regional Office at 1050 EDT on July 14, 2011 to provide a 24-hour verbal notice of a Medical Event (ME). A total treatment dose was administered to the wrong site, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(3). This event also meets the criteria for Abnormal Occurrence (AO) reporting.

"On July 12, 2011 a Yttrium-90 (Y-90) SIR-Sphere treatment was performed. The written directive was for treatment of the liver's right lobe, but the total treatment was delivered to the left lobe. The prescribed dose was 31.5 millicurie (mCi) of Y-90.

"There are several open questions regarding root cause, potential health impact on the patient and communications to the patient and their physician. PaDEP/BRP will be performing a reactive inspection, which is scheduled for Monday July 18, 2011. Updates to this NRC report will be made once we investigate the ME at Lehigh Valley Health Network and obtain the follow-up written report from the licensee."

PA report Number: PA110016

* * * UPDATE AT 1500 EDT ON 08/02/11 FROM D. ALLARD TO S. SANDIN VIA FAX * * *

The State of Pennsylvania is retracting this report based on the following:

"After a PaDEP reactive inspection on July 28, 2011 and discussion with the licensee regarding the circumstances of a SirSphere infusion performed on July 12, 2011, it was determined a Medical Event [and Abnormal Occurrence) did not occur.

"The licensee's report concludes that there was no medical event because the authorized user intended to treat a lesion in the right lobe of the liver and that was what happened. The interventional radiologist who performed the procedure elected to use the left hepatic artery because a prior treatment through the right hepatic artery was unsuccessful in treating this lesion. The interventional radiologist and the authorized user discussed this at the time of the treatment and were in full agreement on the procedure.

"Medical Event should be retracted; no further action to be taken at this time."

Notified R1DO (Bellamy) and FSME (McKenney).

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: 47114
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MONTANA
HQ OPS Officer: VINCE KLCO
Notification Date: 08/01/2011
Notification Time: 19:43 [ET]
Event Date: 08/02/2011
Event Time: 07:00 [EDT]
Last Update Date: 08/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ALAN BLAMEY (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 Y 100 Power Operation 100 Power Operation

Event Text

PLANNED MAINTENANCE THAT WILL RESULT IN TECHNICAL SUPPORT CENTER UNAVAILABILITY

"On August 02, 2011, at 0700 EDT, the Technical Support Center will be unavailable due to pre-planned maintenance to maintain the Technical Support Center and Emergency Response Data Acquisition and Display System ventilation system. The TSC is expected to be restored to available status in approximately 12 hours.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures, and the TSC staff will relocate to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility (ERF). An update will be provided once the TSC has been restored to normal operation. The NRC Resident Inspector has been notified."

* * * UPDATE FROM TIM MILLER TO VINCE KLCO ON 8/2/2011 AT 1726 EDT* * *

On August 2, 2011 at 1645 EDT the TSC was restored and is now fully functional.

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Desai).

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Power Reactor Event Number: 47116
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: LINDSEY KOBERLEIN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/02/2011
Notification Time: 15:30 [ET]
Event Date: 08/02/2011
Event Time: 09:48 [EDT]
Last Update Date: 08/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RONALD BELLAMY (R1DO)

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

FITNESS-FOR-DUTY REPORT INVOLVING AN EMPLOYEE SUPERVISOR

A utility non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The individual's access to the site has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 47118
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JASON SOLBERG
HQ OPS Officer: VINCE KLCO
Notification Date: 08/02/2011
Notification Time: 19:52 [ET]
Event Date: 06/04/2011
Event Time: 22:43 [CDT]
Last Update Date: 08/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

INVALID SIGNAL CAUSED A PARTIAL CONTAINMENT SYSTEM ISOLATION

"While preparing to restore AOV 3-1601-22, Drywell /Torus Vent Valve, to operable status following solenoid replacement, operations personnel attempted to open AOV 3-1601-22 in accordance with plant procedures. When the control switch was taken to the open position, the U3 control room received a partial U3 Containment System Isolation. Light indication was lost for several Containment Isolation valves.

"Troubleshooting revealed that a control power fuse had blown during the attempt to open AOV 3-1601-22. Operations personnel entered the appropriate Technical Specification and Technical Requirement Manual Required Actions.

"Operations personnel replaced the blown fuse and indication was restored to the affected valves.

"Following the fuse replacement, the following containment air sample valves were observed to have repositioned during the event: 3-8501-3B, 3-8501-1B, 3-8501-5B, 3-9205B, 3-9206B, 3-9207B, and 3-9208B.

"Subsequent troubleshooting revealed that during the AOV solenoid replacement, the conduit cover screw penetrated the tape of an electrical splice and caused a short to ground.

"The solenoid was repaired and systems were restored as required.

"During this event, all valves repositioned to their intended safety position. There was no loss of function as a result of this condition. Therefore, the health and safety of the public were not compromised.

"Since this ESF actuation was caused by an invalid signal, it is being reported pursuant to 10 CFR 50.73(a) (2) (iv) (A) as specified by 10 CFR 50.73(a) (1), which allows a telephone notification in lieu of a written licensee event report within 60 days."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47119
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JASON SOLBERG
HQ OPS Officer: VINCE KLCO
Notification Date: 08/02/2011
Notification Time: 19:52 [ET]
Event Date: 08/03/2011
Event Time: 04:00 [CDT]
Last Update Date: 08/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED PREVENTATIVE MAINTENANCE

"At 0400 [CDT] on Wednesday, August 3, 2011, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system will be removed from service for planned preventative maintenance activities on the TSC ventilation radiation monitoring system (PING). The TSC air handing and filtration units will be nonfunctional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 48 hours. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning procedures and checklists. If radiological conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with, EP-AA-112-200-F-01.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 47120
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: ALBERT MARTIN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/02/2011
Notification Time: 21:27 [ET]
Event Date: 08/02/2011
Event Time: 13:46 [CDT]
Last Update Date: 08/02/2011
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):
BOB HAGAR (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

VULNERABILITY FROM A POTENTIAL HIGH ENERGY LINE BREAK

"The following condition is being reported by Arkansas Nuclear One, Unit 2 (ANO-2) in accordance with 10CFR 50.72(b)(3)(ii)(B), 'Unanalyzed Condition' and in accordance with 10CFR 50.72(b)(3)(v)(D), 'A Condition That Could Have Prevented Fulfillment of a Safety Function.' On 08/02/2011 at 1346 CDT, the ANO Unit 2 Control Room was notified by Engineering that a postulated High Energy Line Break (HELB) could potentially cause both the Red and Green Train Emergency Safeguard Features (ESF) Rooms to exceed their environmentally qualified temperature limits. This postulated condition would be possible due to normally open room purge dampers exposing ESF equipment in these rooms to a common area impacted by HELB conditions. The ESF Rooms contain the Red and Green Trains of High Pressure Safely Injection Pumps, Low Pressure Safety Injection Pumps, Containment Spray Pumps, and Shutdown Cooling Heat Exchangers. Until further Engineering evaluation can be performed to validate this postulated scenario, ANO-2 has closed ESF room purge dampers to provide Red and Green ESF train separation during a potential HELB event.

"Refer to [ANO-2] Condition Report CR-ANO-2-2011-02772 for further information. The NRC Resident has been notified."

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Thursday, March 29, 2012