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Event Notification Report for August 25, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/24/2011 - 08/25/2011

** EVENT NUMBERS **


47152 47173 47174 47175 47181 47184 47196

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Fuel Cycle Facility Event Number: 47152
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/13/2011
Notification Time: 11:00 [ET]
Event Date: 08/12/2011
Event Time: 12:00 [EDT]
Last Update Date: 08/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(5) - DEV FROM ISA
Person (Organization):
GEORGE HOPPER (R2DO)
THOMAS HILTZ (NMSS)

Event Text

INTEGRATED SAFETY ANALYSIS (ISA) - UNANALYZED CONDITION

"As part of the ongoing GNF-A review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis, accident sequences associated with hydrogen piping are being evaluated. As part of this evaluation, facility walk downs of the piping were performed that identified a configuration that had not previously been analyzed. Based on a review of this as found condition, it was determined at approximately 12 p.m. on August 12, 2011 that the system was improperly analyzed in the ISA and resulted in a failure to meet performance requirements.

"Hydrogen supply to the affected piping system inside the building has been isolated. Additional corrective actions and extent of condition are being evaluated.

"This event is being reported pursuant to the reporting requirements of 10 CFR 70 Appendix A (b)(1) within 24 hours of discovery."

The licensee will notify NRC Region 2 and appropriate state and local authorities.

* * * UPDATE FROM PHILLIP OLLIS TO ERIC SIMPSON AT 1228 EDT ON 8/24/11 * * *

"Unnecessary piping branches have been removed and caps welded in place. The new piping configuration has been analyzed for ISA accident sequences.

"Based upon this, hydrogen supplies to affected equipment will resume and normal operations will commence."

The licensee will notify NRC Region 2.

Notified R2DO (Widmann) and NMSS EO (Campbell).

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Agreement State Event Number: 47173
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 14:52 [ET]
Event Date: 08/16/2011
Event Time: 14:44 [PDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LEAKING IODINE-125 BRACHYTHERAPY SEEDS

The following information was obtained from the State of California via email:

"UCLA contacted the Brea office of RHB [Radiologic Health Branch] to report a leaking source of I-125 brachytherapy seeds. Initial survey of the packaging, upon receipt, did not show any contamination. Subsequent testing showed 1.8 microCuries of contamination. The order was for 19 seeds, 16 for treatment, one for calibration and 2 for spares. A physician was preparing an eye plaque using the 16 seeds. A dish of acetone was used to remove glue from the seeds. A radiation survey discovered that the dish had become contaminated with I-125. The patient's procedure was cancelled and EH&S [Environmental Health and Safety] personnel were notified about the issue. EH&S collected all 19 seeds and performed a leak test on the 16 treatment seeds by soaking them in isopropyl alcohol. The fluid was analyzed on a liquid scintillation counter which found 1.8 microCuries of removable contamination.

"Per 10 CFR 35.3067, a licensee shall file a report within 5 days if a leak test required by 35.67 reveals the presence of 185 Bq (0.005 uCi) or more of removable contamination.

"RHB is requesting UCLA to obtain copies of the leak tests performed by the manufacturer to determine if the seeds were leaking prior to being shipped to UCLA. These copies will be in the final report. If the seeds were discovered to be shipped in a compromised condition, the Virginia Division of Radiological Health will be notified since the manufacturer (Best Medical International, Inc. of Springfield, Virginia) is located within their jurisdiction."

California Report Number: 5010-081611

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Agreement State Event Number: 47174
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: CARILLION CLINIC
Region: 1
City: ROANOKE State: VA
County:
License #: 770-051-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 15:42 [ET]
Event Date: 08/07/2011
Event Time: [EDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

VIRGINIA AGREEMENT STATE REPORT - DOSE RECEIVED BY PATIENT GREATER THAN PRESCRIBED

The following information was obtained from the State of Virginia via fax:

"On August 7, 2011, the licensee's RSO received notification of an incident. A patient was treated for bronchial/trachea carcinoma using temporary brachytherapy employing a HDR delivery system. Subsequent to treatment, it was realized that dwell positions were misrepresented on the approved treatment plan. Reconstruction of the applicator position led to the conclusion that dose to organs or tissue other than the treatment site received more than 50 Rem and more than 50% of the expected dose. Licensee notified Virginia Department of Health on August 17, 2011. Referring physician was notified on August 17, 2011. Physician is meeting with patient on August 19, 2011. Licensee indicated organs at risk and health effects to patient are under development."

Virginia Report ID: VA-11-08

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: 47175
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OUR LADY OF BELLEFONTE HOSPITAL
Region: 1
City: ASHLAND State: KY
County:
License #: 202-144-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: PETE SNYDER
Notification Date: 08/19/2011
Notification Time: 15:39 [ET]
Event Date: 07/15/2011
Event Time: 12:15 [CDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - IMPROPER THERAPEUTIC HYPERTHYROID DOSE

Kentucky provided the following information via e-mail:

"On July 15, 2011, an 82 year old male patient was scheduled for a therapeutic dose of I-131, 15 mCi for the treatment of subclinical hyperthyroidism with [the prescribing physician]. The therapeutic dose received from the radiopharmacy was assayed prior to administration and indicated an amount of 19.9 mCi.

"The technologist assaying the dose contacted [the physician] concerning the difference in the amount ordered and the amount received. [The physician] chose to accept the dose and administer it to the patient based on the patient's age and symptomatic subclinical hyperthyroidism and enlarged lobe.

"[The physician] accepted the dose clinically but did not document this on the written directive prior to administration. The change in dose is documented in [the physician's] dictation, completed on July 15, 2011 at 1:44 p.m., acknowledges the change in the dose administered and it is documented that the technologist informed him of the difference in dose and his acceptance and why this amount was acceptable.

"The failure to change the written directive prior to administration was not identified until August 8, 2011 during OLBH's [Our Lady of Bellefonte Hospital] annual audit conducted by a Medical Physicist. [The] RSO and the Director of Radiology contacted the RHB [Radiation Health Branch] on August 9, 2011 for notification of the medical event.

"Contributing Factor: Failure to change the written directive prior to administration of the I-131.

"Corrective Actions by Licensee: A policy and procedure review was conducted. The Quality Management form and Written Directive used with administration of I-131 therapies was reviewed and updated to include an area that requires explanation of any dose that differs from the prescribed dose being administered and the signature of the AU [authorized user] confirming the change in dose prior to administration."

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: 47181
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: LEE BARON
HQ OPS Officer: ERIC SIMPSON
Notification Date: 08/23/2011
Notification Time: 14:24 [ET]
Event Date: 08/23/2011
Event Time: 14:03 [EDT]
Last Update Date: 08/24/2011
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MALCOLM WIDMANN (R2DO)
JOHN THORP (NRR)
SCOTT MORRIS (IRD)
JACK GROBE (NRR)
VICTOR MCCREE (R2RA)
JAMES (DHS)
ERWIN (FEMA)
REDINGTON (USDA)
FOOTE (DOE)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

ALERT DECLARED DUE TO AN EARTHQUAKE IN THE AREA AND A LOSS OF OFFSITE POWER

At 1403 hrs. EDT, North Anna Power Station declared an Alert due to significant seismic activity onsite. The Alert was declared under EAL HA6.1. Both units experienced automatic reactor trips from 100% power and are currently stable in Mode 3. All offsite electrical power to the site was lost. All four emergency diesel generators (EDG) automatically started and loaded and provided power to the emergency buses.

While operating, the 2H EDG developed a coolant leak and was shutdown. As a result, the licensee added EAL SA1.1 to their declaration.

All control rods inserted into the core. Decay heat is being removed via the steam dumps to atmosphere. No personnel injuries were reported.

* * * UPDATE FROM ROBERT RINK TO HOWIE CROUCH AT 1116 EDT ON 8/23/11 * * *

The licensee has downgraded the Alert to a Notification of Unusual Event based on equipment alignments and inspection results.

The licensee notified R2 IRC. Notified IRD (Marshall), NRR (Thorp), FEMA (Hollis), DHS (Inzer), USDA (Ferezan), HHS (Willis) and DOE (Parsons).

* * * UPDATE FROM ROBERT RINK TO HOWIE CROUCH AT 1317 EDT ON 8/23/11 * * *

The licensee has exited the Notification of Unusual Event at 1315 EDT. The exit criteria was that all inspections and walkdowns were completed and plant conditions no longer meet the criteria for a NOUE.

Notified R2DO (Widmann), IRD (Marshall), NRR (Thorp), FEMA (Hollis), DHS (Inzer), USDA (Ferezan), HHS (Willis) and DOE (Jackson).

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Power Reactor Event Number: 47184
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JAMES HUBER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/23/2011
Notification Time: 14:53 [ET]
Event Date: 08/23/2011
Event Time: 14:05 [EDT]
Last Update Date: 08/24/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
PAUL KROHN (R1DO)
WILLIAM DEAN (R1RA)
JOHN THORP (NRR)
JACK GROBE (NRR)
SCOTT MORRIS (IRD)
JAMES (DHS)
ERWIN (FEMA)

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

NOTIFICATION OF AN UNUSUAL EVENT DUE TO A SEISMIC EVENT

"At 1354, the Calvert Cliffs Nuclear Plant (CCNPP) felt seismic activity in the control room.

"Both Unit 1 and Unit 2 maintained full power operations. At 1405 CCNPP declared an Unusual Event (UE) for Unit 1 and Unit 2. NRC Operations center was notified at 1453 via dedicated phone (CCNPP event 4189).

"Both Units continued to operating safely with no actuations. There were no radiological releases.

"An Issue Response Team (IRT) was formed and the site commenced walkdown and inspections of all systems, structures and components for possible seismic damage. All problems found will be entered into the site's Corrective Action Program (CAP) and evaluated for operability."

The licensee notified the NRC Resident Inspector, State, and local government agencies.

* * * UPDATE FROM JUSTIN INLOW TO CHARLES TEAL AT 0027 EDT ON 8/24/11 * * *

They have terminated their Notification of Unusual Event as of 0005 EDT. The licensee has notified the NRC Resident Inspector.

Notified R1DO (Krohn), IRD (Morris), DHS (Knox), FEMA (Via).

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Power Reactor Event Number: 47196
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BEN SCHRUM
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2011
Notification Time: 01:48 [ET]
Event Date: 08/25/2011
Event Time: 01:18 [EDT]
Last Update Date: 08/25/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MALCOLM WIDMANN (R2DO)
VICTOR MCCREE (R2RA)
JACK GROBE (NRR)
JANE MARSHALL (IRD)
JOHN KNOX (DHS)
MIKE BLANKENSHIP (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO AN AFTERSHOCK EARTHQUAKE

On August 25th at 0118 EDT, North Anna Power Station declare an Unusual Event due to seismic activity onsite (EAL HU 1.1). Both units are currently shutdown and electrical power is being supplied from offsite. There were no personnel injuries. There was no radiological release. Site structure and system inspections are in progress. No damage has been identified.

The NRC Resident Inspector and state and local authorities have been notified.

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