Event Notification Report for November 16, 2011

KENTUCKY AGREEMENT STATE REPORT - WRONG BRACHYTHERAPY TREATMENT PLAN PERFORMED ON WRONG PATIENT

The following information was obtained from the Commonwealth of Kentucky via email:

"Kentucky RHB [Radiation Health Branch] was notified via e-mail on 11/17/11 at 10:30 a.m. [EST] and via telephone call on 11/17/11 at 10:45 a.m. of a possible medical event occurring on 11/16/11. The medical event involved using the wrong permanent prostate brachytherapy implant treatment plan on the wrong patient. The facility performed back to back procedures on two patients on two consecutive days and the implant procedure used on the second patient was actually developed for the first patient. The RSO reported that immediately after completing the procedure, the mishap was noted by the Radiation Oncologist and a post implant CT and MRI were performed immediately. The Radiation Oncologist who developed the treatment plan and performed the procedure determined the dose delivered to the target organ based on D90 was 90%. According to the RSO, written directives for both patients called for the same number of seeds of the same radionuclide and same activity and both called for the same prescribed dose thus accounting for the oversight on the part of the Radiation Oncologist. These similarities however, allowed for a D90 of 90% despite the wrong treatment plan being used. The State will continue to keep NRC informed of the status of their investigation."

The patient was given 79 seeds with 0.0406 mCi of I-125 per seed (STM 1251). The manufacturer was Bard Brachytherapy Inc.

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.

IRRADIATOR SOURCE STUCK IN UNSHIELDED POSITION

On November 16, 2011 at 1637 EST, the licensee's Radiation Safety Officer called the NRC Operations Center, as required by 10 CFR 36.83, to report a source not being able to be returned to its normal down position inside a J.L. Shepherd Model 81-24Q Beam Irradiator.

At approximately 1109 EST on November 16, 2011 the source, located inside the right side of the irradiator, was not able to be returned to the down position. An emergency shutter built into the system was deployed, which reduced the radiation intensity surrounding the irradiator, permitting access into the irradiator room. Upon entering the room, it was noted that the source position indicator found on the operating tower mounted on the top of the irradiator showed that the source was about halfway up from its normal down position. A radiation survey taken around the irradiator found one point in front of the emergency shutter to be less than 10 mR/hr at one foot from the irradiator. Further shielding was added at this point which reduced it down to about 0.3 mR/hr.

Contact was made to J. L. Shepherd and arrangements are being made to have a representative come onsite to help return the source to its normal down position.

RHR CAPABILITY AFFECTED DUE TO BOTH TRAINS OF RIVER WATER SUPPLY HVAC SYSTEMS INOPERABLE

"At 1622 [CST] on November 16, 2011, NextEra Energy Duane Arnold declared the 'A' River Water Supply inoperable following discovery that the HVAC damper controller was installed in reverse. This would have closed the HVAC intake dampers on high temperature instead of opening them. At this time, the 'B' River Water Supply system was already inoperable for HVAC damper maintenance. This resulted in entering TS 3.7.2 Condition B for both River Water Supply systems inoperable [required action to restore a train or be shutdown in 12 hours]. Both trains of River Water Supply inoperability potentially affect the plant capability to remove residual heat. Therefore, this event is being reported pursuant to the requirements of 10CFR 50.72(b)(3)(v)(B).

"At 1735 [CST] on November 16, 2011 Post Maintenance testing on the 'B' River Water Supply HVAC Dampers was completed and 'B' River Water Supply was declared operable, restoring the capability to remove residual heat.

"The NRC Resident Inspector has been notified."

* * * UPDATE AT 1440 EST ON 01/16/12 FROM BOB MURRELL TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"The purpose of this notification is to retract a previous report made on 11/16/2011 at 19:04 (ET) (EN 47448). Notification of the event to the NRC was initially made as a result of declaring both trains of the River Water Supply (RWS) system inoperable following the discovery that the HVAC damper controller was installed incorrectly.

"Subsequent to the initial report, NextEra Energy Duane Arnold (NextEra) has determined that the RWS system was capable of performing its safety function and was fully operable during the period that the HVAC controller was incorrectly configured. Specifically, based on the environmental conditions that existed during the period from November 8, 2011 to November 16, 2011, the non-TS RWS Intake HVAC system was Functional, but Degraded.

"This event is not considered a Safety System Functional Failure or a Condition Prohibited by TS and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73.

"The NRC Senior Resident Inspector has been notified."

Notified R3DO (Orth).

HPCI DECLARED INOPERABLE DUE TO DUAL POSITION INDICATION ON CLOSED STEAM ADMISSION ISOLATION VALVE

"On November 16, 2011, at 1600 hours [EST], with the reactor at 100% core thermal power and steady state conditions, the High Pressure Coolant Injection (HPCI) system was removed from service for planned testing and the appropriate Limiting Condition for Operation was entered (14 days per TS 3.5.C.2). At 1700 hours during restoration from the testing, the normally closed HPCI steam admission isolation valve (HPCI-2301-3) displayed dual indication (not full closed). The HPCI-2301-3 is a motor-operated valve (MOV) whose safety function is to open upon a HPCI injection/actuation signal.

"The Limiting Condition for Operation (LCO) that had been entered in a planned manner was continued as of 1700 hours due to the apparent degraded performance of the HPCI-2301-3 valve. Currently, troubleshooting into the cause of the anomalous dual indication on HPCI-2301-3 is in progress. However, it is projected that the troubleshooting will not be complete within reportability assessment requirements. Therefore, in accordance with 50.72(b)(3)(v)(D), Pilgrim Nuclear Power Station is providing an 8 hour non-emergency notification that the HPCI System is inoperable.

"This event had no impact on the health and/or safety of the public.

"The NRC Resident Inspector has been notified."

* * * UPDATE AT 1715 EST ON 01/16/12 FROM JOSEPH BRACKEN TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"Event Notification Number 47449 was conservatively made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 were satisfied pending further evaluation of HPCI system operability due to dual valve position indication when the HPCI Turbine Steam Supply Valve (MO-2301-3) valve was taken to the fully closed position after HPCI system surveillance testing from the Alternate Shutdown Panel.

"Evaluation of the MO-2301-3 valve condition was performed. The dual position indication from the valve position instrumentation was determined to be valid based on the as-found valve position. The valve did not fully close because the torque switch opened prematurely due to high stem torque. The apparent cause evaluation identified that a lack of grease due to a tight stem to valve configuration and inadequate guidance to perform proper periodic stem lubrication were the apparent cause of the valve closure failure.

"The valve is limit switch controlled in the open direction and torque switch controlled in the closed direction. The valve is normally closed and has no automatic closing function necessary to ensure HPCI System safety functions are satisfied. The valve has an active safety function to open to allow steam to the HPCI Turbine. The surveillance test that was performed verified capability of the valve to open on demand. Based on the surveillance test, failure of the HPCI Turbine Steam Supply Valve to close would not have prevented the HPCI System from operating and meeting required safety functions.

"Therefore, the initial 50.72(b)(3)(v)(D) report is being retracted."

The licensee will inform the NRC Resident Inspector. Notified R1DO (Trapp).

ALERT DUE TO FIRE IN ELECTRICAL BUS AFFECTING SAFETY RELATED EQUIPMENT

At 0222 EST on November 16, 2011, an ALERT was declared due to an electrical fire in the auxiliary building which houses safety related equipment. The apparent cause of the fire was due to an unknown source of water leaking on a breaker, thus causing an arc. The electrical fire is out. The plant was at 0% power and will remain shutdown in Mode 5. There was no impact on core cooling, or emergency power supplies.

The licensee has notified the NRC Resident Inspector and state and local agencies.

* * * UPDATE FROM JANE MALLERNEE TO JOHN KNOKE AT 0449 EST ON 11/16/11 * * *

At 0443 EST on November 16, 2011, Davis Besse, Unit 1 exited their ALERT. The electrical short affected the Control Room Emergency Ventilation Fan #1 Damper.

The licensee has notified the NRC Resident Inspector. Notified R3DO (Hills) and Canada Nuclear Safety Commission (Jim Sandlef).

UNUSUAL EVENT DUE TO DRYWELL LEAKAGE GREATER THAN 10 GPM

"On 11/16/11 at 0208 EST, Brunswick Nuclear Plant, Unit 2 calculated a drywall floor drain 42 minute leak rate of 5.88 gpm, following several hours of gradually rising floor drain leakage during a plant startup. Tech Spec 3.4.4 A was entered, requiring floor drain leakage to be restored below 5 gpm within 8 hours. At 0253 EST, a 45 minute leak rate of 10.11 gpm was calculated. At 0301 EST, Unusual Event SU 6.1 was declared for unidentified leakage exceeding 10 gpm, and at 0309 EST, a manual reactor scram was inserted from approximately 7% power [10 CFR 50.72(b)(2)(iv)(B)]. Following the scram, the reactor was depressurized at a maximum cooldown rate of 92.5 deg F/hr, and the unidentified leak rate fell less than 10 gpm within 1 hour and less than 5 gpm within 2 hours. Leak rate at 0614 EST on 11/16/11 is 3.82 gpm with reactor pressure at 228 psig.

"The exact nature of the leak is unknown at this time. The current plan is to continue to depressurize and cool down the reactor to Mode 4, such that a full drywall inspection can commence. At present, Brunswick has not terminated the Unusual Event."

Level control is currently being maintained with control rod drives (CRD). The MSIVs were manually closed to control cooldown. The maximum cooldown was observed to be 92.5 F/hour. The plant plans to reopen MISIVs and depressurized to condensate booster pump injection pressure of 350 psig. The plan is to achieve Mode 4 for a leak inspection.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM DAVID FASHCHER TO CHARLES TEAL AT 0550 EST ON 11/16/11 * * *

The leakage rate is currently 3.73 gpm. The decrease is due to lower pressure which is currently at 258 psig. There are no additional changes. The leakage source is not identified at this time. The licensee has notified the NRC Resident Inspector.

Notified R2DO (Vias).


* * * UPDATE FROM DUSTIN LUPTON TO JOHN SHOEMAKER AT 0648 EST ON 11/16/11 * * *

The leakage rate is currently below the T.S. limit due to lower pressure which is currently at 210 psig. There are no additional changes. The plant will remain in an Unusual Event (UE) until further notice. The licensee has notified the NRC Resident Inspector.

Notified R2DO (Vias).

* * * UPDATE FROM DUSTIN LUPTON TO CHARLES TEAL AT 0749 EST ON 11/16/11 * * *

The leakage rate is stable. The leak rate is calculated at 3.04 gpm at 183 psig at 0708 EST. The current reactor pressure is 162 psig. The licensee has notified the NRC Resident Inspector.

Notified R2DO (Vias).

* * * UPDATE FROM DUSTIN LUPTON TO JOHN KNOKE AT 0832 EST ON 11/16/11 * * *

The licensee terminated from their Unusual Event at 0815 EST. The leakage is still unidentified.

The licensee has notified the NRC Resident Inspector.

Notified R2DO (Vias).

POSTULATED FLOODING SCENARIO RESULTS IN UNANALYZED CONDITION

"On November 16, 2011, at 2000 hours (EST), control room operators accepted the results of an immediate investigation related to the adequacy of a calculation related to the flooding analysis for service water piping in the control complex. The conclusions of the original analysis assumed operator actions to mitigate the flooding. The existing procedural guidance at that time lacked specificity for the required operator actions. This was identified as a non-conforming condition with respect to a USAR flooding analysis. The immediate investigation determined that significant margin exists for mitigation of the service water leakage crack compared to the 30 minute actions required in the original analysis. A preliminary strategy for flood mitigation was identified in the immediate investigation. Guidance was provided to the operators for a leak mitigation strategy in a night order, and a prompt functionality assessment was requested for the control complex building with respect to the flooding analysis. On November 22, 2011, at 1957 hours (EST), the prompt functionality assessment was accepted by the control room operators. The assessment included compensatory measures that simplified guidance for mitigating the flooding from the service water system. The compensatory measures were implemented. On December 2, 2011, the NRC Component Design Basis Inspection team debriefed that the condition identified should have been called in to the NRC Operations Center within eight hours and that missing the call was a violation of 10 CFR 50.72(b)(3)(ii)(B). On December 7, 2011, at 1320 hours (EST), a call was received from the NRC Region III informing the compliance supervisor that the eight-hour notification should still be made.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM CHARLES ELBERFELD TO JOHN KNOKE AT 1412 EST ON 12/10/11 * * *

The licensee added further clarification to the event reported above as follows:

"Given that an unanalyzed condition existed until the appropriate measures were implemented, an eight-hour call in accordance with the aforementioned section of 10 CFR 50.72 should have been made. After further consideration, station management decided the eight-hour call was missed and it is being reported as required.

"The NRC Resident Inspector has been notified." R3DO (Skokowski) notified.