| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/26/2012 - 07/27/2012 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 48118 | Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS
Region: 3
City: RACINE State: WI
County:
License #: 101-1299-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: DONALD NORWOOD | Notification Date: 07/19/2012
Notification Time: 17:06 [ET]
Event Date: 07/19/2012
Event Time: [CDT]
Last Update Date: 07/19/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
LAURA KOZAK (R3DO)
FSME via E-mail ()
| Event Text AGREEMENT STATE REPORT - 15 PROSTATE BRACHYTHERAPY MEDICAL EVENTS
The following information was received via facsimile:
"On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS [Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001.
"--Overdose to the prostate (medical event criteria used -D90>130%):
08/20/2009: 137.3%
"--Underdose to the prostate (medical event criteria used -D90<80%):
07/15/2005: 79.27%
03/13/2006: 79.17%
03/15/2006: 67.10%
07/26/2006: 72.35%
07/26/2006: 57.06%
02/13/2006: 78.37%
05/14/2009: 78.67%
"--Overdose to the rectum (medical event criteria used -V100>2cc):
12/13/2006: 2.42cc
12/19/2007: 2.23cc
03/03/2009: 2.54cc
07/08/2009: 3.32cc
11/19/2009: 2.89cc
05/05/2010: 2.41cc
05/20/2010: 3.92cc
"DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review."
Wisconsin Event Report ID No.: WI120008
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. |
| Non-Agreement State | Event Number: 48119 | Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: KAPARIK OIL FIELD State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: PATTON D. PETTIJOHN
HQ OPS Officer: DONALD NORWOOD | Notification Date: 07/19/2012
Notification Time: 17:18 [ET]
Event Date: 07/01/2012
Event Time: 23:45 [YDT]
Last Update Date: 07/19/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
DAVID PROULX (R4DO)
FSME via E-mail ()
| Event Text UNABLE TO RETRACT SOURCE INTO RADIOGRAPHY CAMERA
"On July 1, 2012 at 11:45 pm, a radiography crew using remote access technology at the Kuparuk Oil Field on the North Slope of Alaska had the jig, collimator and guide tube dislodge and fall while cranking out the source. With the added weight of the connected jig and collimator, the guide tube ended up hanging straight down 30 feet above a platform floor, creating a sharp bend where the guide tube connects to the camera. The crew was not able to retract the source immediately after the accident. Kakivik's onsite Radiation Safety Supervisor and the RSO were immediately notified. The 2 mr/hr boundary was re-surveyed and adjusted. Constant surveillance and control of the boundary was maintained. Per guidance from the Kakivik's emergency procedures and RSO, the exposure device was to be lowered by ropes onto a suitable working surface. During the camera decent, the guide tube came in contact with piping and was straightened sufficiently to allow the source to be safely cranked into the fully
shielded and secured position while still suspended from the ropes. The source was fully shielded within the exposure device by 2:13 am July 2nd. The operation to lower the camera to straighten the guide tube and crank in the source to the fully shielded position took approximately one minute. No exposure to the public or overexposure to Kakivik employees or unauthorized entry into the restricted area was made. All the radiographic equipment was inspected after the accident. The ball connector at the end of the crank drive cable was bent and was replaced. The outside of the guide tube was damaged and taken out of service. The camera including the source pigtail connector was not damaged and was returned to service.
"After investigation, the cause of the incident was determined to be the improper use of a magnetic jig that was attached to a surface that did not have sufficient force to hold the combined weight of jig, collimator, guide tube and source.
"The corrective actions taken to prevent recurrence included writing a company policy that clearly states that a radiographer may not use magnetic jigs to support the guide tube and collimator unless it is also supported with ratchet straps or a chain wrench or unless the magnetic jig is being used on a flat steel floor surface. This policy will be required to be read and adhered to by all current and new radiographers. This incident will be reviewed with all the Kakivik radiographers and assistants by the RSO or RSS."
There were no injuries as a result of this event and there were no overexposures to members of the public or employees. |
| Power Reactor | Event Number: 48136 | Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: HOWARD MAHAN
HQ OPS Officer: PETE SNYDER | Notification Date: 07/26/2012
Notification Time: 14:27 [ET]
Event Date: 07/26/2012
Event Time: 09:25 [EDT]
Last Update Date: 07/26/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
MARK FRANKE (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | N | 0 | Under Construction | 0 | Under Construction | | 4 | N | N | 0 | Under Construction | 0 | Under Construction | Event Text CONFIRMED POSITIVE ON A FITNESS FOR DUTY TEST
A non-licensed employee supervisor had a confirmed positive for alcohol during a follow-up fitness for duty test. The employee's unescorted access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 48139 | Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MOT HEDGES
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/26/2012
Notification Time: 17:52 [ET]
Event Date: 05/31/2012
Event Time: 05:35 [PDT]
Last Update Date: 07/26/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
| Person (Organization):
JAMES DRAKE (R4DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 86 | Power Operation | 86 | Power Operation | Event Text 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID PRIMARY CONTAINMENT ISOLATION VALVE ACTUATION
"At 0535 [PDT] on 5/31/12 during power ascension following a maintenance outage, a loss of power to the Reactor Protection System (RPS) 'B' occurred due to the unexpected opening of the circuit breaker (RPS-CB-MG2) for the RPS 'B' motor generator. The loss of RPS 'B' resulted in a half scram signal, closure of Primary Containment Isolation Valves (PCIVs) from multiple systems and loss of power to main steam line radiation monitors (MS-RIS-610B & MS-RIS-610D). No plant parameters or maintenance activities existed which would cause the opening of RPS-CB-MG2; therefore, this is considered to be an invalid actuation of a system listed in 10CFR50.73(a)(2)(iv).
"The half scram signal, closure of Primary Containment Isolation Valves (PCIVs) from multiple systems, and loss of power to MS-RIS-B & D were an expected response to the loss of RPS 'B'.
"Power ascension was temporarily halted. RPS 'B' was repowered from an alternate power supply. The half scram signal was reset, the containment isolation valves were opened and the affected systems were returned to normal operation. Power ascension was resumed. The circuit breaker (RPS-CB-MG2) was replaced and RPS 'B' was returned to its normal power supply.
"Initial investigation efforts have not determined a cause for RPS-CB-MG2 opening. Investigations into the cause of RPS-CB-MG2 opening are continuing.
"As indicated in 10CFR50.73(a)(1), in the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv)(A), the licensee may, at its option, provide a telephonic notification to the NRC Operations Center within 60 days of discovery of the event instead of submitting a written LER. This 60-day telephone notification is being made to meet the reporting requirements instead of submitting an LER since the actuation was invalid.
"The following additional information is provided as specified in NUREG-1022:
"The specific train(s) and system(s) that were actuated: PCIVs in multiple systems
EDR-V-19 Drywell Equipment Drain Inboard Isolation Valve
EDR-V-20 Drywell Equipment Drain Outboard Isolation Valve
FDR-V-3 Drywell Floor Drain Inboard Isolation Valve
FDR-V-4 Drywell Floor Drain Outboard Isolation Valve
RWCU-V-1 Reactor Water Cleanup Suction Inboard Isolation Valve
RWCU-V-4 Reactor Water Cleanup Suction Outboard Isolation Valve
RRC-V-19 Reactor Water Sample Inboard Isolation Valve
RRC-V-20 Reactor Water Sample Outboard Isolation Valve
TIP-V-15 Traversing In-Core Probe Purge Isolation Valve
CRD-V-11 Control Rod Drive Scram Discharge Volume Drain Valve
"Whether each train actuation was complete or partial:
All PCIVs actuations for a loss of RPS 'B' were complete
The reactor half scram for a loss of RPS 'B' was a partial activation
"Whether or not the system started and functioned successfully:
All PCIVs functioned successfully"
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 48140 | Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHUCK BAREFIELD
HQ OPS Officer: PETE SNYDER | Notification Date: 07/26/2012
Notification Time: 23:24 [ET]
Event Date: 07/26/2012
Event Time: 21:51 [CDT]
Last Update Date: 07/26/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
| Person (Organization):
MARK FRANKE (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 99 | Power Operation | Event Text TECH SPEC REQUIRED SHUTDOWN FOR DIESEL MAINTENANCE EXCEEDING ALLOWED OUTAGE TIME
"At 21:51 [CDT] [on 7/26/12], Farley has commenced shutdown of Unit 1 in accordance with T.S. 3.8.1, AC Sources - Operating. 1B Diesel Generator was removed from service on 7/16 at 21:52 [CDT] for a planned 24 month outage. Due to emergent equipment issues with the diesel, the RAS (Required Action Statement) time of 10 days to return the diesel generator to service has not been met. Unit 1 shutdown to Mode 3 has commenced. The unit must be in Mode 3 by 03:52 [CDT] on 7/27/12, and Mode 5 by 09:52 [CDT] on 7/28/12."
The licensee has informed the NRC Resident Inspector. |
| Power Reactor | Event Number: 48141 | Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: JAMES CRABILL
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 07/27/2012
Notification Time: 00:29 [ET]
Event Date: 07/26/2012
Event Time: 21:20 [CDT]
Last Update Date: 07/27/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
JAMES DRAKE (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 | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text LOSS OF AC POWER TO THE EMERGENCY OPERATIONS FACILITY
"At 2120 [CDT] [on 07/26/12], a loss of AC power to the Emergency Operations Facility (EOF) occurred effecting emergency response capability. The Technical Support Center (TSC) remained available. In the event of on emergency declaration requiring an EOF, the emergency Response Organization (ERO) would have been directed to report to the Backup EOF.
"Assessment capability via SPDS was not lost during this time period and communications equipment also remained available.
"Coincident with no local offsite power being available, the backup diesel generator was unable to supply AC power to the facility due to an overvoltage condition present on the transfer switch. No power was available from the time period of 2120 [CDT] to 2133 [CDT] when local offsite power was restored to the building.
"This notification is being made in accordance with 10 CFR 50.12(b)(3)(xiii) due to the unavailability of an emergency response facility."
The licensee has notified the NRC Resident Inspector. | |