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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/29/2012 - 08/30/2012
** EVENT NUMBERS **
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| Agreement State |
Event Number: 48216 |
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: BED BATH AND BEYOND
Region: 1
City: CONCORD State: NH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: TWILA KENNA
HQ OPS Officer: STEVE SANDIN |
Notification Date: 08/21/2012
Notification Time: 09:23 [ET]
Event Date: 08/08/2012
Event Time: [EDT]
Last Update Date: 08/21/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
WILLIAM COOK (R1DO)
ANGELA MCINTOSH (FSME)
FSME RESOURCE (EMAI) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF TRITIUM EXIT SIGNS
The following information was received from the State of New Hampshire:
"On August 8, 2012, a [Bed Bath and Beyond Vice President] called to report the loss of seventeen tritium exit signs. After taking the signs down, they were stored for Shaw Environmental to package and ship them for disposal. While being stored, they were mistakenly taken by another contractor as part of the waste from light bulb removal. This removal was viewed on videotape after Shaw Environmental reported that the box of signs was missing from the storage area.
"[The Bed Bath and Beyond VP] contacted RL Carriers (the removal contractor) to find out where they send the waste for disposal. The location was Waste Management in South Carolina. [The Bed Bath and Beyond VP] contacted Waste Management and was told that they had not received any exit signs but if they had, they would have sent them to Synergy Recycling in North Carolina. When contacted, Synergy Recycling stated that they had not received any exit signs.
"The serial numbers for the 17 Tritium Exit Signs that cannot be located are listed below. The Manufacturer is Safety Light, model SLK-60.
301364 - 301367
301370 - 301376
301381
303792
303794 - 303797"
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 |
| Agreement State |
Event Number: 48218 |
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER |
Notification Date: 08/21/2012
Notification Time: 16:27 [ET]
Event Date: 08/21/2012
Event Time: [EDT]
Last Update Date: 08/21/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
WILLIAM COOK (R1DO)
FSME_EVENTS RESOURCE (EMAI) |
Event Text
AGREEMENT STATE - RADIATION TREATMENT OVERDOSE RESULTING FROM A POTENTIAL GENERIC ISSUE
The following information was provided by the State of Pennsylvania via facsimile:
"On Monday, August 20, 2012, the licensee informed the Pennsylvania Department of Environmental Protection's Southcentral Regional Office of a medical event which occurred the same day. It is reportable within 24-hours under 10 CFR 35.3045(a)(1)(iii).
"During the first fraction of radiation therapy treatment, using a Nucletron Corporation microSelectron HDR (High Dose Rate) Model 106.990 remote afterloader, the unit's treatment planning software malfunctioned, resulting in an overdose to the patient of approximately 76.5%. Facility staff also failed to complete a required worksheet which may have alerted the Authorized User to the dosage difference prior to treatment. A total dose of 600 cGy (rad) was delivered instead of the prescribed 340 cGy (rad). The patient was notified on the same day, while the referring physician was notified the following day. The treating physician anticipates no effect to the patient, however, dose reconstruction is currently in progress. We believe this incident also qualifies the event as an Abnormal Occurrence.
"Cause of the event is equipment malfunction and human error.
"Licensee is contacting a service provider for the HDR unit to investigate the incident, and if needed, repair the equipment. The Pennsylvania Department of Environmental Protection will be evaluating possible generic implications and plans to do a reactive inspection as soon as possible."
PA Event Report No: PA120025
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. |
| Agreement State |
Event Number: 48222 |
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: BED BATH AND BEYOND
Region: 3
City: COUNCIL BLUFFS State: IA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSON
HQ OPS Officer: BILL HUFFMAN |
Notification Date: 08/22/2012
Notification Time: 16:35 [ET]
Event Date: 07/20/2012
Event Time: [CDT]
Last Update Date: 08/22/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ERIC DUNCAN (R3DO)
FSME EVENT RESOURCE (EMAI) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
AGREEMENT STATE REPORT- 12 MISSING TRITIUM EXIT SIGNS
The Iowa Department of Public Health provided a preliminary notification that 11 or 12 tritium exit signs are missing from a Bed Bath and Beyond store in Council Bluffs Iowa. The store has replaced all its tritium exit signs with LED exit signs. The tritium exit signs were removed by an electrical subcontractor specifically instructed to keep the removed signs segregated for special disposal by Shaw Industries. The removed tritium exit signs could not be located when Shaw arrived at the store to package and ship the signs. A representative for the store believes that either the signs were mixed with fluorescent lights that were being sent to a separate recycling facility or that the subcontractor may have inadvertently disposed of the tritium signs at an unknown location. The fluorescent light recycling facility has been contacted but was unable to find any evidence that the signs were sent to their location.
The tritium exit signs were generally licensed with a nominal activity of 11.5 curies each. The sign manufacturer was Shield Source.
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 |
| Power Reactor |
Event Number: 48246 |
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN STERMER
HQ OPS Officer: JOHN KNOKE |
Notification Date: 08/29/2012
Notification Time: 00:16 [ET]
Event Date: 08/28/2012
Event Time: 17:00 [PDT]
Last Update Date: 08/29/2012 |
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):
DAVID PROULX (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
MITIGATING ACTIONS IMPLEMENTED FOR INOPERABLE CONTROL ROOM ENVELOPE
"On August 28, 2012, 17:00 PDT, Pacific Gas and Electric Company (PG&E) identified additional release pathways that could affect the control room (CR) operator dose following a Large-Break Loss-of-Coolant Accident (LBLOCA). Consequently, PG&E declared the control room envelope (CRE) inoperable and is establishing mitigative actions in accordance with TS 3.7.10, Action B.1, 'Initiate action to implement mitigating actions' immediately, and Action B.2, 'Verify mitigating actions ensure CRE occupant exposures to radiological hazards will not exceed limits, and CRE occupants are protected from smoke and chemical hazards' within 24 hours.
"PG&E is establishing mitigative actions in accordance with TS 3.7.10 and RG 1.196. These mitigative actions are for operations control room personnel to administer potassium iodide and don self-contained breathing apparatus equipment in a timely fashion should a LBLOCA occur. They will be communicated and controlled by a standing order to the control room staff.
"PG&E previously established controls on other release pathways that offset the potential increases to the maximum predicted offsite dose due to the new release pathways. No increase in maximum predicted offsite dose is expected from the new release pathways.
"Diablo Canyon (DCPP) is making this 8-hour, non-emergency notification under 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(D).
"Plant personnel notified the NRC Resident Inspector." |
| Power Reactor |
Event Number: 48247 |
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: D. W. MCGAUGHEY
HQ OPS Officer: JOHN KNOKE |
Notification Date: 08/29/2012
Notification Time: 10:00 [ET]
Event Date: 08/29/2012
Event Time: 08:57 [CDT]
Last Update Date: 08/29/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
DAVID PROULX (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
PARTIAL LOSS OF PLANT RADIATION MONITORING SYSTEM REMOTE READOUT
"On August 29, 2012, power was removed from SCADA B of the Radiation Monitoring System (RMS) to perform a planned system modification. During this period, data for most Unit 2 radiation monitors will not be electronically available in the emergency response facilities and will not be supplied to the Emergency Response Data System (ERDS), if activated. System alarms and data displays will still be available to the plant operators in the Control Room. The expected duration of RMS remote data partial inoperability is approximately 72 hours. The loss of Unit 2 remote readout capability requires compensatory measures to be used for the acquisition of radiological data in the emergency response facilities. These compensatory measures have been communicated to the emergency response organization. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still be made, if required, during the time that the portions of the RMS are inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. An update message will be provided when the RMS is restored.
"The NRC Resident and Region IV EP Inspectors have been notified." |
| Power Reactor |
Event Number: 48250 |
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JUSTIN KELLY
HQ OPS Officer: HOWIE CROUCH |
Notification Date: 08/29/2012
Notification Time: 15:35 [ET]
Event Date: 08/29/2012
Event Time: 08:27 [EDT]
Last Update Date: 08/29/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
STEVEN VIAS (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 |
Event Text
LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO LIMITED RANGE ON INDICATOR
"This is a non-emergency report regarding a condition that does not apply in our current operating mode. No actual event has occurred.
"At 0827 hours EDT, on August 29, 2012, Harris Operations discovered that the instrumentation used for determination of Emergency Action Levels (EALs) during Modes 5 and 6 for loss of Reactor Coolant System (RCS) inventory would not provide the required information. Specifically, the criterion states that an Alert should be declared if standpipe level is less than -96.5 inches (72% on the Reactor Vessel Level Indication System [RVLIS]). During a loss of inventory from the reactor vessel below the RCS loop nozzles, the standpipe indication would not reflect a level below -95.5 inches. This condition was discovered during an assessment of EAL implementing procedures in response to industry operating experience.
"There is no adverse impact on nuclear safety. All Site Emergency Coordinators and Emergency Response Managers will be directed to use the alternate RVLIS indication to ensure emergency classifications continue to be accurately assessed, which will also be communicated in a shift order. The EAL guidance will be revised to fully resolve the issue in an expeditious manner.
"This report is submitted based upon a loss of emergency assessment capability in accordance with º50.72(b)(3)(xiii).
"The NRC Resident Inspector has been informed." |
| Power Reactor |
Event Number: 48251 |
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: JACK MORRISON
HQ OPS Officer: HOWIE CROUCH |
Notification Date: 08/29/2012
Notification Time: 23:15 [ET]
Event Date: 08/29/2012
Event Time: 15:30 [CDT]
Last Update Date: 08/29/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
R4 RESPONSE CENTER ()
DAVID PROULX (EMAIL) (R4DO) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 3 |
N |
N |
0 |
Hot Shutdown |
0 |
Hot Shutdown |
Event Text
EVACUATION ROUTE UNAVAILABLE DUE TO FLOODING FROM HURRICANE ISAAC
"This is a non-emergency notification being made under 10CFR50.72(b)(3)(xiii) due to the potential loss of emergency preparedness capabilities. At approximately 1530 CDT, Entergy Operations, Inc. was informed of a road closure which could impact the ability to perform a potential evacuation required by the Waterford 3 Emergency Plan.
"Louisiana Governor's Office of Homeland Security and Emergency Preparedness (GOHSEP) reported that US Highway 51 to Interstate 10 was closed due to flooding from elevated water levels in Lake Pontchartrain resulting from Hurricane Isaac.
"Alternate evacuation routes remain available."
The licensee has notified the NRC Resident Inspector. |
| Power Reactor |
Event Number: 48252 |
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TOM JONES
HQ OPS Officer: JOHN KNOKE |
Notification Date: 08/30/2012
Notification Time: 00:31 [ET]
Event Date: 08/29/2012
Event Time: 19:30 [EDT]
Last Update Date: 08/30/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
JOHN ROGGE (R1DO) |
| 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
PRIMARY PLANT COMPUTER OUT OF SERVICE
"Calvert Cliffs Unit 2 Primary Plant Computer (PPC) is out of service. The PPC provides monitoring capability for the Emergency Response Data System and Safety Parameter Display System. The loss of the PPC requires alternate monitoring methods, as described in plant procedures, to be used. Therefore, appropriate assessment of plant conditions, notifications and communications can still be made, if required, during the time that the PPC is unavailable.
"This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii) which is any event that results in major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As previously stated, alternate means remain available to assess plant conditions, make notifications and accomplish required communications, as necessary."
The licensee has notified the NRC Resident Inspector. |
| Power Reactor |
Event Number: 48253 |
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MIKE O'DELL
HQ OPS Officer: DONG HWA PARK |
Notification Date: 08/30/2012
Notification Time: 02:34 [ET]
Event Date: 08/29/2012
Event Time: 21:34 [EDT]
Last Update Date: 08/30/2012 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION |
Person (Organization):
STEVEN VIAS (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
LOCAL CONTROL CAPABILITY OF EMERGENCY DIESEL GENERATOR #2 NOT AVAILABLE UNDER CERTAIN CONDITIONS
"On August 28, 2012, during planned maintenance on Emergency Diesel Generator No.2, a post-maintenance continuity testing associated with the Alternate Safety Shutdown (ASSD) switch on Emergency Diesel Generator No.2 (EDG 2) reveled unexpected results when the switch was taken to the LOCAL position. Troubleshooting activities determined the switch to be operating properly, meaning the contacts are actually open. However, a current path preventing isolation of the control room circuit remained. It was determined that a wire, not identified in EDG wiring diagrams, created a short between two ASSD switch contacts.
"At 2134 hours Eastern Daylight Time (EDT) on August 29, 2012, it was concluded that the condition may impact the ability of EDG 2 to perform its intended ASSD function. In the event of a fire, an induced fault could potentially affect the ability to locally control EDG 2. Local control of EDG 2 is credited in the safe shutdown analysis. Therefore, this condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition.
"This condition did not result in any adverse impact to the health and safety of the public. This condition has no affect on the Technical Specification operability of EDG 2 and it was fully capable of performing its intended design basis accident response functions given the as-found condition of the circuitry.
"The initial safety significance of this condition is minimal. This condition has no affect on the Technical Specification operability of EDG 2 and it was fully capable of performing its intended design basis accident response functions given the as-found condition of the circuitry.
"Repairs to the ASSD switch wiring have been completed. Post maintenance testing is occurring at this time. Planning is in progress to inspect the remaining Emergency Diesel Generators for similar conditions."
The licensee has notified the NRC Resident Inspector. |
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