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Event Notification Report for November 2, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/01/2012 - 11/02/2012

** EVENT NUMBERS **


48395 48438 48441 48444 48445 48468 48471 48475

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Power Reactor Event Number: 48395
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/10/2012
Notification Time: 00:32 [ET]
Event Date: 10/03/2012
Event Time: 18:15 [PDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DON ALLEN (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

UNANALYZED FIRE PROTECTION DEFICIENCIES

"On 10/9/12, at 16:30 PDT control room operators were questioned whether recently identified fire protection program deficiencies should have been reported to the NRC.

"On October 3 and October 8, 2012, DCPP [Diablo Canyon Power Plant] staff reviewing NFPA 805 Nuclear Safety Capability Assessment (NSCA) Variance From Deterministic Requirements (VFDRs) identified fire areas that neither conformed to Appendix R requirements nor had established, proceduralized and practiced compensatory measures in place. The issues were identified in the DCPP corrective action program and compensatory measures were established in accordance with the DCPP fire protection program requirements.

"Event: 10/3/12 Fire areas containing cables associated with startup transformers 1-2 and 2-2 could result in loss of startup power and also prevent the emergency diesels from performing their Appendix R safe shutdown function.

"Event: 10/8/12 Fire areas containing reactor coolant pump (RCP) breakers could result in loss of RCP seal cooling and prevent the credited local manual trip of the RCPs, contrary to the specified method of performing the Appendix R safe shutdown function.

"Event: 10/8/12 Fire areas containing cables for the ventilation systems of the 480V switchgear, DC panels, and battery chargers could require unproceduralized use of portable fans to maintain adequate cooling of the electrical equipment necessary to perform the Appendix R safe shutdown function.

"Operators established fire watches as compensatory measures as required by the DCPP fire protection program requirements.

"The above late notification of discovery of the unanalyzed conditions has been entered into the DCPP corrective action program.

"NRC Resident Inspector has been notified."

*****UPDATE AT 0028 EDT ON 11/01/12 FROM GLENN GOELZER TO S. SANDIN*****

"This is an update to EN #48395 reported on October 10, 2012, at 0032 EDT.

"During the NRC's Fire Protection Triennial Inspection the NRC identified that several Alternate Compensatory Measures (ACMs) were not in the current post-fire procedure CP M-10. The ACMs address potential Appendix R non-conformance issues identified via the initiative to convert the DCPP fire protection program to NFPA 805. PG&E has established compensatory measures for all the identified areas in accordance with the DCPP fire protection program requirements.

"[The] NRC Resident Inspector has been notified."

Notified R4DO (Deese).

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Agreement State Event Number: 48438
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MARATHON PETROLEUM COMPANY
Region: 4
City: GARYVILLE State: LA
County:
License #: LA-3239, AI 3
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/24/2012
Notification Time: 17:07 [ET]
Event Date: 09/13/2012
Event Time: [CDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON A FIXED NUCLEAR GAUGE

The following information was received from the State of Louisiana via fax:

"Event date and Time: [On] 09/13/2012, the RSO for Marathon Petroleum called to be in compliance with Condition #4 of his radioactive material license.

"Event Location: Production/process field at the refinery located at 4663 Airline Highway, Garyville, LA 70051

"Event type: Fixed gauge, stuck shutter

"Event description: On 09/13/2012, the RSO for Marathon called to report a stuck shutter on a fixed level gauge utilized in a process in the refinery. There was no possible exposure to the plant workers because the gauge was installed on process [equipment] and the shutter remaining [open] was not a problem. [The RSO] called in the incident to comply with Condition #4 of Marathon's Radioactive Material License. The gauge is an Ohmart Vega gauge Model SHFBI, loaded with 20 mCi of Cs-137. The gauge has been [exposed to] the elements in excess of 10 years and the shutter malfunctioned due to corrosion in the mechanism. Eight [gauges] were evaluated and only one needed repair. The manufacturer stated that it appeared to be from being in the elements. The manufacturer stated that they were looking into finding a modification to shield the shutter mechanism from the elements. The Department [Louisiana Department of Environmental Quality] considers this item closed.

"Event Report ID No.: LA 12-0005"

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Agreement State Event Number: 48441
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA-153-1
Agreement: Y
Docket:
NRC Notified By: JOEL MIMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/25/2012
Notification Time: 08:03 [ET]
Event Date: 05/24/2011
Event Time: [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - Y-90 THERASPHERE SPILL

The following information was obtained from the State of Georgia via facsimile:

"Description of Event: A spill involving Y-90 microspheres (SIR-Spheres) that occurred on May 24, 2011 at Emory University Hospital [and] was reported by the Deputy Radiation Safety Officer. During an embolization treatment using Y-90 microspheres, resistance was encountered when flushing the catheter following the initial successful microsphere administration. The authorized user examined the catheter which was found to be occluded. Preparations were made to continue the administration with a second measured dose, but this was halted when further examination showed evidence of a leak between the Y-90 vial and the catheter. The procedure was postponed until contamination controls were complete. The patient received the completion of the prescribed dose pursuant to the Authorized User's written directives when the Interventional Suite was available for use on the following day.

"Describe clean-up actions taken by RCP [Georgia Radiation Control Program]: No action performed by RCP but the licensee sealed the Y-90 shielding and cart and removed [them] for decay and evaluation. The floor and equipment were decontaminated by licensee radiation safety staff.

"List radiation measurements taken by RCP: No measurements performed by the RCP but the licensee initiated spill containment procedures [and surveyed] the staff before allowing anyone to exit the room. Some minor contamination was discovered on staff clothing and shoes, but no contamination was detected on the skin of staff after removal of affected items. The deputy RSO surveyed the patient and had a bremsstrahlung scan of patient. No contamination was found on the patient during the scan.

"List any other actions required of RCP: The licensee is storing all waste from this event for decay and subsequent investigation."

Georgia Incident Summary number GA-2011-61i.

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Non-Agreement State Event Number: 48444
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BABTIST MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-1128-02
Agreement: N
Docket:
NRC Notified By: THOMAS MOENSTER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/25/2012
Notification Time: 15:54 [ET]
Event Date: 05/01/2012
Event Time: 13:00 [CDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

RADIOPHARMACEUTICAL THERAPY RECORD TRANSPOSITION ERROR

A doctor prescribed a patient 0.4 mCi/Kg Zevalin (a prescription medication containing Yttrium-90). The calculated dose based on the patient's weight was 44 mCi; however, the package insert for the drug says the maximum dose to be used is 32 mCi. So 32 mCi of Y-90 was to be given to the patient.

A radiopharmaceutical therapy record was prepared as required at the hospital but the dose on the radiopharmaceutical therapy record was improperly copied as 23 mCi.

The dose prepared at the radiopharmacy and delivered to the patient was 31.8 mCi. The dose differed from that specified on the radiopharmaceutical therapy record by more than 20%.

The prescribing physician is aware and there is no significant impact to the patient.

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: 48445
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: GERDAU CHARLOTTE
Region: 1
City: CHARLOTTE State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES D. ALBRIGHT
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/25/2012
Notification Time: 15:24 [ET]
Event Date: 10/25/2012
Event Time: [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - HIGH PORTAL MONITOR READINGS AT SCRAP YARD

The State of North Carolina reported the following via email:

"NC Radiation Protection Section received a call from Gerdau Charlotte regarding a load of scrap tire-wire that tripped their portal monitor. [An individual] measured 10 mR/hr on contact at the rear of the truck trailer using a handheld meter (Ludlum 192, background reported at 3 mR/hr). The shipment originated from Liberty Tire in Atlanta, GA.

"[The shipment] will be returned to Liberty Tire, Atlanta, GA, via CRCPD exemption NC-GA-12-01."

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Power Reactor Event Number: 48468
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/01/2012
Notification Time: 08:20 [ET]
Event Date: 11/01/2012
Event Time: 08:00 [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

INTEGRATED PLANT COMPUTER SYSTEM OUT-OF-SERVICE OUTSIDE THE CONTROL ROOM FOR PLANNED MAINTENANCE

"Beginning November 01, 2012, at approximately 1000 [EDT], the Fermi 2 Integrated Plant Computer System (IPCS) will be removed from service outside of the Control Room to support installation of a Cyber Security Modification. The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and will be out of service when the IPCS is removed from Emergency Response Facilities (ERFs). These systems will be unavailable to all Emergency Response Facilities (ERFs) for approximately 196 hours.

"By 1600 [EDT] on November 9, 2012 it is planned to restore IPCS, including SPDS and ERDS, to the Operational Support Center, the Technical Support Center, and alternate facilities. During this time dose assessment (Raddose) capability will only be available in the manual data input mode. The SPDS indications and Raddose remain available to the plant staff in the Control Room, and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored.

"This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability. ERDS previously reported out of service under event number EN 48451 ."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 48471
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 15:35 [ET]
Event Date: 11/01/2012
Event Time: 12:15 [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

OFFSITE NOTIFICATION - OIL SPILL INTO NAVIGABLE WATERS

"At approximately, 1215 EDT, November 1, 2012, Fermi 2 experienced an oil spill to navigable waters, requiring notification of National Response Center, Michigan Department of Environmental Quality (MDEQ) Pollution Emergency Alert System (PEAS), and Primary Public Safety Answering Point (911). The spill has not left site. A fuel oil and water mixture overflowed from a tank onto the ground during the performance of station fire header flushing. It is estimated that the volume of the overflow was less than ten gallons. A portion of the overflow entered the site storm drains. The source of the spill has been terminated.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48475
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON CHERNY
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/02/2012
Notification Time: 03:30 [ET]
Event Date: 11/02/2012
Event Time: 01:42 [CDT]
Last Update Date: 11/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4DO)

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

Event Text

MANUAL REACTOR TRIP DUE TO HIGH REACTOR COOLANT PUMP MOTOR BEARING TEMPERATURE

"At 0142 CDT, Comanche Peak Nuclear Power Plant Unit 1 was manually tripped due to high temperature indications on the 1-04 reactor coolant pump motor radial bearing concurrent with a high / low oil reservoir level alarm. The trip was uncomplicated; all control rods and shutdown rods fully inserted; neither emergency diesel generator started; all safety systems functioned as designed. Both motor driven and the turbine driven auxiliary feed water pumps started as required to restore steam generator levels as a result of the trip. The turbine driven AFW pump was stopped per procedure and returned to auto-start status. Currently, Unit 1 is in Mode 3, no load Tave of 557 degrees F, with temperature being maintained with AFW and steam dumps to the main condenser. All electrical busses are powered from offsite and grid conditions are stable."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, March 24, 2021