United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for May 9, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/08/2014 - 05/09/2014

** EVENT NUMBERS **


50074 50084 50095 50096 50097 50098 50099 50100

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Agreement State Event Number: 50074
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: SENTARA NORFOLK GENERAL HOSPITAL
Region: 1
City: NORFOLK State: VA
County:
License #: 710-189-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/30/2014
Notification Time: 15:26 [ET]
Event Date: 04/24/2014
Event Time: [EDT]
Last Update Date: 04/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
FSME EVENT RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - SECOND SCHEDULED MEDICAL DOSE NOT DELIVERED DUE TO EQUIPMENT FAILURE

The following information was provided by the State of Virginia via facsimile:

"On April 24, 2014, the licensee performed a two part therapy procedure using yttrium-90 microspheres (Sirtex SirSpheres). The procedure was to treat the same lobe of the liver via two different arterial pathways. There were no problems with the first injection, but the second injection failed and none of the yttrium-90 was delivered to the patient. The licensee determined that the failure occurred because of a faulty Surefire Medical catheter. The authorized user decided not to repeat the administration of the second dose but will treat the region with an alternate method. The licensee indicated that the prescribed dosage for the first injection was 11.7 millicuries and that 12.7 millicuries (27,500 rem to the target region of the loft lobe) was delivered. The prescribed dosage for the second injection was 8.3 millicuries (to give a dose of 26,200 rem to the targeted region) but no activity was delivered. This resulted in a medical event for the second injection (or fraction) as well as for the entire procedure."

VA Event Report ID No.: VA-2014-003

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: 50084
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: NICHOLAS RULLMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/03/2014
Notification Time: 03:42 [ET]
Event Date: 05/02/2014
Event Time: 19:20 [PDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK HAIRE (R4DO)

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

REACTOR BUILDING STACK RADIATION MONITOR FAILURE

"This notification is being made due to a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). At 1920 (PDT), on 05/02/2014, PRM-RE-18, Reactor Building Stack Monitor - Intermediate Range Detector, failed downscale. PRM-RE-1A and PRM-RE-1C, the Reactor Building Stack Monitor - Low and High Range Detectors, both remain operable and fully functional. Compensatory measures are being implemented per plant procedures at this time.

"The NRC Resident Inspector has been notified."

* * * UPDATE AT 1754 EDT ON 05/08/14 FROM JASON LOVEGREN TO DONG PARK * * *

"Following completion of maintenance activities PRM-RE-1B, Reactor Building Stack Monitor - Intermediate Range Detector was returned to operable status at 0810 PDT on 05/08/2014, restoring its required emergency assessment capability.

"The NRC Resident Inspector has been notified."

Notified R4DO (Whitten).

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Power Reactor Event Number: 50095
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL GREMBECKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/08/2014
Notification Time: 12:17 [ET]
Event Date: 05/08/2014
Event Time: 04:29 [EDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (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

LOSS OF 34 EMERGENCY SIRENS

"At approximately 0429 hours (EDT) on May 8, 2014, McGuire was informed that 34 emergency sirens were incapable of activation from the primary location. The loss of these 34 sirens for more than one hour is reportable pursuant to 10 CFR 50.72(b)(3)(xiii). Until repairs are complete, backup route alerting is in place.

"Troubleshooting is in progress. During troubleshooting, an inadvertent actuation of emergency sirens occurred at 1030 hours (EDT) on May 8, 2014. Mecklenburg County Emergency Management was notified of this inadvertent actuation which is being reported pursuant to 10 CFR 50.72(b)(2)(xi). Although these sirens were activated there was no incident at McGuire. This event does not impact public health and safety.

"The NRC Resident Inspector and local agencies were notified."

* * * UPDATE FROM NICHOLAS BARTSCHER TO DANIEL MILLS ON 5/08/2014 AT 1603 EDT * * *

The emergency sirens have been repaired and are functional.

The NRC Resident Inspector has been notified.

Notified R2DO (Bonser).

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Part 21 Event Number: 50096
Rep Org: SCIENTECH
Licensee: SCIENTECH
Region: 4
City: IDAHO FALLS State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: VINCENT CHERMAK
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/08/2014
Notification Time: 14:57 [ET]
Event Date: 05/07/2014
Event Time: [MDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
KENNETH RIEMER (R3DO)
JACK WHITTEN (R4DO)
NRR PART 21 (EMAI)

Event Text

PART 21 - POTENTIAL DEFECT IN NUS-710DU TRIP UNIT TO PRODUCE A VALID TRIP OUTPUT SIGNAL

The following summary was provided by Curtiss-Wright Flow Control Corporation:

"In certain operating configurations, NUS-710DU Trip Units could fail to produce a valid trip output signal.

"Transistor Q8 on the referenced units uses a TO-66 package and is flush mounted on the component side of the PCB. The TO-66 package, based on JDEC drawing TO-213 does not specify the size of the glass-sealed holes in the case (collector) around the base and emitter leads. Random samples measure approximately 0.11" in diameter. The PCB includes standard 0.100" solder pads on both non-component and component sides. During manufacture, Q8 is secured using screws and nuts with leads centered in the through-holes, so no direct solder pad to case contact is possible. However, the presence of the pad on the component side could facilitate, under certain conditions, excessive solder flow, creating a close proximity, or in the extreme case bridging, between solder on the emitter or base solder pad and the Q8 case. Permanent bridging would be detected during acceptance testing. However, in at least one case, with the trip unit mounted in the trip unit chassis via an extender card, the proximity was close enough to create contact when the board was slightly flexed.

"The trip units have two modes of operation, NORM and REV, selectable by switch S2, and four operating configurations: (1) NORM mode, rising trip, energize on trip, (2) REV mode, falling trip, energize on trip, (3) NORM mode, falling trip, de-energize on trip and (4) REV mode, rising trip, de-energize on trip.

"In configuration (1 ), the set point is applied to the negative terminal of a comparator and the input is applied to the positive terminal. When the input rises above the set point, the output of the comparator goes to the positive rail, turning on Q7. When Q7 turns on, it pulls the base of Q8 low, causing Q8 to turn on. When Q8 turns on, the trip output goes to approximately +24V.

"In configuration (2), the set point is applied to the positive terminal of the comparator and the input is applied to the negative terminal. When the input drops below the set point, the output of the comparator goes to the positive rail and turns on Q8, resulting in a trip output of approximately +24V.

"In configurations (1) and (2), bridging at Q8 would cause an output trip signal.

"In configuration (3), when the input drops below the reset point, the output of the comparator goes to the negative rail, which causes Q8 to turn off. When Q8 turns off, the trip output goes to approximately zero volts.

"In configuration (4), when the input rises above the reset point, the output of the comparator goes to the negative rail and turns off Q8, de-energizing the unit output.

"In configurations (3) and (4), bridging at Q8 would prevent a valid trip signal from being generated by keeping the output at logic high.

"Plant: Limerick/Part Number: NUS-710DU0TS/Quantity: 2/Serial Numbers:1303582, 1303583
"Plant: Limerick/Part Number: NUS-710DU0TT27000/Quantity: 6/Serial Numbers: 1304197, 1304198, 1304199, 1304200, 1304201, 1304202

"Plant: Columbia/Part Number: NUS-710DU0TT45059/Quantity: 5/Serial Numbers: 1303632, 1303633, 1303634, 1303635, 1303636

"Plant: Grand Gulf/Part Number: NUS-710DU0TT27000/Quantity: 3/Serial Numbers: 1303672, 1303673, 1303674

"Plant: Perry/Part Number: NUS-710DU0TT27000/Quantity: 33/Serial Numbers: 1304219, 1304220, 1304221, 1304222, 1304223, 1304224, 1304225, 1304226, 1304227, 1304228, 1304229, 1304230, 1304231, 1304232, 1304233, 1304234, 1304235, 1304236, 1304237, 1304238, 1304239, 1304240, 1304241, 1304242, 1304243, 1304244, 1304245, 1304246, 1304247, 1304248, 1304249, 1304250, 1304251.

"Should you have any questions regarding this matter, please contact Robert Queenan, Division Manager, Scientech/Instrumentation and Controls, at (208) 524-9311."

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Power Reactor Event Number: 50097
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: ROBERT W. OESTERLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/08/2014
Notification Time: 17:46 [ET]
Event Date: 05/04/2014
Event Time: 08:32 [EDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KENNETH RIEMER (R3DO)

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

Event Text

MANUAL INITIATION OF THE REACTOR PROTECTION SYSTEM WHILE SHUTDOWN

"On 5/4/14 while the plant was in Mode 3 and the reactor not critical, unexpected position indications were observed on a Control Rod while withdrawing an Axial Power Shaping Rod (APSR). Due to the uncertainty of rod positions, the APSR was inserted into the core. The reactor trip breakers were then opened from the Control Room using the manual trip pushbuttons. All Control and Safety Rods were unlatched and fully inserted into the reactor core before the reactor trip breakers were opened.

"This manual initiation of the Reactor Protection System with the reactor not critical is being reported per 10 CFR 50.72(b)(3)(iv)(A). The reportability of this event was determined based on an extent of condition review for Event Number 50086 that occurred 5/5/14. The failure to meet the 8-hour reporting requirement has been entered into the Corrective Action Program."

The licensee notified the NRC Resident Inspector, the State of Ohio, and Ottawa and Lucas Counties.

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Power Reactor Event Number: 50098
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: GRETCHEN CARTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/08/2014
Notification Time: 20:57 [ET]
Event Date: 05/08/2014
Event Time: 16:45 [EDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)

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

POSTULATED HOT SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"A review of industry operating experience regarding the potential for secondary fires being caused by DC Motor control circuit wiring has determined the described condition to be applicable to Nine Mile Point Unit 1 resulting in a potentially unanalyzed condition with respect to 10 CFR 50 Appendix R analysis requirements. The original plant wiring design and configuration for the containment isolation valve IV-33-04 does not include separate over current protection for the power and control wiring. The only protection for the control circuit wiring is provided by the power circuit fuses.

"In the postulated event, a fire in the reactor building at the DC MOV could cause one of the control circuit wires to short and potentially over heat creating a secondary fire in the raceway system in a different fire zone. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10 CFR 50 Appendix R. This event entered into the Nine Mile Point corrective action program as Condition Report (CR) 2014-004630.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). Interim compensatory measures (i.e., fire zone inspections) have been implemented for affected areas of the plant."

The licensee has notified the State and the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 50099
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: DEREK WARFORD
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/08/2014
Notification Time: 21:15 [ET]
Event Date: 05/08/2014
Event Time: 10:24 [CDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BRIAN BONSER (R2DO)
PATTI SILVA (NMSS)

Event Text

HIGH PRESSURE FIRE WATER SPRINKLER SYSTEM B-6 DECLARED INOPERABLE

"At 1024 CDT, on 05-08-2014, the Plant Shift Superintendent was notified that the C-333 High Pressure Fire Water (HPFW) Sprinkler System B-6 had been inspected by Fire Services and 5 sprinkler heads had visible corrosion or paint on them, including 2 heads adjacent to each other. The system configuration was evaluated using EN-C-822-99-047 [Engineering Notice], 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads potentially impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to TSR LCO [Technical Safety Requirement Limiting Condition for Operation] 2.4.4.5. HPFW Sprinkler System B-6 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage.

"Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the actual effect on operability.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

"The NRC Region II (Marvin Sykes) has been notified of this event.

"PGDP Assessment and Tracking Report No. ATR-14-0444; PGDP Event Report No. PAD-2014-05; NRC Worksheet No. 50099; Responsible Division: Operations."

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Power Reactor Event Number: 50100
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: KEVIN DALTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/08/2014
Notification Time: 21:57 [ET]
Event Date: 05/08/2014
Event Time: 18:24 [EDT]
Last Update Date: 05/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3DO)

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

OFFSITE NOTIFICATION MADE DUE TO OIL LEAK

"At 1824 hours [EDT] on May 8, 2014, an oil leak was discovered on EX-07 Safeguards Transformer 1-1 that sprayed outside the transformer containment berm. The oil released to the ground was approximately 70 gallons, which is greater than the reporting requirements. The oil was not released to any surface water and has no drain path to reach any surface water. The State of Michigan, via the Pollution Emergency Alert System (PEAS) and Van Buren County was notified as required by the Site Spill Plan by the Control Room at 2003 hours."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014