U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/24/2015 - 07/27/2015 ** EVENT NUMBERS ** | Non-Agreement State | Event Number: 51181 | Rep Org: ELECTRIC POWER RESEARCH INSTITUTE Licensee: ELECTRIC POWER RESEARCH INSTITUTE Region: 1 City: CHARLOTTE State: NC County: License #: Agreement: Y Docket: NRC Notified By: TRACY WILSON HQ OPS Officer: DONG HWA PARK | Notification Date: 06/25/2015 Notification Time: 15:40 [ET] Event Date: 05/01/2015 Event Time: [EDT] Last Update Date: 07/24/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(a)(2) - INTERIM EVAL OF DEVIATION | Person (Organization): JOHN ROGGE (R1DO) KATHLEEN O'DONOHUE (R2DO) VIVIAN CAMPBELL (R4DO) | Event Text PART 21 REPORT - DEVIATION IN NOZZLE MODELING INTERNAL REPORTS The following was received via facsimile: "[This report pertains] to a deviation in a basic product (EPRI nozzle modeling internal reports) supplied by EPRI (Electric Power Research Institute) regarding Westinghouse Pressurizer Head Nozzle Inner Corner Region Ultrasonic Inspections. EPRI will complete all evaluation efforts and provide a determination of reportability in accordance with 10 CFR Part 21 no later than July 24, 2015. "EPRI has conducted an evaluation to the basic product's actual use and determined that the ASME examination volume coverage for at least one of the pressurizer nozzles has changed and is now 90 percent or less. A 90 percent threshold is required by ASME Boiler & Pressure Vessel Code, Section XI. "Design inputs used in EPRI modeling for ultrasonic scanning coverage for nuclear safety related component nozzles may have been inaccurate. In some cases, the upper and lower heads of Westinghouse pressurizers can be offset from the center of each nozzle (spray, safety, relief, surge). This offset results in a change in the thickness of the pressurizer head as compared to an on-axis pressurizer head with the same radial dimensions. Some of the computer models EPRI used to describe these pressurizer heads did not account for an increase in the thickness due to these offsets. As a result, in some cases the ultrasonic inspection parameters produced by these computer models may have produced inaccuracies in the examination volume coverage calculations. "In the case of a basic component which contains a defect or falls to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part. Utility Name/Plant Name Exelon Corporation / Ginna First Energy Nuclear Operating / Beaver Valley 1 Entergy / Indian Point 2 Entergy / Indian Point 3 Pacific Gas & Electric Co. / Diablo Canyon Unit 2 Dominion Generation / North Anna "EPRI has reviewed the pressurizer upper and lower head drawings for the nozzles that it has modeled and determined if these offsets are present. For those cases that are potentially affected EPRI has recalculate the new examination volume coverage for the nozzle inspection detection techniques and provided this information to the corresponding licensees. "EPRI staff shall develop a matrix or table to better define the necessary design inputs for computer modeling of nozzles. This should also include a question to the utility regarding any obstructions or thickness changes which would impact the ultrasonic inspection parameters. EPRI staff shall improve its documentation for review and approval of design inputs for computer modeling. Consideration shall also be given to including a review of design inputs by the member along with an acknowledgement from the member that the design inputs are appropriate for use. EPRI staff shall consider methods of including additional conservatism to the modeling results to better accommodate changes which may be observed in the field. The project quality plan and quality project instruction shall be updated as necessary to accommodate or clarify these improvements. Completion commitment date - 10/27/2015. "The coverage calculations indicated in the notification letters would likely increase if the EPRI modeled scan plans are exceeded and or if additional inspection angles were implemented. Conversely, these coverage calculations would likely decrease if physical field limitations prevented the ultrasonic probe from executing the EPRI modeled scan pattern. It is on this basis that recipients of this letter must evaluate the condition pursuant to 10 CFR Part 21.21 to determine if it could represent a substantial safety hazard reportable under 10 CFR Part 21." Potentially affected US plants include Ginna, Beaver Valley Unit 1, Indian Point Units 2 and 3, Diablo Canyon Unit 2, and North Anna. * * * UPDATE AT 0938 EDT ON 07/24/15 FROM NEIL WILMSHURST TO JEFF HERRERA VIA FACSIMILE * * * "As part of the evaluation, EPRI [Electric Power Research Institute] performed an 'extent of condition' review. During the course of the review, EPRI found that the above described deviation also affected EPRI nozzle modeling internal reports supplied by EPRI (Electric Power Research Institute) regarding Westinghouse Steam Generator Primary Nozzles. "After conducting the 'extent of condition' review, which included recalculation of the modeling data, EPRI concluded that there were no other known reportable conditions associated with this deviation. "EPRI has completed all evaluation efforts and issued reportability notification letters in accordance with 10CFR Part 21 within the respective reporting timeframes." Notified the R1DO (Kennedy), R2DO (Musser) and R4DO (Gepford) and Part 21 Group (via email). | Agreement State | Event Number: 51237 | Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: READING HOSPITAL Region: 1 City: WEST READING State: PA County: License #: PA-0023 Agreement: Y Docket: NRC Notified By: JOSEPH MELNIC HQ OPS Officer: DONALD NORWOOD | Notification Date: 07/16/2015 Notification Time: 14:09 [ET] Event Date: 07/15/2015 Event Time: [EDT] Last Update Date: 07/16/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFIC (EMAI) | Event Text AGREEMENT STATE REPORT - OVERDOSE TO PATIENT DURING PROSTATE SEED IMPLANT The following information was received via facsimile: "On July 16, 2015 the licensee informed the Department's [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Central Office of a medical event. The event is reportable within 24-hours per 10 CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified. "On July 15, 2015, a patient was scheduled to receive a partial iodine-125 (I-125) prostate seed implant of 107 Gy, to be followed by a course of external beam radiation therapy of 45 Gy. During the procedure, the physician made an error and administered a full I-125 implant of 160 Gy. This resulted in a 49.5 percent overdose. No harm is expected to the patient. "Cause of the event: Human error. "The licensee plans to compensate for the overdose by eliminating the follow-up external beam therapy. A full report is expected within 15 days. The Southcentral Regional Office plans to perform a reactive inspection. More information will be provided as received." Pennsylvania Event Report ID No.: PA150020 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: 51238 | Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: CORNEJO AND SONS Region: 4 City: WICHITA State: KS County: License #: 22-B952 Agreement: Y Docket: NRC Notified By: JASON BARNEY HQ OPS Officer: DONG HWA PARK | Notification Date: 07/16/2015 Notification Time: 15:16 [ET] Event Date: 07/16/2015 Event Time: 01:00 [CDT] Last Update Date: 07/16/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICA (EMAI) | Event Text AGREEMENT STATE REPORT - DAMAGED TROXLER The following was received from the Kansas Department of Health and Environment via email: "A nuclear density gauge was struck at approximately 0100 [CDT], Thursday, July 16, 2015. At 0132 [CDT], [Kansas Division of Emergency Management] KDEM on duty staff officer, received a call from the Kansas Highway Patrol that a nuclear density gauge had been struck in Wichita. [Kansas Department of Transportation] KDOT was on scene. [KDOT] said the gauge was in use at the time by Cornejo and Sons. The supervisor from Cornejo was on the scene. He said the gauge was completely destroyed. He could see the source plate containing the neutron source and said the source rod was stuck in the car that hit the gauge. [KDEM] had similar incidents in the past and could put the source in 5 gallon bucket of dirt for shielding and transport both sources back to their shop, place in a secure area, and contact Troxler for further instructions. KDOT had a radiation survey instrument on scene and did not detect any unusual readings. "At that time emergency response personnel at the scene were not letting anyone approach the debris and the source rod. [Personnel at the scene] confirmed that the Cs-137 source was still intact and that Cornejo could transport both sources back to their shop. [The licensee] recovered the sources and were transporting them back to their shop. On the afternoon of July 16, 2015, [Kansas Department of Health and Environment] confirmed that Cornejo had the source rods secured. [The licensee RSO] stated that they contacted Troxler to begin the source return process i.e. pictures of the source rods as well as leak tests." Kansas Item Number: KS150008 | Agreement State | Event Number: 51239 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: SUTTER-SOLANO Region: 4 City: VALLEJO State: CA County: License #: 1943 Agreement: Y Docket: NRC Notified By: GENE FORRER HQ OPS Officer: DONG HWA PARK | Notification Date: 07/16/2015 Notification Time: 17:40 [ET] Event Date: 06/22/2015 Event Time: [PDT] Last Update Date: 07/16/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICA (EMAI) | Event Text AGREEMENT STATE REPORT - BRACHYTHERAPY SEED IMPLANT RESULTS IN UNDERDOSE The following was received by the State of California via email: "During the investigation of the licensee's brachytherapy program, the RHB [Radiation Health Branch] personnel discovered a possible medical event. After further review, the RHB personnel determined on 7/14/15 that a medical event had occurred on 6/22/15 which resulted in an underdose of 27 percent to a patient than the dose called for in the written directive. The licensee is in agreement with the RHB that this is a medical event. The investigation is ongoing and there may be additional medical events discovered as documentation is reviewed." State 5010 Number: 070115 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. | Power Reactor | Event Number: 51253 | Facility: CALLAWAY Region: 4 State: MO Unit: [1] [ ] [ ] RX Type: [1] W-4-LP NRC Notified By: WALTER GRUER HQ OPS Officer: JEFF HERRERA | Notification Date: 07/23/2015 Notification Time: 04:21 [ET] Event Date: 07/23/2015 Event Time: 01:15 [CDT] Last Update Date: 07/26/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(2)(xi) - OFFSITE NOTIFICATION | Person (Organization): HEATHER GEPFORD (R4DO) SCOTT MORRIS (NRR) JEFFERY GRANT (IRD) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 1 | N | Y | 100 | Power Operation | 0 | Cold Shutdown | Event Text INITIATION OF PLANT SHUTDOWN DUE TO RCS LEAKAGE "On July 23, 2015 at 0115 [CDT], Callaway Plant initiated a shutdown required by Technical Specifications (TS). At 2139 [CDT] on July 22, 2015, TS 3.4.13 Condition A was entered due to unidentified RCS leakage being in excess of the 1 gpm TS limit. The leak was indicated by an increase in containment radiation readings, increasing sump levels, and decreasing levels in the Volume Control tank (VCT). "A containment entry identified a steam plume; due to personnel safety the exact location of the leak inside the containment building could not be determined. "At this time radiation levels inside [the] containment are stable and slightly above normal. There have been no releases from the plant above normal levels. "The [NRC] Senior Resident Inspector was notified." * * * UPDATE PROVIDED BY ROB STOUGH TO JEFF ROTTON AT 1757 EDT ON 07/23/2015 * * * "Callaway entered TS 3.4.13 Condition B at 0053 [CDT on July 23, 2015] for the subject leakage since reactor coolant pressure boundary leakage could not be ruled out by visual inspection. The estimated leak rate when the decision was made to shut down the plant was approximately 1.8 gpm. The plant entered Mode 3 at 0600 CDT. "Additionally, at approximately 1315, it was determined that the duration of the required outage would be greater than three days, thus requiring notification to the Missouri Public Service Commission. This offsite notification is reportable to the NRC [per 10CFR50.72(b)(2)(xi)], and the above table has been updated to reflect this reporting requirement." The licensee notified the NRC Resident Inspector. Notified R4DO (Gepford). * * * UPDATE FROM RICHARD HUGHEY TO VINCE KLCO AT 0728 EDT ON 7/26/2015 * * * "Clarification to the initial event notification: the term 'RCS' used above means 'Reactor Coolant System.' Therefore the second sentence from the initial notification is clarified to read, 'At 2139 [CDT] on July 22, 2015, TS 3.4.13 Condition A was entered due to unidentified Reactor Coolant System (RCS) leakage being in excess of the 1 gallon per minute (gpm) TS limit.'" The licensee notified the NRC Resident Inspector. Notified the R4DO (Gepford). | Power Reactor | Event Number: 51259 | Facility: SEQUOYAH Region: 2 State: TN Unit: [1] [ ] [ ] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: CLAY CAMENISCH HQ OPS Officer: HOWIE CROUCH | Notification Date: 07/24/2015 Notification Time: 17:04 [ET] Event Date: 07/24/2015 Event Time: 13:51 [EDT] Last Update Date: 07/24/2015 | 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): RANDY MUSSER (R2DO) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP ON MAIN GENERATOR LOCKOUT "At 1351 EDT on 7/24/2015, Sequoyah Unit 1 reactor/turbine automatically tripped. "Following the reactor trip, all safety-related equipment operated as designed. Auxiliary Feedwater automatically initiated as expected from the Feedwater Isolation Signal. "Unit 1 is currently being maintained in Mode 3 at NOT/NOP, approximately 548 F and 2235 psig, with auxiliary feedwater supplying the steam generators and decay heat removal via the condenser steam dumps. The immediate cause of the trip was an electrically-induced turbine trip. There was no associated work in progress related to this and all systems were normally aligned. "There is no indication of any primary/secondary leakage. All rods fully inserted on the reactor trip and remain inserted. The electrical alignment is normal with shutdown power supplied from off-site power. The 2B-B Emergency Diesel Generator is currently in service for the performance of an unrelated surveillance. There is no operational impact to Unit 2. Unit 2 continues to operate in Mode 1 at 100%. "There was no impact on public health and safety. Post-trip investigation is in progress and planned restart timeline has not yet been determined. "The licensee notified the NRC Resident Inspector." The cause of the main generator lockout is under investigation. | Part 21 | Event Number: 51260 | Rep Org: FLOWSERVE CORPORATION Licensee: FLOWSERVE CORPORATION Region: 1 City: RALEIGH State: NC County: License #: Agreement: Y Docket: NRC Notified By: MICHAEL ROY HQ OPS Officer: JEFF ROTTON | Notification Date: 07/24/2015 Notification Time: 04:55 [ET] Event Date: 07/24/2015 Event Time: [EDT] Last Update Date: 07/24/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE | Person (Organization): SILAS KENNEDY (R1DO) AARON MCCRAW (R3DO) HEATHER GEPFORD (R4DO) PART 21/50.55 REACT (EMAI) | Event Text PART 21 - ACTUATOR SHAFT DID NOT MEET DIMENSIONAL REQUIREMENTS The following information was excerpted from a facsimile provided by Flowserve: "In accordance with the provisions of 10CFR Part 21, [Flowserve] has identified a potential issue and is submitting our evaluation of the event. "DESCRIPTION: Energy Northwest - Columbia Station reported a replacement actuator shaft for 6-900 Anchor/Darling swing check was different than the one removed and could not be installed. After consultation with Flowserve, it was determined the actuator shaft did not meet the dimensional requirements of the manufacturing drawing. The shaft includes an off-set lug that engages the hinge and allows testing or exercising the valve disc. The shaft diameter opposite the lug was too large but must be equal to or less than the basic diameter adjacent to the lug in order to allow free disc swing. "SCOPE: Replacement actuator shafts supplied by Flowserve using manufacturing drawings that do not definitively specify the radius/diameter at the lug. Applies to Anchor/Darling swing check valves with levers or actuators. "PROPOSED ACTION: Flowserve will revise actuator shaft drawing to clearly define the radius/diameter at the lug. Flowserve will notify the customers of the attached evaluation of the defect and will request that the actuator shafts be returned to Flowserve for evaluation and/or replacement at no charge. "SUBJECT: Actuator Shaft supplied for 6-900 Exercisable Swing Check Valve, Drawing No. 3489-3 manufactured by Anchor/Darling Valve Co. and installed at Energy Northwest (ENW) - Columbia Station. "ROOT CAUSE: The actuator shaft was machined by a Flowserve subvendor which incorrectly interpreted the machining drawing and produced the shaft with a large, out of tolerance radius around the lug. The drawing was not clear to the subvendor. Flowserve inspection did not discover the discrepancy during subsequent dimensional inspection. "POTENTIAL EFFECT: An excessively large diameter at the lug will not allow installation of a replacement actuator shaft. A shaft with a diameter opposite the lug that is greater than design but still small enough to allow installation could retard or prevent free disc swing and adversely affect check valve function. "EVALUATION: Swing check valves normally operate automatically reacting to fluid flow and do not include external operating mechanisms. Some valves include external mechanisms to confirm valve operation using an external lever or actuator to cycle the disc. Normally these check valves are allowed to swing freely and the external mechanism is not engaged. The external mechanism is only engaged for testing or exercising. The engagement is accomplished by a lug on the actuator shaft that rides in a cut out in the hub of the hinge. The hinge rotates on the actuator shaft during normal, free operation therefore the clearance between the hinge hub bore and shaft is a critical design feature and can affect operation. Proper operation of valve assemblies are verified during production testing therefore are not within the scope of this evaluation. "CONCLUSION: Although the ENW actuator shaft could not be installed due to the excess material, inadequate removal to allow installation could affect the function. In addition shafts manufactured to similar manufacturing drawings supplied as replacement parts could be capable of installation but not allow complete free disc / hinge swing." Affected plants include Exelon - Limerick, Exelon - Quad Cities, and Energy Northwest - Columbia. | Part 21 | Event Number: 51262 | Rep Org: FLOWSERVE CORPORATION Licensee: FLOWSERVE CORPORATION Region: 1 City: RALEIGH State: NC County: License #: Agreement: Y Docket: NRC Notified By: MICHAEL ROY HQ OPS Officer: JEFF ROTTON | Notification Date: 07/24/2015 Notification Time: 17:05 [ET] Event Date: 07/24/2015 Event Time: [EDT] Last Update Date: 07/24/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE | Person (Organization): SILAS KENNEDY (R1DO) PART 21/50.55 REACT (EMAI) | Event Text PART 21 - MOUNTING BRACKET SEISMIC QUALIFICATION The following information was excerpted from a facsimile from FLOWSERVE: "In accordance with the provisions of 10CFR Part 21, [Flowserve] has identified a potential issue and is submitting our evaluation of the event. "DESCRIPTION: Entergy Design Specification, SPEC-09-0001-P, paragraph 3.1.1 a, requires that position indicators remain operable during a seismic event. The seismic analysis performed [for installation at Pilgrim Station] did not include mounting brackets for the position indicators. Later review of these brackets found them to be inadequate for the application. "SCOPE: The engineering evaluation searched all instances of the use of safety related Topworx C7 position indicators, base part number 04126889, by the Flowserve, Raleigh facility. "PROPOSED ACTION: Flowserve will provide seismically analyzed replacement mounting brackets to Entergy Pilgrim Station at no charge. To prevent reoccurrence of this situation, additional training on the use of nuclear order checklists will be performed. | Power Reactor | Event Number: 51263 | Facility: CLINTON Region: 3 State: IL Unit: [1] [ ] [ ] RX Type: [1] GE-6 NRC Notified By: KEVIN MITCHELL HQ OPS Officer: HOWIE CROUCH | Notification Date: 07/26/2015 Notification Time: 11:50 [ET] Event Date: 07/26/2015 Event Time: 04:49 [CDT] Last Update Date: 07/26/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE | Person (Organization): AARON MCCRAW (R3DO) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 1 | N | Y | 99 | Power Operation | 99 | Power Operation | Event Text INVALID SEISMIC EVENT ALARM "At 0449 CDT on July 26, 2015, the station's Seismic Instrumentation generated a seismic event alarm that was determined to be invalid based upon no seismic activity being felt on site, and no activity detected in the area by either the National Earthquake Information Center, or nearby Exelon plants. The instrumentation that actuated recorded a value of 0.0449 g on a single axis of one instrument, which is greater than the 0.02 g threshold value in the Emergency Action Level in the station's emergency procedures; however, no other instrument channel or axis indicated a valid event exceeding the 0.02 g threshold. Since the event alarm was determined to be invalid as described above, no EAL thresholds were met. "The seismic instrumentation was declared non-functional since it would not generate a seismic event alarm during an actual event until the invalid event was reset. The alarm was reset through the alarm reset process. The seismic instrumentation was declared functional and returned to service at 0520. "This resulted in a Loss of Emergency Assessment Capability while the Seismic Instrumentation was out of service. This is a reportable condition in accordance with 10 CFR 50.72(b)(3)(xiii). "The licensee has notified the NRC Resident Inspector." | Power Reactor | Event Number: 51264 | Facility: MILLSTONE Region: 1 State: CT Unit: [ ] [2] [ ] RX Type: [1] GE-3,[2] CE,[3] W-4-LP NRC Notified By: JOHN HUFF HQ OPS Officer: JEFF ROTTON | Notification Date: 07/26/2015 Notification Time: 22:08 [ET] Event Date: 07/26/2015 Event Time: 20:25 [EDT] Last Update Date: 07/26/2015 | Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE | Person (Organization): SILAS KENNEDY (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 UNIT 2 SITE STACK RADIATION MONITOR FAILURE "The Millstone Site Rad Monitor, RM-8169, has failed and was declared NOT FUNCTIONAL at 2025 [EDT] on July 26, 2015. "This is reportable pursuant to 10CFR50.72(b)(3)(xiii), as any event that results in a major loss of emergency assessment capability, off-site response capability, or off-site communication capability. "I&C [Instrumentation and Control] is developing a troubleshooting and repair plan." The licensee notified the NRC Resident Inspector, the State of Connecticut Department of Energy and Environmental Protection, and the City of Waterford Dispatch. The loss of this radiation monitor is considered a major loss of assessment capability since it is used in Emergency Action Level (EAL) classification and there is no compensatory measure available. | |