United States Nuclear Regulatory Commission - Protecting People and the Environment

Current Event Notification Report for September 2, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/29/2014 - 09/02/2014

** EVENT NUMBERS **


49974 50321 50388 50394 50397 50399 50417 50418 50420

To top of page
Part 21 Event Number: 49974
Rep Org: GE-HITACHI NUCLEAR ENERGY
Licensee: GE-HITACHI NUCLEAR ENERGY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DALE PORTER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/31/2014
Notification Time: 09:07 [ET]
Event Date: 03/31/2014
Event Time: [EDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
MARVIN SYKES (R2DO)
PART 21 REACTOR GROU (EMAI)

Event Text

INTERIM PART 21 REPORT - CONTAINMENT LOADS POTENTIALLY EXCEED LIMITS WITH HIGH SUPPRESSION POOL WATER LEVEL IN THE ABWR DESIGN

The following summary was excerpted from GE Hitachi Interim Part 21 Report received via email:

"A potential analysis error has been identified that is associated with the ABWR (Advanced Boiling Water Reactor) hydrodynamic loads determined by using the Technical Specification Suppression Pool High Water Level (HWL) as an analysis input condition. Vessel coolant inventory is transferred into the containment Suppression Pool during a postulated LOCA blowdown, thereby increasing the Suppression Pool water level. The correction in the analysis may lead to a Suppression Pool water level greater than what is currently assumed in structural analyses which apply the containment hydrodynamic loads generated during a postulated LOCA event."

Facility Identification: South Texas Project Units 3 and 4, Clinton ESP Site, Grand Gulf ESP Site, North Anna ESP Site, and includes the ESP application for the PSEG Site and Victoria County Station ESP application.

If you have any questions, then contact: Dale E. Porter, GE-Hitachi Nuclear Energy Americas LLC, Ph. #(910) 819-4491.

* * * UPDATE AT 1343 EDT ON 06/26/14 FROM JIM HARRISON TO S. SANDIN VIA EMAIL * * *

"June 26, 2014
"MFN 14-013 R1

"This letter provides supplemental information concerning an evaluation being performed by GE Hitachi Nuclear Energy (GEH) regarding the potential increase in hydrodynamic loads that may be experienced by containment structures during a postulated Loss of Coolant Accident (LOCA) associated with Reference 1, and requests additional time to complete the evaluation for the determination of reportability of this condition.

"A potential analysis error has been identified that is associated with the ABWR hydrodynamic loads determined by using the Technical Specification Suppression Pool High Water Level (HWL) as an analysis input condition. Vessel coolant inventory is transferred into the containment Suppression Pool during a postulated LOCA blowdown, thereby increasing the Suppression Pool water level. The correction in the analysis may lead to a Suppression Pool water level greater than what is currently assumed in structural analyses which apply the containment hydrodynamic loads generated during a postulated LOCA event. For example, a postulated Feedwater Line Break (FWLB) may transfer a large quantity of FW liquid into the Suppression Pool with a notable increase in pool water level, even assuming a portion of the discharged fluid spills over into the lower drywell region of the ABWR containment. A higher Suppression Pool water level may result in increased hydrodynamic loads acting on the submerged walls and structures in the containment. The higher Suppression Pool water level can extend the wetted regions of the Suppression Pool walls and the ABWR access tunnel, as well as result in wetted submerged structure segments that were not previously considered wetted. This potential analysis error affects the LOCA containment hydrodynamic loads including condensation oscillation (CO) and chugging, as well as Safety Relief Valve (SRV) actuation loads.

"Assessing the overall impact of increased hydrodynamic loads calculated with higher Suppression Pool water level requires an evaluation of the containment structural components' design bases. GEH is in the process of examining revised containment loads, and determining available margin in the ABWR containment component design specifications to accommodate potentially increased load source forcing functions. ABWR plants may then compare affected plant-specific containment structural design bases to these specifications for relative margin. An extended time period is needed in order to complete the revised containment load determination and evaluate the impact on containment structures.

"GEH is requesting additional time to complete the analysis previously noted in Reference 1. The information required for this GEH 60-Day Interim Report Notification per 21.21(a)(2) is provided in Attachment 1. The commitment for follow-on actions is provided in Attachment 1, item (vii).

"If you have any questions, please call me at (910) 819-4491.

"Sincerely,

"Dale E. Porter
Safety Evaluation Program Manager
GE-Hitachi Nuclear Energy Americas LLC"

Notified R2DO (Rich) and Part 21 Reactor Group via email.

* * * UPDATE FROM LISA SCHICHLEIN TO JOHN SHOEMAKER AT 0745 ON 8/29/14 VIA EMAIL * * *

"August 29, 2014, MFN 14-013 R2, Specification 000N7289-R2

"When considered with the realistic assumptions and the lowered scale factors, the condition reported in Reference 1 [of the final report] is determined as non-reportable, and there is no Substantial Safety Hazard nor will it lead to exceeding a Technical Specification Safety Limit for the affected plants and plant designs. The GEH evaluation within 10 CFR Part 21 is now closed."

If you have any questions, please call;

Dale E. Porter
Safety Evaluation Program Manager
GE-Hitachi Nuclear Energy Americas LLC
Ph. (910) 819-4491.

Notified R2DO (Rose) and Part 21 Reactor Group via email.

To top of page
Agreement State Event Number: 50321
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: COVENANT HEALTH SYSTEM
Region: 4
City: LUBBOCK State: TX
County:
License #: 06028
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/30/2014
Notification Time: 10:48 [ET]
Event Date: 07/28/2014
Event Time: [CDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PAMELA HENDERSON (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DUE TO TREATMENT GIVEN TO WRONG PATIENT

The following information was obtained from the state of Texas via email:

"On July 30, 2014, the Agency was notified by the licensee that a patient had received a portion of a treatment intended for a different patient. The licensee's Risk Compliance Officer (RCO) stated two patients had arrived for treatment. Both patients were female of similar size. Both were to receive treatment to the brain, one patient to the right side and the other to the left side. The treatment head frame had been placed on both patients. It was decided that patient two would be treated first. This information was not provided to the individual entering the program into the treatment system so the program for patient one was entered into the treatment system. Patient two was placed on the treatment table and the treatment started. About two minutes into the treatment, a physician reviewing the treatment realized the wrong plan for the patient was being used and halted the treatment.

"The licensee determined the patient received 3.7 gray to 0.5 cc of brain tissue during the treatment. The patient and the patient's physician were notified of the error. The RCO stated the patient's doctor evaluated the event and stated the patient should not experience any adverse effects from the exposure. The patient was later treated using the correct treatment plan.

"The licensee has implemented several corrective actions as a result of the event. They include adding a second time out prior to treatment and requiring multiple staff to identify.

"The device was a Leksell Gamma System Model 24001 containing about 1800 curies of cobalt-60.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9217

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.


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1508 EDT ON 8/29/2014 * * *

The following information was received via E-mail:

"On July 30, 2014, the Agency [Texas Department of Health Services] was notified by the licensee that a patient had received a portion of a gamma knife treatment intended for a different patient. The incident was investigated at the facility and confirmed that a patient received a portion of a fractional treatment dose intended for another patient. The treatment time was for 2.68 minutes with a calculated total dose of 3.5 gray to the centerpoint maximum with 50% to the isodose lines at 1.75 gray to the wrong patient. The error occurred due to rescheduling patient one who had a much longer treatment time than patient two. The health physicist and radiation oncologist lacked communication with nursing staff regarding the switch to treat patient two before patient one. This communication error along with a lack of patient identification played a major role in the unintended treatment process. The facility completed a root cause analysis of the problem and self-reported the incident. Corrective actions have been implemented to include new policies and procedures incorporating better scheduling, patient identification practices to include 'time outs' during the treatment process and limiting distractions during the treatment procedure. No violations were cited."

Per the Texas Department of State Health Services, this event was not an Abnormal Occurrence as initially reported on 7/30/2014.

Notified R4DO (Pick) and FSME Events Resource.

To top of page
Agreement State Event Number: 50388
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TESTAMERICA LABORATORIES, INC.
Region: 4
City: ARVADA State: CO
County:
License #: CO 486-03
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/21/2014
Notification Time: 10:25 [ET]
Event Date: 08/12/2014
Event Time: [MDT]
Last Update Date: 08/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING ELECTRON CAPTURE DEVICE SEALED SOURCE

The following report was received from the State of Colorado via email:

"Event description: The Department [Colorado Department of Public Health and Environment] was notified via e-mail on 8/13/2014, by TestAmerica Laboratories Inc (license # CO 486-03), that a leak test result for a Ni-63 Electron Capture Device [ECD] source had shown counts exceeding 185 Bq.

"The licensee has removed the source from service, decontaminated the instrument that the ECD was mounted on and sent the unit, containing the source, to the manufacturer for repair and source replacement.

"The email was sent to the department pursuant to Section 4.58 of the Colorado Regulations.

"The Department has requested a few additional details regarding specifics of the source (serial Number, manufacturer, etc.) at this time and will populate the NMED database as soon as they are received."

Colorado Event Report ID No.: CO14-I14-21

To top of page
Agreement State Event Number: 50394
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CLARK DIETRICH BLDG SYSTEMS
Region: 3
City: ROCHELLE State: IL
County:
License #: 9223802
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/22/2014
Notification Time: 16:41 [ET]
Event Date: 08/21/2014
Event Time: [CDT]
Last Update Date: 08/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE PASSEHL (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE STUCK OPEN SHUTTER

The following was received via email:

"On August 21 the Agency [Illinois Emergency Management Agency] received a call from a representative of Clark Dietrich Building Systems (CDBS), Rochelle, IL (reg no 9223802) concerning findings made by their contractor for a generally licensed gauging device at their facility. A Gamma Instruments model GR100 device (s/n 930-706) with a 1000 milliCi Am-241 source was found to have a stuck [open] shutter during maintenance/operability checks being performed by a field engineer from Advanced Gauging Technologies. Repairs were made by the contractor and the gauge subsequently returned to service with no additional issues noted. The field engineer reported that apparently dirt and debris had accumulated from the rolling operations line in such a manner as to prevent proper closure. The caller from CDBS indicated that the gauge had just been last checked by their own staff on July 8, 2014 and no issues with the shutter were detected at that time. He went on to say that he expected a full report from the contractor to be provided in a few days and would forward that information when it became available.

"Until the full report from the registrant and the field engineer are received, this matter will remain open. However, based on the information provided at this time no on-site investigation is warranted."

No personnel exposures resulted from this event.

Illinois Incident Number: IL-14014

To top of page
Power Reactor Event Number: 50397
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM MULLINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/25/2014
Notification Time: 04:10 [ET]
Event Date: 08/25/2014
Event Time: 05:00 [CDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVE PASSEHL (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"On 8/25/2014, planned preventive maintenance activities are being performed on the Braidwood Generating Station Technical Support Center (TSC) Ventilation System. The work will be completed within approximately 42 hours. This activity includes preventive maintenance on the TSC condensing unit which affects the TSC ventilation. During the planned maintenance, the TSC condensing unit will be rendered non-functional.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff as necessary. This planned maintenance will not impact the emergency filtration capability of the TSC.

"This event is reportable per 10CFR50.72(b)(3)(xiii) for 'any event that results in a major loss of emergency assessment capability.' The planned maintenance will not be able to restore the TSC condensing unit to service within the facility activation time specified in the emergency plan (1 hour) in the event of an accident. The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency.

"The licensee has notified the NRC Resident Inspector."

* * * UPDATE AT 1526 EDT ON 08/29/14 FROM ANNE MATHEWS TO S. SANDIN * * *

"Braidwood Generating Station TSC ventilation was restored to available status at 1200 CDT on August 29th, 2014.

"The previously reported system preventative maintenance has been completed."

The licensee informed the NRC Resident Inspector. Notified R3DO (Stone).

To top of page
Agreement State Event Number: 50399
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: US NDI LLC
Region: 4
City: ABILENE State: TX
County:
License #: 06597
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2014
Notification Time: 17:21 [ET]
Event Date: 08/25/2014
Event Time: [CDT]
Last Update Date: 08/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF RADIOGRAPHER

The following was received from the State of Texas via email:

"On August 25, 2014, the Agency [State of Texas] received notice that a dosimetry badge for a radiographer trainee had come back with an exposure of 8.6 roentgen for the period of July 5 to August 4, 2014. The individual has stated that he dropped his badge during work and picked it up later. The trainer working with the trainee received 210mR for the same period. The trainee worked 10 days with the company in all. Currently awaiting written statements from trainee and trainer and further reports from dosimetry provider. Additional information will be provided in accordance with SA-300."

Texas Incident #: I-9225

To top of page
Power Reactor Event Number: 50417
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MIKE ADAMS
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/29/2014
Notification Time: 16:15 [ET]
Event Date: 08/29/2014
Event Time: 09:32 [EDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KEVIN MANGAN (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

DIGITAL RADIATION MONITORING SYSTEM OPERATING INTERMITTENTLY

"At 0932 EDT on August 29, 2014, Beaver Valley Power Station (BVPS) Unit 2 determined that the Digital Radiation Monitoring System (DRMS) was operating intermittently. This resulted in an intermittent loss of radiation monitor capability to alarm and indicate in the control room. BVPS Unit 2 DRMS was declared non-functional. Repair efforts were initiated and compensatory measures were established.

"At 1556 EDT on August 29, 2014, following initial investigation and repairs, BVPS Unit 2 DRMS was declared functional.

"Since the BVPS Unit 2 DRMS was non-functional, this event resulted in a loss of emergency assessment capability and is reportable per 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident Inspector has been notified."

The cause was attributed to an automatic reboot of the computer based on lack of disk space.

To top of page
Power Reactor Event Number: 50418
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: SCOTT BRAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/29/2014
Notification Time: 16:23 [ET]
Event Date: 08/29/2014
Event Time: 14:57 [EDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ROSE (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

NOTIFICATION TO STATE OF VIRGINIA REQUIRED BY SITE DISCHARGE PERMIT

"On 08/29/2014 at 1457 hours [EDT], Surry Power Station notified the State of Virginia Department of Environmental Quality (DEQ) that two of the three turbine building sumps, required to be sampled by the discharge permit VA00004090, indicated an out of specification condition for oil and grease parameters. The laboratory supervisor reviewed the analysis and found no discrepancies. Sample methods and sample locations were reviewed and were unchanged from previous samples. A review of the operation of the sump oil skimmers indicated that they have been operating properly. In addition, there have been no oil spills or maintenance that would cause elevated readings in the sumps.

"Backup samples of both sumps were obtained on 08/27/14 and 08/28/14. The results of the backup samples were received on 08/29/2014 and all samples indicated a less than the detectable levels.

"Based upon an initial review of the issue, the results of the backup samples, and at least 5-year history of less than detectable oil and grease levels in the sump, the original samples for the sumps are considered anomalous. The results, however, are being reported in accordance with the permit requirements. This report is being issued in accordance with 10 CFR 50.72(b)(2)(xi), any event or situation related to the protection of the environment for which notification to other government agencies has been made.

"The Surry NRC Senior Resident Inspector has been notified."

To top of page
Non-Agreement State Event Number: 50420
Rep Org: NATIONAL INST OF STANDARDS & TECH
Licensee: NATIONAL INST OF STANDARDS & TECH
Region: 1
City: GAITHERSBURG State: MD
County: MONTGOMERY
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: TOM O'BRIEN
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2014
Notification Time: 16:00 [ET]
Event Date: 08/29/2014
Event Time: 16:00 [EDT]
Last Update Date: 08/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
KEVIN MANGAN (R1DO)
KING STABLEIN (NMSS)

Event Text

UNPLANNED CONTAMINATION INCIDENT IN THE RESEARCH REACTOR FACILITY

At approximately 1600 EDT on 08/29/14, a 60 nanocurie Pu-239 wafer source dropped from its holder during change out following neutron irradiation in building 235 (Research Reactor Test Facility). The wafer struck the floor and cleaved in half. Radiation surveys confirmed alpha contamination of approximately 200 counts per minute. The area was decontaminated, resurveyed and released.

The licensee will notify their NMSS PM (Naquin) and the State of Maryland Department of Environment as a courtesy.

* * * UPDATE AT 1840 EDT ON 08/30/14 FROM TOM O'BRIEN VIA EMAIL * * *

"Follow-up to the dropped source (Pu-239 RS#- 87-0039(4) on 8/29/14)) at NG-6MAll personnel involved have been evaluated, with the exception of two nasal swipes, on two separate individuals not directly involved with the incident, but near the location, reporting about 0.17 dpm alpha each, all surveys find the personnel to be clear of contamination. It is believed the two 0.17 dpm nasal swipes are statistically not different than zero, follow-up measurements will be done to confirm this. Even if we assume them to be positive, the resulting estimated dose from these measurements would be on the order of 10 mrem.

"The NG-6M instrument area has been surveyed and cleared for normal use. All contamination swipe surveys of the floor, tools, furniture and equipment potentially involved in this incident have been found to be clean. With the exception of one alpha instrument survey, all surveys with alpha and beta/gamma survey instruments have found levels less than or equal to background. The one survey where positive indication was found was performed at the source drop location, directly underneath where the source fell. This survey was done after the source was retrieve. Initially measured about 200 cpm alpha contamination and very localized, the spot was carefully deconned and subsequent surveys found to be less than or equal to background. All swipes of this spot were also found to be clean.

"The source has been safely retrieved, secured and is locked in our safe in A134. No removable contamination was found on the source containers or during retrieval of the source. Gamma spectrum measurements of the retrieved source, detecting the Am-2421 trace nuclide, and correlating this activity by know nuclide ratios find that the Pu-239 activity of the source is within good agreement of the original activity of the source (2190 Bq). While this confirmation has many errors incorporated into it, it is the best measurement we can make at this time, that along with the negative findings of any removable contamination to speak of, and visual inspections of the source, I conclude that to the best of my knowledge, the source material is intact on the broken source substrate pieces, inside the source container. Careful follow-up measurements would need to be performed to confirm this for certain, but based on the info I have at present this is my conclusion."

Notified R1DO (Mangan), NMSS EO (Stablein) and NMSS PM (Naquin).

Page Last Reviewed/Updated Tuesday, September 02, 2014
Tuesday, September 02, 2014