Event Notification Report for February 10, 2015

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE ADMINISTRATION OF Y-90 MICROSPHERES

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"Notifications: The Department [Pennsylvania Department of Environmental Protection] was notified of this event on Wednesday, February 11, 2015. It is immediately reportable as per 10 CFR 35.3045(a)(1)(i).

"Event Description: A patient was receiving Y-90 Sirtex Sirspheres when the administering device failed and a portion of the dose was lost in the apparatus. The patient received 10.4 mCi, or 58% of the prescribed 17.82 mCi dose.

"Cause of the event: The device came apart during the procedure and the remainder of the dose was contained in the packaging.

"Actions: The Department plans a reactive inspection."

Pennsylvania Event Report ID No: PA150004

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.

UNANALYZED CONDITION IN STATION BLACKOUT IMPLEMENTATION AT MONTICELLO

"On February 10, 2015, at 1240 EST, Northern States Power-Minnesota (NSPM) determined that the Station Blackout (SBO) implementation at Monticello Nuclear Generating Plant (MNGP) was not consistent with the NRC Safety Evaluation (SE). Specifically, the High Pressure Coolant Injection (HPCI) system was not being utilized in a manner consistent with the NRC SE for SBO. Current battery calculations do not reflect a full complement of HPCI system equipment running for the duration (coping requirements) of the SBO event. The calculation assumed a manual action to remove the HPCI auxiliary oil pump from operating during an SBO event in order to preserve the station battery.

"NSPM is reporting this as an Unanalyzed Condition pursuant to the requirements of 10 CFR 50.72(b)(3)(ii)(B). The health and safety of the public was not affected since no SBO event occurred. All station batteries and the HPCI system remain operable in accordance with the plant Technical Specifications.

"The NRC Resident Inspector was notified of the event."

* * * RETRACTION PROVIDED BY MICHAEL BURTON TO JEFF ROTTON AT 1254 EDT ON 04/03/2015 * * *

"An engineering analysis was performed updating the battery calculations for Station Blackout (SBO) implementation demonstrating the ability of the safety related station batteries to provide sufficient capacity and capability to ensure that the core is cooled and appropriate containment integrity is maintained in the event of the SBO for the specified four hours. Therefore, the battery calculation is analyzed and specifically the High Pressure Cooling Injection (HPCI) System is analyzed to run in automatic for the entire duration of the SBO event meeting the site licensing basis for SBO. The SBO procedure has been revised to incorporate HPCI running in automatic for the entire duration of the SBO event.

"The NRC Resident Inspector has been notified."

Notified R3DO (Duncan)

HIGH HEAD SAFETY INJECTION INOPERABLE DUE TO MISSING PIPING SUPPORT

"This is a non-emergency 8 hour report in accordance with 10 CFR 50.72(b)(3)(ii)(B).

"At 1750 [EST] hours on 2/10/15, Unit 4 entered Technical Specification 3.0.3 due to missing tubing supports identified for two separate high point vent lines. This condition is unanalyzed and potentially rendered the cold leg High Head Safety Injection flow path inoperable. Upon discovery, the vent line root isolation valves were closed and Technical Specification 3.0.3 was exited at 1805. Investigation has been initiated to determine cause."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE AT 1250 EDT ON 03/31/15 FROM ERIC JUERGENS TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"On 2/11/2015 at 0103 EST, Event Notification 50807 reported to the Nuclear Regulatory Commission Operations Center (NRCOC) the potential inoperability of the Unit 4 cold leg High Head Safety Injection (HHSI) piping due to missing tubing supports on two separate high point vent lines.

"Subsequent analysis has determined that the Unit 4 HHSI cold leg injection flow path to the reactor coolant system (RCS) remained operable with the missing vent line tubing supports and its safety related function was not affected.

"The Unit 4 HHSI system discharge flow path to the RCS had been operable with the missing vent line tubing supports, Technical Specification (TS) requirements were met, and entry into TS 3.0.3 was not required. The HHSI system remained capable of fulfilling the safety function to mitigate the consequences of an accident on Unit 4. Therefore, the immediate notification to the NRCOC on 2/11/2015 at 0103 EST in accordance with 10 CFR 50.72(b)(3)(ii)(B) is hereby retracted."

The licensee informed the NRC Resident Inspector. Notified R2DO (Walker).

CONTAINMENT DECLARED INOPERABLE DUE TO CONTAINMENT FAN COIL LEAK

"At 2205 CST on February 10, 2015, a cooling water leak of approximately 60 to 90 drops per minute was identified on the 14 Containment Fan Coil Unit Cooling Water face gasket. As a result, Unit 1 Containment was declared inoperable. This required entry into Technical Specifications (TS) LCO 3.6.1 Condition A, Containment inoperable, applicable in MODES 1, 2, 3, and 4. Immediate action was taken to isolate the fan coil unit within 1 hour from the initial identification of the leak.

"After isolating the cooling water leak to 14 Containment Fan Coil Unit, containment was declared operable and TS 3.6.1 Condition A was exited at 2232 CST. A Work Request (WR) has been initiated to restore 14 Containment Fan Coil Unit to an operable condition.

"This condition is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.

"The plant remains in a safe condition and there was no effect to the health and safety of the public.

"The licensee has notified the NRC Resident Inspector."

CONFIRMED POSITIVE TEST FOR CONTROLLED SUBSTANCE

On February 10, 2015, at approximately 1300 EST, the Dominion Medical Review Officer determined that a licensed operator had a confirmed positive follow up test for a controlled substance. The individual's unescorted access has been denied at all of the Dominion sites.

The licensee has notified the NRC Resident Inspector.

PART 21 REPORT - WEIR VALVES AND CONTROLS SPLINE ADAPTER VIBRATED LOOSE

This report was received from Weir Valves & Controls via email:

During a walk down it was discovered that one of the spline adapters had slipped down the shaft of a TRICENTRIC valve supplied by Weir Valves & Controls, USA. This condition could have allowed the valve disc/stem to move from its normally open position to a partially closed or fully closed position. Weir Valve and Controls determined that the valve is designed with a single set screw tightened against the stem key and is susceptible to Human Performance Factors if it is not properly tightened against the shaft.

Name of Manufacturer:
Weir Valves and Controls, USA

Affected Component:
TRICENTRIC Triple Offset Valve

Affected Plant(s):
Peach Bottom Atomic Power Station

VOIDS IDENTIFIED THAT RESULT IN AN UNANALYZED CONDITION

"On February 10, 2015, Prairie Island Unit 1 was shutdown in Mode 3 during a planned outage. Ultrasonic testing in support of Unit 1 Emergency Core Cooling System (ECCS) void verifications identified existing voids with calculated volumes in excess of the OPERABILITY limits specified by the procedure. This rendered both trains of Residual Heat Removal (RHR) systems inoperable requiring entry into Technical Specification 3.0.3 at 0250 [CST].

"The station took prompt actions to vent the identified voids. The void at 1 RH-12 was vented to within acceptable limits allowing LCO 3.0.3 to be exited at 0538 on February 10. Venting at 1RH-11 is in progress.

"Voiding was identified at location 1-RH-11 with a calculated volume of 62.21 cubic inches with an OPERABILITY limit of 11.62 cubic inches.

"Voiding was identified at location 1-RH-12 with a calculated volume of 350 cubic inches with an OPERABILITY limit of 22.84 cubic inches.

"There was no impact to the health and safety of the public as Safety Injection was available and the time both trains of RHR were INOPERABLE was limited.

"This event is being reported as a unanalyzed condition that significantly degrades plant safety and a condition that could have prevented the fulfillment of a safety function (i.e., remove residual heat) under 10CFR50.72(b)(3)(ii) and 10CFR50.72(b)(3)(v)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM TOM HOLT TO JEFF HERRERA AT 1444 EDT ON 4/11/15 * * *

"Further analysis was performed on the two void locations, 1RH-11 and 1RH-12. Based on this additional analysis from AREVA, it was determined that the void located at 1RH-11 (RHR Train A) was operable. The calculations for past operability at inspection location 1RH-11 provides reasonable assurance that a void of 65 cubic inches will not generate forces that will fault any piping and supports. The void location at 1RH-12 (RHR Train B) was considered inoperable due to exceeding current procedural operability limits. The void located at 1RH-11 was determined to be nonconforming due to exceeding procedural design basis limits.

"Therefore, with RHR Train A determined to be operable, this event was not an 8-hour notification for an unanalyzed condition that significantly degrades plant safety, nor a condition that could have prevented the fulfillment of a safety function (i.e., remove residual heat) under 10CFR50.72(b)(3)(ii) and 10CFR50.72(b)(3)(v).

"The licensee has notified the NRC Resident Inspector."

Notified the R3DO (Skokowski).

AGREEMENT STATE REPORT - SOURCE DISCONNECTED

The following was received from the Ohio Bureau of Radiation Protection via email:

"A crew working near Cambridge, Ohio this morning experienced a source disconnect on a QSA Model 880D camera containing 60.5 Curies of Iridium-192, which occurred at 9:26 AM EST.

"The disconnect was discovered after a shot, when the crew's survey instrument indicated that the source was still exposed after the guide cable had been fully retracted. The cause for the source disconnect has not yet been determined.

"The area has been secured, roped off, and is under constant surveillance by the radiography crew. Two Acuren supervisors trained in source recovery are enroute from their Akron office. The customer has been advised and is cooperating in keeping all personnel away from the area.

"There has been no exposure to workers or members of the public from the disconnect.

"An ODH [Ohio Department of Health] Investigator is enroute to the site to observe recovery options."

The QSA Global Camera (Model: 880D; Serial number: 4192) contained an Ir-192 source of 60.5 Ci (Serial number:13665G)

SECONDARY CONTAINMENT INTERLOCK DOORS OPEN SIMULTANEOUSLY

"On February 10, 2015, at 1055 CST, the Shift Manager was notified that both [High Pressure Coolant Injection] HPCI Secondary Containment interlock doors were open simultaneously. The doors were immediately closed and secondary containment pressure remained negative.

"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2 given two doors in a single access opening were open simultaneously. As a result entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC Resident Inspector has been notified."

The licensee reported that personnel were posted in the area as a compensatory measure.

The State of Illinois Emergency Management will be notified.