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Event Notification Report for July 25, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/24/2013 - 07/25/2013

** EVENT NUMBERS **


49194 49197 49199 49211 49213 49214

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Agreement State Event Number: 49194
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: EXCELLIMS CORPORATION
Region: 1
City: ACTON State: MA
County:
License #: 55-0588
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/16/2013
Notification Time: 10:57 [ET]
Event Date: 07/12/2013
Event Time: 17:00 [EDT]
Last Update Date: 07/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SEALED SOURCE FAILED LEAK TEST

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

"When conducting a routine leak test for one of their Ni-63 source foils, the licensee submitted for analysis a leak test swab of the inactive side of the source foil and received on 7/12/13, at the end of the day, a leak test result of 0.008 uCi. The licensee submitted a report on 7/15/2013 to the Agency [Massachusetts Radiation Control Program] which states the source foil was in storage, it remains in storage, and was never used in any projects. Licensee reports the source foil will be decontaminated and the leak test will be repeated. All decontamination materials will be placed and sealed in a radioactive waste container and will be placed in the radioactive material storage area.

"Source will remain in storage until undergoing decontamination cleaning and subsequent leak test.

"Component name: Ni-63 source foil
"Manufacturer: Eckert & Ziegler
"Model # NER-004-13
"Manufacture date: November 2008
"Serial Number: 13-2080
"Isotope activity: 0.015 Ci
"Assay Date: November 2008"

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Agreement State Event Number: 49197
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/17/2013
Notification Time: 13:21 [ET]
Event Date: 07/16/2013
Event Time: 11:30 [CDT]
Last Update Date: 07/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PERMANENT PROSTATE BRACHYTHERAPY UNDERDOSE

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

RHB [Kentucky Radiation Health Branch] was notified by telephone on 7/16/13 at approximately 1445 [EDT] by the licensee's authorized medical physicist of a medical event involving a permanent prostate brachytherapy implant. A CT scan performed at 30 days post-implant revealed that 16 of the 60 I-125 seeds (lsoAid IAI-125A) representing 26% of the implanted activity had migrated from the planning treatment volume to a region cephalad to the prostate. Post implant dosimetry revealed the dose to 90% of the prostate to be 113 Gy rather than the prescribed dose of 144 Gy (78% of prescribed). This represents a V100 of 54% with the current prostate delineation on CT. The licensee is now undertaking a complete investigation as to why these seeds migrated from their initial implantation site. The referring physician is scheduled to perform a cystoscopy 7/25 to check for seeds that may have migrated into the bladder based on CT visualization. The prescribing physician will be scheduling an MRI for final target and adjacent organ delineation. Final dose to the tissues at risk will then be calculated.

"The referring physician was notified 7/17/13 at 1045 EDT. The patient was notified 7/17/13 at 1130 EDT."

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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Non-Agreement State Event Number: 49199
Rep Org: PARADISE FOSSIL PLANT
Licensee: TENNESSEE VALLEY AUTHORITY
Region: 1
City: DRAKEBORO State: KY
County:
License #: 16-25243-01
Agreement: Y
Docket:
NRC Notified By: LEE MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/17/2013
Notification Time: 15:42 [ET]
Event Date: 07/17/2013
Event Time: 10:30 [CDT]
Last Update Date: 07/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
HAROLD GRAY (R1DO)
EUGENE GUTHRIE (R2DO)
FSME EVENTS RESOURCE (FSME)

Event Text

MOISTURE GAUGE SHUTTER STUCK IN OPEN POSITION

"TVA's Paradise Fossil Plant uses a coal scan moisture monitor with a sealed source containing 3 millicuries of Cesium-137. The gauge is used to monitor the moisture in the coal being transferred on a common feed line to three units at Paradise Fossil Plant. On July 17, 2013 at 1030 CDT, the shutter on the moisture gauge was determined not to be operable. The shutter failed in the open position. The shutter failure discovery was made during the six month shutter test. The issue is being entered into the corrective action program. No personnel radiation exposure was received. The source is not shuttered, but the gauge is in the operating position and is in a safe condition.

"A twenty-four hour notification is required per 10 CFR 30.50(b)(2) due to failure of the moisture monitor shutter to close.

"NRC Region II Duty Officer and NRC Region I Duty Officer will be notified."

Gauge model TBM-201.

Licensee stated that there is no danger of personnel exposure.

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Power Reactor Event Number: 49211
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BENJAMIN EGNEW
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/24/2013
Notification Time: 07:55 [ET]
Event Date: 06/14/2013
Event Time: 18:06 [EDT]
Last Update Date: 07/24/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
ANTHONY DIMITRIADIS (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

INVALID PRIMARY CONTAINMENT ISOLATION SYSTEM ACTUATION DUE TO A RADIATION MONITOR SPIKE

"This notification is being made in accordance with 10CFR50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Primary Containment Isolation System (PCIS) Group 3 actuation signal that affected containment valves in more than one system.

"On 6/14/2013, and again on 7/11/2013, with the reactor at 100% power, an invalid PCIS Group 3 actuation occurred from a momentary spike of the 'A' Refuel Floor radiation monitor which reached the instrument's high radiation trip setpoint. A radiation protection technician was dispatched to the refuel floor and dose rates in the vicinity of the 'A' radiation monitor detector were verified to be normal and below the alarm setpoints. The radiation monitor was verified to be indicating normal expected radiation levels. Subsequent visual inspection and functional checks of the radiation monitors were completed satisfactory and the instrument channel was returned to service. The cause of the spurious spikes is attributed to an unknown source of electrical noise. The issue with spurious spiking has been entered into the station's corrective action program.

"Both trains of Standby Gas Treatment System started as designed and Reactor Building ventilation isolated. The train actuation was complete.

"The PCIS functioned successfully providing a complete Group 3 isolation. The PCIS Group 3 isolation involves the following systems.

"Drywell and Suppression Chamber air and vent: V16-19-6A, 6B, 7, 7A, 7B, 8, 9, 10, 23
"Containment Makeup: V-16-20-20, 22A, 22B
"Containment Air Sampling: VG-23, 26, V109-76A, 76B
"Containment Air compressor suction: V72-38A, 38B
"Containment Air Dilution: VG-9A, 9B, 22A, 22B, NG-11A, 11B, 12A, 12B, 13A, 13B

"In accordance with 10CFR50.73(a)(1) a telephone notification is being made instead of submitting a written Licensee Event Report."

The licensee has notified the NRC Resident Inspector and will notify the State and local agencies.

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Power Reactor Event Number: 49213
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/24/2013
Notification Time: 12:21 [ET]
Event Date: 07/23/2013
Event Time: 13:45 [EDT]
Last Update Date: 07/24/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.417(b)(1) - FFD PROGRAMMATIC FAILURE
Person (Organization):
GEORGE HOPPER (R2DO)
JOHN MONNINGER (NRR)
JANE MARSHALL (IRD)

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

PROGRAMMATIC FAILURE TO TEST PERSONNEL RETURNING TO THE SITE

"On July 23, 2013 at 1345 [EDT], the Fitness-for-Duty Snapshot Self-Assessment team identified an anomaly with the Employee Plant Access Control Tracking (EMPACT) program used to randomly select V.C. Summer employees for daily fitness for duty (FFD) screenings. More specifically, when an employee terminates employment at the station, Access Control personnel select 'Exclude from Random' feature in the EMPACT program to remove their name from the program code that randomly selects current employees for daily FFD screenings. When a former employee returns to the station for re-employment, Access Control personnel select 'New Request' within the EMPACT program. The 'New Request' feature is supposed to automatically deselect the 'Exclude from Random' feature, which adds the employee back to the randomly selected population. This feature of the EMPACT program was determined not to be functional.

"In accordance with 10 CFR 26.719(b)(4), this program flaw constitutes: 'Any programmatic .... discovered vulnerability of the FFD program that may permit the undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program.'

"This event has been entered into the station's corrective action program under CR-13-03066. The issue is limited to 53 employees (2.9% of the randomly selected population) that have returned to V.C. Summer for employment in the previous six years. Immediate corrective actions consist of contacting the program vendor, conducting an Access Control Program standdown, and contacting the 53 employees to report for fitness-for-duty screening.

"The NRC Resident Inspector has been notified.

"Other utilities known to use the EMPACT software have been contacted."

This issue does not affect units 2 or 3 since they use a different system.

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Power Reactor Event Number: 49214
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: TOM FOUTS
HQ OPS Officer: PETE SNYDER
Notification Date: 07/24/2013
Notification Time: 17:46 [ET]
Event Date: 07/24/2013
Event Time: 14:19 [EDT]
Last Update Date: 07/24/2013
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):
ANTHONY DIMITRIADIS (R1DO)

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 FROM FULL POWER

"At 1419 EDT on 7/24/2013, the reactor tripped due to a reactor protection system (RPS) actuation signal from a turbine trip, which was caused by a generator trip. All control rods inserted on the trip and reactor coolant system (RCS) pressure is currently 2235 psig and stable with RCS temperature stable at 547 degrees F. Decay heat is being removed by steam dumps [to the main condenser] and auxiliary feedwater which auto started as expected.

"The cause of the generator trip is under investigation. The plant will remain in Mode 3 until the cause of the trip is determined.

"The plant notified the NRC Resident Inspector."

Page Last Reviewed/Updated Thursday, July 25, 2013
Thursday, July 25, 2013