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Event Notification Report for September 6, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/05/2013 - 09/06/2013

** EVENT NUMBERS **


49297 49308 49309 49321 49323 49324 49326 49327

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 49297
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: GOOD SAMARITAN REGIONAL MEDICAL CENTER
Region: 4
City: CORVALIS State: OR
County:
License #: 90202
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/22/2013
Notification Time: 14:33 [ET]
Event Date: 08/21/2013
Event Time: 13:45 [PDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN DOSE PRESCRIBED FOR ANOTHER PATIENT

The following was received from the State of Oregon via facsimile:

"The inpatient was having an Adenosine Myoview stress test. The Nuclear Medicine Technologist took the dose that was already in the dose calibrator (place there earlier by another Nuclear Medicine Technologist). It measured about the same activity as 99m-Tc Myoview would measure in the dose calibrator. The Nuclear Medicine Technologist gave the patient 37.4 millicuries of 99m-Tc DTPA (lung ventilation dose) instead of 30 millicuries of 99m-Tc Myoview. The route of administration for 99m-Tc DTPA is inhalation and the route of administration for 99m-Tc Myoview is intravenous. The 99m-Tc DTPA was intended for a different patient. The patient was informed of the mistake and the stress test will be repeated tomorrow (8/22/13). The ordering physician was also notified of the event. There were no adverse effects to the patient, just delayed the study.

"This will be reported at the next Radiation Safety Committee Meeting along with any actions that will be taken to prevent this in the future."

Oregon Event Number: 13-0031

* * * RETRACTION ON 9/4/13 AT 1310 EDT FROM RICK WENDT TO DONG PARK * * *

"This item is ready for closure. Incident closed. Not a reportable event."

Notified R4DO (Gaddy).

* * * UPDATE ON 9/5/13 AT 1306 EDT FROM RICK WENDT TO PETE SNYDER * * *

The event was not reportable due to the fact that the total organ dose was less than 50 REM.

Notified R4DO (Gaddy).

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 49308
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: FRED SCHIZAS
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2013
Notification Time: 04:10 [ET]
Event Date: 08/26/2013
Event Time: 23:05 [CDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BOB HAGAR (R4DO)

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

POST ACCIDENT MONITORING INSTRUMENTATION POWER SUPPLIES POTENTIALLY DEGRADED

"At 2305 on 26AUG13 the Shift Manager Declared PC-ES-1A and PC-ES-1B inoperable due to a Part 21 Notification that called the operability of the equipment into question. PAM [Post Accident Monitoring] Instrumentation LCO 3.3.3.1.A and 3.3.3.1.C were entered for Functions 1 (Reactor Pressure), 3 (Containment Level), and 7 (Containment Pressure). Both divisions are potentially affected. LCO 3.3.3.1.C represents a 7 Day shutdown LCO.

"CR-CNS-2013-6096 identified a Part 21 issue associated with Foxboro Power Supply PC-ES-1A and PC-ES-1B. The Part 21 issue identifies a potential failure mechanism in which the adhesive backing on aluminum tie-wrap base used in the power supply fails and the base becomes detached from the power supply case. The nylon tie-wrap affixed to these bases becomes brittle with age and fails releasing the aluminum base to fall into the power supply where it has the potential to short out electrical equipment and fail the power supply. The equipment affected is: PC-LRPR-1A, PC-LRPR-1B, NBI-PR-2A, and NBI-PR-2B. These power supplies affect both Control Room Reg. Guide 1.97 Cat A instruments and associated PMIS/SPDS points. This instrumentation is utilized for emergency plan actions (EALs) and EOP 3A actions in addition to monitoring the previously mentioned functions. The loss of this instrumentation represents a significant loss of emergency response capability. The affected instruments are for indication only and perform no active safety functions. All of the referenced instrumentation is currently functioning as required.

"This condition has been entered into the CNS Corrective Action Program.

"A 60 day Licensee Event Report is not required for this event."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM DAVID MADSEN TO VINCE KLCO ON 9/5/13 AT 1854 EDT * * *

"This notification is being made to retract Event Notification EN 49308 that was reported on August 26, 2013. This EN identified Cooper Nuclear Station had equipment potentially affected by a Part 21 issue in which a potential failure mechanism of adhesive on aluminum ty-wrap bases used in two power supplies fails and the base becomes detached from the power supply case. The nylon ty-wraps affixed to these bases become brittle with age and fails, releasing the aluminum base to fall into the power supply with the potential to short out electrical equipment. These power supplies affected Post Accident Monitoring equipment that is used to monitor for Emergency Plan Actions (EALs) and EOP 3A actions. This equipment provides no active safety function and is used for indication only. The equipment affected included PC-ES-1A and PC-ES-1B and they provided divisional power to Post Accident Monitoring equipment for Reactor Pressure, Containment Level and Containment Pressure.

"Ten of the eleven aluminum cable tie holders were found to still be in place during the inspection of PC-ES-1A under WO 4972878. The one cable tie holder that was found to not be adhered was initially attached when the power supply was opened. Based on physical inspection of the removed cable ties and the installed wiring, and ten of the eleven cable tie holders being adhered upon inspection of the power supply it is concluded that this power supply remained qualified to perform its function under all design conditions in its as found configuration. The failure mechanism identified in the Part 21 required two failures. The inspection performed on PC-ES-1A only revealed the failure of one cable tie mount and not the widespread failures reported in the Part 21. Additionally, the cable ties removed from PC-ES-1A remained flexible and would not have failed during a seismic event based on engineering judgment. As such, PC-ES-1A remained capable of performing its design function. By engineering judgment PC-ES-1B also remained capable of performing its function. Therefore, there was no actual or potential major loss of emergency assessment capability per 10 CFR 50.72(b)(3)(xiii)."

The licensee notified the NRC Resident Inspector. Notified the R4DO (Gaddy).

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Agreement State Event Number: 49309
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: NABORS COMPLETION & PRODUCTION SERVICES COMPANY
Region: 4
City: WILLISTON State: ND
County:
License #: 33-48830-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/27/2013
Notification Time: 16:27 [ET]
Event Date: 08/24/2013
Event Time: [MDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE INVOLVED IN FIRE AT WELL SITE

The following information was received via facsimile:

"A fire started at a well site near Williston, ND on Saturday, August 24, 2013. At the time of the event, fracking activities were being performed utilizing a Thermo Fisher Scientific model 5190 nuclear density gauge containing a Cs-137 source attached to a blender. Personnel evacuation was immediately performed and notification was made to the local fire department. Local fire department personnel arrived on-site and established control of the scene. The fire was extinguished later that night. Local fire department personnel restricted access to the site until Sunday morning. At that time, licensee personnel on-site were allowed to approach the gauge from a safe distance working their way towards the gauge while continually monitoring a radiation survey instrument (Ludlum Model 3). As the observed readings were higher than expected, it was believed the lead shielding had melted inside the steel casing and shifted to the lower area within the casing. The steel casing remained intact. After the initial assessment, licensee personnel maintained continual surveillance while site security personnel prohibited access within the public dose boundary set by the licensee. The licensee dispatched their Radiation Compliance Coordinator for further evaluation.

"The licensee's Radiation Compliance Coordinator arrived in Williston late Sunday night. Early Monday morning he arrived on site to perform more complete radiation surveys and leak testing of the involved gauge. The highest radiation levels noted around the gauge were 2.6 R/hr at the surface and 20 mR/hr at 1 meter. Wipe tests were collected and sent to Applied Health Physics of Bethel, PA for analysis. The results of the first two wipe samples demonstrated no evidence of contamination.

"The licensee contacted the manufacturer regarding disposal of the damaged gauge. The manufacturer, not willing to accept receipt of the gauge, suggested the licensee contact a waste broker for final disposal. The licensee subsequently contacted Applied Health Physics (AHP). AHP plans to cut out the gauge and package it in a lead lined 55 gallon steel drum for transport, and ship the container for final disposal. AHP is scheduled to perform this activity on Thursday, August 29, 2013.

"Licensee and site security personnel will continue to maintain surveillance and control of the site until the disposal personnel arrive."

* * * UPDATE FROM DAVID STRADINGER TO PETE SNYDER AT 1756 EDT ON 9/5/13 * * *

AHP removed the gauge and packaged it for transport. Notified R4DO (Gaddy) and FSME EVENTS RESOURCE (e-mail).

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Power Reactor Event Number: 49321
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: MARK BRIDGES
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 12:30 [ET]
Event Date: 09/04/2013
Event Time: 16:15 [CDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MICHAEL KUNOWSKI (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

CONFIRMED POSITIVE FITNESS-FOR-DUTY TEST

A licensed employee had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 49323
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: ERVIN LYSON
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 14:51 [ET]
Event Date: 09/05/2013
Event Time: 13:14 [EDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
TODD JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 45 Power Operation

Event Text

FAILURE TO ALIGN CONTROL ELEMENT ASSEMBLY DURING TESTING

"CCNPP [Calvert Cliffs Nuclear Power Plant] U2 CEA [Control Element Assembly] #27 fully inserted (CEA dropped) into the core during testing per STP 0-029-2. Technical Specification 3.1.4, Action B was entered and required the CEA to be realigned within 2 hours. With this action not met Technical Specification 3.1.4, Action C required the Unit be reduced to < 70% rated thermal power (achieved at 1308 [EDT]) and the CEA to be realigned within 2 hours.

"With the CEA being unable to be realigned, Technical Specification 3.1.4.F was entered at 1314 [EDT] which requires the Unit to be placed in Mode 3 within 6 hours.

"A plant shutdown has been initiated in accordance with this Technical Specification. Therefore, this is reportable under 10 CFR 50.72(b)(2)(i), 'Plant Shutdown Required by Technical Specifications.'"

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 49324
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: DAVID SPARGO
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 17:31 [ET]
Event Date: 09/05/2013
Event Time: 08:31 [CDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

POTENTIAL LOW PRESSURE SAFETY INJECTION PUMP RUN OUT CONDITION

"Current design basis calculations indicate the Low Pressure Safety Injection (LPSI) pumps could potentially operate in a run-out condition under certain worst case design basis conditions. The LPSI pumps could operate in a run-out condition beyond the analyzed time by 20 minutes. Current design basis calculation assumes LPSI Pump would be shutdown by [the] RAS [Recirculation Actuation Signal] in less than one hour, however due to past changes to Containment Spray Pump Start Logic, the time was lengthened to 80 minutes which is beyond the one hour analyzed. This represents a reportable unanalyzed condition."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 49326
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: MICHAEL MASON
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/06/2013
Notification Time: 00:27 [ET]
Event Date: 09/05/2013
Event Time: 16:00 [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF AUXILIARY COMPONENT COOLING WATER SYSTEMS

"This is a non-emergency notification from Waterford 3. Conditions were discovered which appear to require immediate NRC notification per 10CFR50.72(b)(3)(ii)(B) due to both trains of Auxiliary Component Cooling Water [CCW] being inoperable several times since 7/27/2012. A deficiency was identified with Auxiliary Component Cooling Water valve ACCW-126A, which is a part of the ultimate heat sink system, associated with the inability to adequately close this valve manually, locally, in order to preserve Wet Cooling Tower A inventory during an accident. System operability requirements came into question and resulted in Operations declaring the system inoperable on 9/4/2013 at 1509 CDT, and entered Technical Specification (TS) LCO 3.7.3 and associated cascading TS. As part of the review for NRC reporting requirements associated with the inoperable CCW Train A, historical information was discovered that indicated the redundant train of CCW, Train B, was declared inoperable several times, while ACCW-126A was presumably in the degraded or inoperable condition, since ACCW-126A had last been rebuilt on 7/27/2012. This condition requires immediate reporting to NRC under 10CFR50.72(b)(3)(ii)(B), an unanalyzed condition that significantly degrades plant safety. The condition was corrected and the system declared operable on 9/5/2013 at 1231 CDT, exiting the CCW TS LCO and associated cascading TS.

"Prior to the condition with ACCW-126A being corrected, a snubber pin (FWSR-60) was found missing on 9/5/2013 at 1228 CDT that could have adversely affected the ability to feed Steam Generator #2 with Emergency Feedwater. Less than 4 hours later, the pin was replaced, which restored the path to Operable, at 1609 CDT on 9/5/2013.

"The plant remained stable at 100% during this time. Plant risk index was 10.0 green."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49327
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MATT HUMMER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/06/2013
Notification Time: 05:10 [ET]
Event Date: 09/05/2013
Event Time: 22:44 [PDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VINCENT GADDY (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

TURBINE BUILDING STACK RADIATION MONITOR OUT OF SERVICE

"At 2244 PDT on September 5, 2013, the Turbine Building Stack Radiation Monitor - Low Range detector, and the Turbine Building Stack Radiation Monitor - Intermediate Range detector were declared non-functional due to a failure of the sample rack supply fan.

"At 0156 hours PDT on September 6, 2013, a temporary sample cart was installed to return the Turbine Building Stack Radiation Monitor - Low Range detector, and the Turbine Building Stack Radiation Monitor - Intermediate Range detector to service.

"To compensate for the loss of assessment capability while the Turbine Building Stack Radiation Monitoring equipment was nonfunctional, a field team survey would have been used if required.

"This event is being reported as a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Friday, September 06, 2013
Friday, September 06, 2013