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Event Notification Report for November 8, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/07/2013 - 11/08/2013

** EVENT NUMBERS **


49407 49484 49485 49488 49511 49512 49514 49515 49516

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 49407
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: MARK BRIDGES
HQ OPS Officer: PETE SNYDER
Notification Date: 10/04/2013
Notification Time: 02:12 [ET]
Event Date: 10/03/2013
Event Time: 20:45 [CDT]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
NICK VALOS (R3DO)

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 HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE DUE TO DRAIN LINE LEAK

"On October 3, 2013, at 2045 [CDT] hours, a defect (pinhole through-wall leak) was identified on the drain line for the LS 2-2365, HPCI TURBINE INLET DRAIN POT LEVEL SWITCH. The defect was identified during investigation of leakage near LS 2-2365. The LS 2-2365, HPCI TURBINE INLET DRAIN POT LEVEL SWITCH, is provided to detect a failure of the HPCI steam trap during standby line-up. The location of the defect, is in Class 2 Safety related piping. HPCI is a single train safety system and this notification is being made in accordance with 10CFR50.72(b)(3)(v)(D). The instrument isolations for LS 2-2365 have been close and the leak has been isolated."

There is no increase to plant risk and RCIC (Reactor Core Isolation Cooling) is available.

The licensee will inform the NRC Resident Inspector.

* * * RETRACTION ON 11/7/13 AT 1412 EST FROM JEFFERY JACOBSON TO DONG PARK * * *

"The purpose of this notification is to retract the ENS report made on October 4, 2013, at 0212 EDT (ENS Report # 49407).

"Upon further investigation the pinhole through-wall leak discovered in the Unit 2 HPCI room was in a weld at a 'Tee' downstream of the Unit 2 HPCI turbine inlet drain pot level switch (LS 2-2365) on drain line 2-2386B-1-B. The defect was characterized as a 1/16-inch rounded hole due to gas porosity (with no evidence of cracking).

"A subsequent evaluation performed by Quad Cities Station considering the defect size, location, and characterization confirmed the Unit 2 High Pressure Coolant Injection (HPCI) system would have performed its safety function when required. Based on this subsequent evaluation, ENS Report # 49407 is being retracted.

"Note: On October 3, 2013, at 1155 CDT the Unit 2 HPCI drain line leak was isolated and HPCI was declared operable."

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Lipa).

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Agreement State Event Number: 49484
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNIVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DARREN PERRERO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/30/2013
Notification Time: 14:36 [ET]
Event Date: 10/29/2013
Event Time: [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE ()

Event Text

ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE TO A PATIENT

The following report was received from the Illinois Emergency Management Agency via e-mail:

"On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated.

"As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days."

The cause of this event was equipment failure.

Illinois Item Number: IL13032

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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Agreement State Event Number: 49485
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: ALLWEST TESTING & ENGINEERING
Region: 4
City: HAYDEN State: ID
County:
License #: 11-27637-01
Agreement: N
Docket: 03035139
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/30/2013
Notification Time: 14:21 [ET]
Event Date: 10/27/2013
Event Time: 11:25 [MST]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PORTABLE MOISTURE DENSITY GAUGE DAMAGED AT WORKSITE

The following report was received from the North Dakota Department of Health via e-mail:

"A portable moisture/density gauge possessed by ALLWEST Testing & Engineering, LLC of Hayden, Idaho containing a 10 mCi Cesium-137 sealed source and a 50 mCi Americium-241:Beryllium sealed source was crushed by a piece of heavy equipment (excavator bucket) at a temporary job site located southwest of Dickinson, North Dakota. The portable gauge user had failed to maintain constant surveillance of the gauge. Upon observing the heavy equipment running into the gauge, the user flagged down the heavy equipment operator to halt his activity. The operator lifted the bucket off the gauge and set it to the side. The gauge user instructed the operator to relocate to an area approximately 150 feet from the damaged gauge. Subsequently, he phoned his immediate supervisor and the Radiation Safety Officer (RSO) for guidance. An area at an approximate distance of 150 feet in three directions from the damaged gauge was roped off with 'Caution Radiation' tape. The fourth direction (east) consisted of a large hill of soil not readily accessible.

"1:02 PM (MST): The gauge user placed a call to the ND State Radio emergency response number to report the event.

"1:08 PM (MST): ND State Radio personnel notified the Stark County Emergency Manager (SCEM) who in turn notified the Southwestern District Health Unit Executive Officer (HUEO).

"1:10 pm (MST): The HUEO notified the ND Department of Health Radiation Control Program Manager (RCPM) of the event. The RCPM informed the HUEO the gauge should remain in place until radiation surveys had been performed and the site evaluated by his department.

"2:17 pm (MST): The HUEO and the SCEM were present at the event site. They met with the gauge user and the Westcon, Inc. HSE Coordinator for a briefing of the event. The HUEO performed an initial radiation survey using a calibrated SE International, Inc. Model Radiation Alert Inspector survey instrument (SN 35756). The survey was performed beginning at the outer boundary moving inwards toward the damaged gauge. The reading at a distance of 4 feet from the source was 0.063 mR/hr. The background reading was 0.013 mR/hr. The HUEO and SCEM instructed the gauge user to leave the gauge in place and wait for North Dakota Department of Health personnel to be on site the next morning to evaluate the site. Visual assessment of the gauge showed evidence of the two source housings to be physically intact.

"October 28, 2013:

"6:00 am (MST): As instructed by ALLWEST Testing & Engineering's RSO, the gauge user relocated the damaged gauge and associated fragments to the gauge transport case. The case was secured in the box of his pickup truck.

"9:00 am (MST): North Dakota Department of Health (NDDoH) personnel were on site to perform interviews, radiation surveys and evaluation of the site. Radiation surveys were performed by the NDDoH using a calibrated Ludlum Model 19 microR meter (SN 270378) and a Canberra Dineutron neutron meter (SN 18327). The background readings were 12 microR/hr and 0.027 mR/hr respectively. The highest gauge shipping container surface readings were 3.1 mR/hr (gamma) and 0.09 mR/hr (neutron). Surveys of the pathway from the initial impact of the bucket to the gauge's final resting spot revealed background readings. A leak test of the gauge was performed and shipped via overnight express for analysis. The leak test results demonstrated no leakage. The gauge was transported by licensee personnel back to their Idaho office to make arrangements for final disposal.

"Throughout the event, the gauge user had not worn personnel dosimetry. Exposure calculations will be performed by the RSO."

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Agreement State Event Number: 49488
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GB BIOSCIENCES CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: 03521
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2013
Notification Time: 15:46 [ET]
Event Date: 10/29/2013
Event Time: [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER STUCK IN THE OPEN POSITION

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

"On October 30, 2013, the Agency [Texas Department of Health] was notified by the licensee that while conducting routine maintenance checks on a Texas Nuclear model 5196 nuclear gauge containing a 20 milliCurie cesium137 source, the shutter was found stuck in the open position. The licensee lubricated the operating shaft and attempted to close and reopen the shutter. While attempting to reopen the shutter, the operating rod for the shutter broke. The licensee determined the gauge is in the open position, which is the normal operating position for the gauge. The licensee has contacted the gauge manufacturer and will either repair or replace the gauge. No individual received any additional exposure as a result of this event. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."

Texas Incident #: I-9132

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Power Reactor Event Number: 49511
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: COREY A. GRAY
HQ OPS Officer: PETE SNYDER
Notification Date: 11/07/2013
Notification Time: 11:41 [ET]
Event Date: 11/07/2013
Event Time: 12:00 [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ALAN BLAMEY (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 N 0 Defueled 0 Defueled
3 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER TAKEN OUT OF SERVICE FOR PLANNED MAINTENANCE

"Technical Support Center (TSC) out of service due to planned maintenance. This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the work activity affects the functionality of an emergency response facility.

"Planned maintenance activities during the Unit 2 outage on 11/7/2013 will render TSC out of service for approximately 48 hours. The unit 2 work is on electrical equipment that will impact the power supply to the TSC.

"If an emergency is declared requiring TSC activation during this period, the alternate TSC will be used per existing emergency planning procedures.

"The NRC Resident Inspector has been notified. This event poses no threat to the public or station employees."

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Power Reactor Event Number: 49512
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: EDWARD CARRERAS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/07/2013
Notification Time: 13:02 [ET]
Event Date: 11/07/2013
Event Time: 06:00 [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAMES NOGGLE (R1DO)

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

Event Text

REACTOR COOLANT SYSTEM COLD LEG DRAIN LINE ULTRASONIC INDICATION

"On Thursday, November 7, 2013, while performing planned inspections on a 2 inch reactor coolant system drain line, TMI technicians identified an indication of a flaw on the weld internal diameter of an elbow to pipe weld on the line. This flaw is determined to not meet acceptable criteria and a repair is being developed. This condition is reportable under 10CFR50.72(b)(3)(ii). No actual impact occurred during plant operations.

"The NRC Senior Resident Inspector has been notified."

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Power Reactor Event Number: 49514
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BARRETT MULLY
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/07/2013
Notification Time: 15:52 [ET]
Event Date: 11/07/2013
Event Time: 13:33 [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES NOGGLE (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

CONDUIT FLOOD SEAL MISSING

"On 11/7/13, it was identified that a missing conduit flood seal between an outside manhole and the West switchgear room compromised the flooding design of both the East and West switchgear rooms.

"Compensatory measures were implemented for the flood seal in accordance with the plant's barrier control process. Repair of the seal is in progress. The event is being reported under 10CFR 50.72(b)(3)(v) as internal flooding of both Switchgear Rooms could affect (a.) safe shutdown, (b.) removal of decay heat, (c.) control of release of radioactive material and (d.) mitigating an accident.

"The NRC Senior Resident Inspector has been notified of this condition."

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Power Reactor Event Number: 49515
Facility: SUMMER
Region: 2 State: SC
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: DEAN KERSEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/07/2013
Notification Time: 16:05 [ET]
Event Date: 11/05/2013
Event Time: 08:26 [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.417(b)(1) - FFD PROGRAMMATIC FAILURE
Person (Organization):
ALAN BLAMEY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Under Construction 0 Under Construction
3 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS FOR DUTY - VENDING MACHINE MAINTENANCE CONTRACTOR USED ANOTHER WORKER'S BADGE

"On November 7, 2013, at 0826 EST, an investigation determined that a Fitness for Duty (FFD) policy violation as defined in 10 CFR 26.417(b)(1) had occurred in the Chicago Bridge & Iron (CB&I) FFD Program at the South Carolina Electric & Gas (SCE&G) V.C. Summer Units 2 and 3 construction site.

"On November 5, 2013, a CB&I contractor vending machine service employee, in the presence of a CB&I contract security officer, used another contractor vending machine service employee's badge to gain access to the construction site after his badge did not allow access due to being inactivated in an effort to facilitate a random FFD test. The contractor vending machine service employee was escorted out of the construction site.

"Subsequent investigation uncovered that it was a practice within the contractor vending machine service company to maintain an employee's badge in the vehicle and periodically use it to ensure the badge was not deactivated.

"The contractor vending machine service company employee badges have been deactivated pending further investigation. The individuals involved in this event are under 10 CFR 26, Subpart K, and do not perform safety or security related work. This event has been entered in the CB&I and SCE&G Corrective Action Programs for resolution and development of appropriate corrective actions.

"SCE&G is providing this notification in accordance with 10 CFR 26.417(b)(1).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49516
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/07/2013
Notification Time: 16:32 [ET]
Event Date: 11/07/2013
Event Time: 15:52 [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTINE LIPA (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

Event Text

POSTULATED HOT SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"A review of industry operating experience regarding the impact of unfused Direct Current (DC) ammeter circuits has determined the described condition to be applicable to the Palisades Nuclear Plant resulting in a potentially unanalyzed condition with respect to 10 CFR 50 Appendix R analysis requirements.

"The original plant wiring design and associated analysis for the Class 1E batteries ampere indications, located in the cable spreading room at Palisades, do not include overcurrent protection features to limit the fault current. In the postulated event, a fire could cause one of the ammeter wires to short to ground. Simultaneously, it is postulated that the fire causes another DC wire from the opposite polarity on the same battery to also short to ground. This could cause a ground loop through the unprotected ammeter wiring. This event could result in excessive current flow (i.e., heating) in the ammeter wiring to the point of causing a secondary fire in the raceway system. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10 CFR 50 Appendix R.

"Interim compensatory measures (i.e., fire tours) have been implemented for affected areas of the plant.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, November 08, 2013
Friday, November 08, 2013