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Event Notification Report for March 17, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/14/2014 - 03/17/2014

** EVENT NUMBERS **


49851 49881 49883 49905 49913 49915 49916 49918 49919

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Power Reactor Event Number: 49851
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: PAUL GRESH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/23/2014
Notification Time: 12:23 [ET]
Event Date: 02/23/2014
Event Time: 12:00 [EST]
Last Update Date: 03/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HIRONORI PETERSON (R3DO)

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

Event Text

INTEGRATED PLANT COMPUTER SYSTEM REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"[On] February 23, 2014, at approximately 1200 [EST], the Fermi 2 Integrated Plant Computer System (IPCS) was removed from service outside of the Control Room to support planned system maintenance. The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and [was rendered] out of service when the IPCS [was] removed from Emergency Response Facilities (ERFs). These systems will be unavailable to all Emergency Response Facilities (ERFs) for approximately 50 hours. During this time, dose assessment (Raddose) capability will only be available in the manual data input mode. The SPDS indications and Raddose remain available to the plant staff in the Control Room, and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored, including SPDS and ERDS, to the Operational Support Center, the Technical Support Center, and alternate facilities. This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE AT 0905 EDT ON 03/15/14 FROM PAUL GRESH TO S. SANDIN * * *

The following update was received from the licensee:

"On February 23, 2014, at approximately 1200 [EST], the Fermi 2 Integrated Plant Computer System (IPCS) was removed from service to support planned system maintenance. The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and were out of service when IPCS was removed from service.

"On March 15, 2014 at approximately 0800 [EDT], planned maintenance on ERDS, SPDS, and IPCS is complete, restoring full Emergency assessment capabilities to the control room and all onsite emergency response facilities."

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

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Agreement State Event Number: 49881
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UMASS MEMORIAL HEALTH CARE
Region: 1
City: WORCESTER State: MA
County:
License #: 60-0096
Agreement: Y
Docket:
NRC Notified By: MICHAEL WHALEN
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/07/2014
Notification Time: 08:27 [ET]
Event Date: 03/05/2014
Event Time: [EST]
Last Update Date: 03/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE INVOLVING YTTRIUM 90 MICROSPHERES

The following information was received by email:

"On March 6, 2014, UMass Memorial Health Care (license number 60-0096) reported [to the Massachusetts Radiation Control Program] that on March 5, 2014 they had under dosed a patient by more than 20% using Y-90 microspheres. Further pertinent data is:

"Prescribed Activity: 26.4 mCi of Y-90 (in one fraction injection)
Delivered Activity: 20.4 mCi of Y-90 (more than 20% different from prescribed)

"Resulting in:
Prescribed Liver dose: = 32.6 Gy
Delivered Liver dose: = 25.2 Gy
Dose difference in organ: = 740 rads (i.e., greater than 50 rem and 20% difference)

"Note Also:
Effective dose (requested): 32.6 Gy * 0.04 = 1.3 Sv
Effective dose (delivered): 25.2 Gy * 0.04 = 1.0 Sv
Effective dose difference: 1.3-1.0=0.3 Sv = 30 rem (greater than 5 rem difference)"

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: 49883
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ULRICH ENGINEERS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 03950
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2014
Notification Time: 16:52 [ET]
Event Date: 02/18/2014
Event Time: [CST]
Last Update Date: 03/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On March 7, 2014, the Agency [Texas Department of Health] was notified by the licensee that one of its vehicles had been stolen on February 18, 2014. The vehicle contained a moisture density gauge, Troxler model 3340, serial number 17909, containing 1.48 GBq of Americium-241/Beryllium serial number 4713350 and 0.30 GBq of Cesium-137 serial number 507394. A local police report was filed. No recovery of vehicle or gauge. One violation cited for not reporting incident within regulatory timeframe. Any further information will be reported within SA 300 guidelines."

Texas Incident #: I-9162

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 49905
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: PAUL GALLANT
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/12/2014
Notification Time: 18:15 [ET]
Event Date: 03/12/2014
Event Time: 13:15 [EDT]
Last Update Date: 03/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARC FERDAS (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

LOSS OF COMMUNICATION - FEDERAL TELEPHONE SYSTEM (FTS)

"At 1315 [EDT] on Wednesday March 12, 2014, while performing monthly communications testing, Pilgrim Nuclear Power Station (PNPS) discovered that portions of the Federal Telephone System (FTS) were not functioning as designed. Specifically, the Emergency Notification System (ENS), is not available from the Control Room or Technical Support Center/ Operations Support Center (TSC/OSC) while the Health Physics Network (HPN), the Reactor Safety Counterpart Link (RSCL), and the Protective Measures Counterpart Link (PMCL) are not currently available from the Technical Support Center/ Operations Support Center (TSC/OSC). All four of these systems were confirmed to be available from the Emergency Operations Facility (EOF). The initial investigation has determined that the failure has not impacted the entire FTS, but may have the potential to impair the licensee's ability to communicate in the event of an emergency.

"Immediate actions are being taken to restore the system to functional status and applicable plant procedures have been entered to determine any further mitigating actions. Members of the Emergency Response Organization have been notified of the failures and the need to utilize commercial phone lines as a compensatory action. The NRC Operations Center has been contacted and informed of these communication system failures.

"It cannot be determined at the time of this notification as to when the system will be restored to full functional status.

"This event had no impact on the health and/or safety of the public.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is conservatively being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of certain emergency response communication capabilities as provided by the FTS."

The NRC Resident Inspector has been notified. The licensee will notify the state.

* * * UPDATE FROM KEN GRACIA TO HOWIE CROUCH @ 1712 EDT ON 3/14/14 * * *

"Federal Telephone System (FTS) communications testing was completed at 1130 EDT on March 14, 2014. The FTS System has been restored to full functional status. The Emergency Response Organization (ERO) has been informed.

"The licensee has notified the NRC Senior Resident Inspector and the Commonwealth of Massachusetts."

Notified R1DO (Ferdas).

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Fuel Cycle Facility Event Number: 49913
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: ROSS LINDBERG
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/13/2014
Notification Time: 15:46 [ET]
Event Date: 03/13/2014
Event Time: 13:00 [CDT]
Last Update Date: 03/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
JAMES ANDERSEN (NMSS)

Event Text

CONTAMINATED PLANT EMPLOYEE RECEIVED MEDICAL TREATMENT INSIDE THE RESTRICTED AREA

"An employee with a wooden splinter in his right hand reported to the on-site dispensary this afternoon. The plant nurse administered first aid. A whole body survey of the employee in his plant clothing was performed; the maximum amount of contamination present was on the employee's right pant leg, 12,550 dpm/100cm2. The plant nurse allowed the employee to return to work. The employee remained inside the Restricted Area over the course of the event."

The licensee will inform R2 (Hartland).

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Power Reactor Event Number: 49915
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GUY GRIFFIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/14/2014
Notification Time: 15:38 [ET]
Event Date: 03/14/2014
Event Time: 11:55 [EDT]
Last Update Date: 03/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
KATHLEEN O'DONOHUE (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

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

"While evaluating IER 13-54, regarding the impact of unfused direct current (DC) circuits, a determination was made that the described condition is applicable to Edwin I. Hatch Units 1 and 2 for reactor protection system (RPS) battery/battery charger ammeter circuits. This results in an unanalyzed condition with respect to 10CFR50 Appendix R analysis requirements.

"In the postulated event, a fire induced hot short could adversely impact safe shutdown equipment. The Unit 1 and 2 RPS battery/battery charger ammeter indication circuits are routed from the affected components to the main control room. It is postulated that a fire in one fire area can damage the affected cables and cause short circuits without protection that would overheat the cable and possibly result in secondary fires in other fire areas where the cables are routed. 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 10CFR50 Appendix R.

"Interim compensatory measures (i.e., fire watches) have been implemented for the affected areas of the plant. This condition is being reported pursuant to 10CFR50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

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Fuel Cycle Facility Event Number: 49916
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: ROSS LINDBERG
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2014
Notification Time: 16:15 [ET]
Event Date: 03/14/2014
Event Time: 12:45 [CDT]
Last Update Date: 03/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
JAMES ANDERSEN (NMSS)

Event Text

UNPLANNED MEDICAL TREATMENT OF A CONTAMINATED INDIVIDUAL

"An employee with a wooden splinter in his right hand reported to the on-site dispensary this afternoon. The plant nurse administered first aid. A whole body survey of the employee in his plant clothing was performed; the maximum amount of contamination present was on the employee's right boot, 2760 dpm/100cm2. The plant nurse allowed the employee to return to work. The employee remained inside the Restricted Area over the course of the event."

The licensee will inform R2 (Hartland).

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Fuel Cycle Facility Event Number: 49918
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: RON DOCKERY
HQ OPS Officer: PETE SNYDER
Notification Date: 03/15/2014
Notification Time: 11:32 [ET]
Event Date: 03/14/2014
Event Time: 13:30 [CDT]
Last Update Date: 03/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
JAMES ANDERSEN (NMSS)

Event Text

HIGH PRESSURE FIRE WATER SYSTEMS DECLARED INOPERABLE

"On 3/14/2014 at 1330 hours, the Plant Shift Superintendent was notified by Fire Services that adequate pressure could not be verified during post maintenance testing of an inoperable High Pressure Fire Water System for the C-335 building. During investigation into the issue, it was discovered that eleven operable High Pressure Fire Water Systems were also impacted. The facility is in TSR mode three as all cells have been sampled UF6 negative and the cell motors are not energized. In this mode, the High Pressure Fire Water Systems are still required to be operable per TSR 2.4.4.6; however, due to inadequate pressure, the eleven systems may not have been able to perform the intended safety function. The eleven operable High Pressure Fire Water Systems were declared inoperable and hourly fire patrols were initiated according to TSR LCO 2.4.4.5.9.1 at 1520 hours on 3/14/2014.

"On 2/26/2014 at 1212 hours, three High Pressure Fire Water System Sectional Valves were isolated and declared inoperable in order to isolate a section of header which contained a small leak. Isolating these valves resulted in a single supply to twelve High Pressure Fire Water Systems in C-335. Upon investigation of the lack of pressure, it was determined that the sectional supply valve in the remaining supply loop was not operating as designed and is suspected to be the cause of the restricted water flow.

"Sectional supply valves that had been used for isolation of the small leak have been opened to provide unrestricted flow to the affected sprinkler systems. Following the confirmation of adequate flow, the sprinkler systems were declared operable and the hourly fire patrols were discontinued at 1739 hours on 3/14/2014. The small leak will be monitored until repairs can be initiated or the leak becomes unmanageable. At that point TSR LCO actions will be entered as necessary.

"This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Region II (Marvin Sykes) has been notified of this event via voice mail."

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Power Reactor Event Number: 49919
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BLAINE PETERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/15/2014
Notification Time: 14:56 [ET]
Event Date: 03/15/2014
Event Time: 11:02 [CDT]
Last Update Date: 03/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVE PASSEHL (R3DO)

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

Event Text

MOMENTARY LOSS OF SHUTDOWN COOLING DUE TO A LOSS OF OFFSITE POWER

"[Unit] 1 experienced a loss of offsite power (LOOP). [Unit] 1 station aux transformers (SATs) tripped. 1A and 1B emergency diesel generators (EDGs) started and properly restored power to ESF [engineered safety feature] bus 141 and 142. Safe shutdown loads (1A/B SX [essential service water] pumps and 1A/B CC [component cooling] pumps) properly started when signaled by the EDG sequencers. The 1A residual heat removal pump was manually restarted at 1105 [CDT] to restore shutdown cooling. There was no impact to RCS temperature. Additionally, a containment isolation signal was actuated when containment radiation monitors which are powered from the ESF buses briefly lost power until restored by the EDGs. All related equipment realigned as expected except for the 0A VC [control room] chiller that didn't start when required on the EDG sequencer. The cause of the LOOP and the 0A VC chiller issue is under investigation. Fuel moves were in progress and stopped safely. All fuel bundles are in a safe location."

Unit 2 was not affected and remains in mode 1.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014