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Event Notification Report for April 1, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/31/2014 - 04/01/2014

** EVENT NUMBERS **


49944 49945 49946 49955 49969 49974 49975 49977 49978 49979

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Agreement State Event Number: 49944
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: APPLUS RTD INC.
Region: 1
City: SHUNK State: PA
County:
License #: PA-1482
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/21/2014
Notification Time: 13:59 [ET]
Event Date: 03/20/2014
Event Time: [EDT]
Last Update Date: 03/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - INABILITY TO RETRACT RADIOGRAPHY SOURCE TO ITS FULLY SHIELDED POSITION

The following information was received via facsimile:

"The Department's [PA Department of Environmental Protection Bureau of Radiation Protection] Central Office was informed of this event on March 20, 2014. This event is reportable within 24 hours per 10 CFR 30.50(b)(2) and within 30 days per 10 CFR 34.101(a)(2).

"Upon completion of a shot, the source was found to be stuck within the collimator and unable to be retracted. The area was roped off and controlled, the Radiation Safety Officer was notified, and a service provider (QSA Global) was called to perform retrieval operations. The source was returned to its fully shielded position at 0002 EDT on March 21, 2014. The radiographer, assistant radiographer, and recovery team received minimal exposure from this source retrieval operation. No one from the general public was exposed to radiation from this operation. Additional information will be provided upon receipt.

"Camera Model: QSA Global 880 Delta; Isotope: Ir-192; Activity: 68 Ci.

"The cause of the event is unknown at this time. The camera and cables are being returned to the manufacturer to be inspected. The Department plans a reactive inspection."

PA Event Report ID No: PA140010

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Agreement State Event Number: 49945
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TEAM INDUSTRIAL
Region: 3
City: ABERDEEN State: OH
County:
License #: 03320990000
Agreement: Y
Docket:
NRC Notified By: CHUCK MCCRACKEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/21/2014
Notification Time: 17:32 [ET]
Event Date: 03/21/2014
Event Time: 04:30 [EDT]
Last Update Date: 03/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA WITH STUCK SOURCE

The following Ohio Bureau of Radiation Protection report was received via facsimile:

"The [Ohio] Bureau of Radiation Protection [BRP] was notified by the licensee's corporate RSO [Radiation Safety Officer] at 1505 [EDT] on 3/21/2014, about an incident involving a stuck radiography source. The incident took place at 0430 on 3/21/2014. Crew members were performing radiography in a boiler penthouse in Aberdeen, Ohio, when a magnetic stand fell over and crimped the source guide tube while the source was still out. Crew members called the RSO at their Woodlawn, Ohio [location], who instructed them to survey and post the area and control access until he arrived. The Woodlawn RSO arrived at the site around 0900, shielded the source and was able to bend the guide tube so the source could be retracted back into the camera. The source was safely [positioned] back into the camera around 0945 on 3/21/14. Because licensee personnel wear Instadose dosimetry badges by Mirion Technologies, the Woodlawn RSO was able to determine that the exposure he received from this source retrieval activity was 159 mRem. The licensee understands they are responsible to provide a written report to the BRP within 30 days."

The radiography device is a QSA 880 Delta camera with a 27 Ci Ir192 source.

Ohio State BRP Incident Report: #2014-006.

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Non-Agreement State Event Number: 49946
Rep Org: BOZEMAN DEACONESS HOSPITAL
Licensee: BOZEMAN DEACONESS HOSPITAL
Region: 4
City: BOZEMAN State: MT
County:
License #: 25-10994-04
Agreement: N
Docket:
NRC Notified By: KARI CANN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/21/2014
Notification Time: 17:53 [ET]
Event Date: 09/09/2008
Event Time: [MDT]
Last Update Date: 03/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

THREE MEDICAL MISADMINISTRATION INCIDENTS

During a recent review of historical records, it was determined that three medical misadministration incidents had occurred. Two of these incidents occurred on September 9, 2008 and the third incident occurred on September 30, 2008.

The patients were being treated for prostate cancer and were receiving I-125 brachytherapy. Two patients were each prescribed a source activity of 0.269 mCi but received 0.341 mCi. The third patient was prescribed 0.340 mCi but received 0.439 mCi.

The patients have been followed elsewhere for the last few years. The licensee will assess the patients as soon as they are available. The licensee is in the process of notifying the patients of the misadministrations.

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: 49955
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NATIONAL TECHNICAL SYSTEMS
Region: 4
City: NEWARK State: CA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: KENT PREDERGAST
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/24/2014
Notification Time: 18:15 [ET]
Event Date: 03/03/2014
Event Time: [PDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENT RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING NICKEL 63 SOURCE

The following information was received via email:

"Operations Manager of National Technical Systems, NTS- Silicon Valley, contacted RHB [California - Radiation Health Branch] Sacramento and reported that their analytical equipment, manufactured by Particle Measuring Systems, used for analyzing gases by ionizing them with a 10 milliCi Nickel-63 source was leaking. The Nickle-63 source leakage was discovered in their recent leak test that was performed in anticipation of shipping the unit to the calibration lab. This resulted in a reading well above the 11,000 DPM limits (it was 4.8 million DPM inside the outflow fitting of the equipment). National Technical Systems shipped the detector cell and equipment to Particle Measuring Systems for disposal. National Technical Systems conducted surveys in the area where the unit was stored and used, and no Nickel-63 contamination was found. According to the radiation safety officer of Particle Measuring Systems, the contamination was contained inside the outflow part of the equipment.

"Equipment Manufacturer: Particle Measuring Systems; Equipment Name and Model: Air Sentry II, Chlorides Monitor

"Based upon disposal and appropriate surveys, this item is closed."

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Fuel Cycle Facility Event Number: 49969
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/28/2014
Notification Time: 16:45 [ET]
Event Date: 03/28/2014
Event Time: 13:30 [EDT]
Last Update Date: 03/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
MARVIN SYKES (R2DO)
MERAJ RAHIMI (NMSS)

Event Text

ITEMS RELIED ON FOR SAFETY NOT OPERABLE

"It was determined at 1:30PM today (3/28/14) that one of the Items Relied on for Safety (IROFS) associated with the Dry Conversion Process recycle operation was inoperable. Although the second IROFS preventing moderation intrusion to the recycle container continued to operate within its allowable parameters, it alone was not sufficient to meet performance requirements.

"The affected equipment has been shut down and at no time was an unsafe condition present. While this did not result in an unsafe condition, the event is being reported pursuant with the reporting requirements of 10CFR70 Appendix A (b)(2) within 24 hours of discovery.

"Additional corrective actions, extent of condition, and the cause of the failure are being determined."

The licensee will notify NRC Region 2, State of North Carolina Radiation Protection, and New Hanover County Emergency Management.

* * *UPDATE PROVIDED BY SCOTT MURRAY TO JEFF ROTTON AT 1219 EDT ON 03/31/2014 * * *

"After further review, it was determined, at approximately 1125 EDT on 3/31/2014, that the second IROFS [mentioned in the initial report] was not reliable to meet performance requirements. As a result, the report is amended as follows:

"The second IROFS preventing significant moderator intrusion to the recycle container was available, but its reliability could not be confirmed. The control continued to limit significant moderator intrusion and an unsafe condition did not exist. The remaining IROFS was not sufficient to meet performance requirements.

"As a result, the event report is being conservatively amended pursuant with the reporting requirements of 10CFR70 Appendix A (a)(4) within 1 hour of discovery."

The IROFS that was inoperable in the initial report was a process flow moisture probe. The second IROFS that was believed to be available in the initial report but later determined to not be reliable was a set of process control valves used to prevent moderation intrusion to the recycle container.

The licensee will notify NRC Region 2, State of North Carolina Radiation Protection, and New Hanover County Emergency Management.

Notified R2DO (Sykes) and NMSS EO (Rahimi)

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Part 21 Event Number: 49974
Rep Org: GE-HITACHI NUCLEAR ENERGY
Licensee: GE-HITACHI NUCLEAR ENERGY
Region: 1
City: WILMINGTON State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DALE PORTER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/31/2014
Notification Time: 09:07 [ET]
Event Date: 03/31/2014
Event Time: [EDT]
Last Update Date: 03/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
MARVIN SYKES (R2DO)
PART 21 REACTOR GROU (EMAI)

Event Text

INTERIM PART 21 REPORT - CONTAINMENT LOADS POTENTIALLY EXCEED LIMITS WITH HIGH SUPPRESSION POOL WATER LEVEL IN THE ABWR DESIGN

The following summary was excerpted from GE Hitachi Interim Part 21 Report received via email:

"A potential analysis error has been identified that is associated with the ABWR (Advanced Boiling Water Reactor) hydrodynamic loads determined by using the Technical Specification Suppression Pool High Water Level (HWL) as an analysis input condition. Vessel coolant inventory is transferred into the containment Suppression Pool during a postulated LOCA blowdown, thereby increasing the Suppression Pool water level. The correction in the analysis may lead to a Suppression Pool water level greater than what is currently assumed in structural analyses which apply the containment hydrodynamic loads generated during a postulated LOCA event."

Facility Identification: South Texas Project Units 3 and 4, Clinton ESP Site, Grand Gulf ESP Site, North Anna ESP Site, and includes the ESP application for the PSEG Site and Victoria County Station ESP application.

If you have any questions, then contact: Dale E. Porter, GE-Hitachi Nuclear Energy Americas LLC, Ph. #(910) 819-4491.

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Power Reactor Event Number: 49975
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: DOUG KNUDSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/31/2014
Notification Time: 14:44 [ET]
Event Date: 03/28/2014
Event Time: 21:10 [PDT]
Last Update Date: 03/31/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
HEATHER GEPFORD (R4DO)
JOHN MONNINGER (NRR)
JEFFERY GRANT (IRD)

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

Event Text

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION -- UNUSUAL EVENT DUE TO SEISMIC EVENT

"On March 28, 2014 at 2110 PDT, station staff felt a minor seismic event, which was verified on the NEIC [National Earthquake Information Center]. On-shift staff reviewed basis documentation and EAL [Emergency Action Levels] classification, and concluded the event was below the threshold to classify the event.

"During post event reviews [conducted on 3/31/2014], it has been determined that those events met the classification criteria for declaration of a Notification of Unusual Event for a seismic event as specified by the Emergency Plan. No emergency situation exists at this time."

Site personnel did perform the steps of the Earthquake abnormal operating procedure even though the entry requirements were not met. There were no plant or equipment issues identified during the site walk downs.

The licensee has notified the NRC Resident Inspector, the State of California and other Local authorities.

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Power Reactor Event Number: 49977
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM STRICKLAND
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/31/2014
Notification Time: 18:57 [ET]
Event Date: 03/31/2014
Event Time: 13:02 [CDT]
Last Update Date: 03/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DAVE PASSEHL (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 87 Power Operation 54 Power Operation

Event Text

UNIT 2 REACTOR PRESSURE BOUNDARY LEAKAGE AND UNIT SHUTDOWN

"On March 31, 2014, at 1302 [CDT], with Unit 2 operating in Mode 1 (coastdown), leakage was identified from the body of a one inch isolation valve associated with a Control Rod Drive Hydraulic Control Unit (CRD HCU 18-27 insert valve 101). The leakage is several drops per minute; attempts to isolate the leak have been unsuccessful. The associated piping communicates with the reactor coolant system (through the CRD mechanism).

"Technical Specification 3.4.4 (RCS Operational Leakage), Condition C, was entered at 1302 hours. Condition C requires the unit to be placed in Mode 3 (Hot Shutdown) in 12 hours. At 1616 hours, a Technical Specification required shutdown was initiated on Unit 2.

"The cause and resolution of the leakage are being pursued.

"This condition is being reported under 50.72(b)(3)(ii)(A) given the defect is associated with the primary coolant system pressure boundary. This notification is also being made in accordance with 10 CPR 50.72(b)(2)(i) given the initiation of a plant shutdown required by the plant Technical Specifications."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49978
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: PATRICK TUMY
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2014
Notification Time: 20:30 [ET]
Event Date: 03/31/2014
Event Time: 15:58 [CDT]
Last Update Date: 03/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HEATHER GEPFORD (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 SIX EMERGENCY SIRENS

"At approximately 15:58 hours (CDT) on March 31, 2014, Waterford 3 was informed that five emergency sirens were inoperable during the performance of a monthly siren inspection. Subsequent review during preparation of this notification has identified an additional one inoperable siren, which brings the total number of inoperable sirens to six. There are a total of seventy-three sirens distributed among two parishes (counties). The loss of these six sirens for more than one hour is considered a major loss of offsite response capability and is reported pursuant to 10 CFR 50.72(b)(3)(xiii).

"The affected parish Emergency Operations Center was notified of the condition and it was confirmed that they will use the preplanned alternative method of Route Alerting for the affected areas until notified that repairs to the sirens have been completed.

"Waterford 3 has initiated preparations to repair the sirens, with actual repairs expected to commence tomorrow. The performance of the monthly siren inspection will continue during daylight hours today and resume tomorrow. There is no effect on the plant. This issue has been entered into the Waterford 3 Corrective Action Program and appropriate corrective actions will be developed.

"The NRC Resident Inspector and local agencies were notified."

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Power Reactor Event Number: 49979
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PALUL DUNDEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/01/2014
Notification Time: 02:44 [ET]
Event Date: 04/01/2014
Event Time: 00:26 [EDT]
Last Update Date: 04/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 15 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO ELECTRICAL ISSUE

"At 0026 on 04/01/2014, following the turbine shutdown and removal of the main generator from service in preparation for refueling outage 16, Seabrook had a reactor trip and all control rods were fully inserted. The trip was caused by an electrical issue that caused 345 KV bus 6 to deenergize and power was lost to the Unit Auxiliary Transformers (UATs). The in-house busses transferred to the Reserve Auxiliary Transformer (RAT) supplies and the momentary loss of power to in-house Bus 1 caused 2 reactor coolant pumps to trip, generating a 2 loop loss of flow reactor trip signal. The exact cause of the initialing electrical issue is being investigated.

"The resident NRC Inspector has been notified.

"Emergency feedwater actuated at 0035 due to a low low water level in steam generator 'C'. Plant equipment response is being evaluated and the plant is stabilized in Mode 3 with decay heat removal through the steam dump system to the condensers. There was no release and the emergency feedwater system is being restored to standby.

"The event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73."

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