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Event Notification Report for June 20, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/19/2014 - 06/20/2014

** EVENT NUMBERS **


50192 50193 50195 50196 50211 50212 50213 50214 50215

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Agreement State Event Number: 50192
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: SIRTEX WILMINGTON LLC
Region: 1
City: WILMINGTON State: MA
County:
License #: 55-0539
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/12/2014
Notification Time: 09:50 [ET]
Event Date: 05/14/2014
Event Time: [EDT]
Last Update Date: 06/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL DOSE EXCEEDING EXTREMITIES LIMIT

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

"On 6/11/14, licensee reported to Agency [Commonwealth of Massachusetts] a potential dose exceeding the adult occupational shallow dose equivalent to the skin or extremities limit of 50 rem. Licensee reported situation occurred during March-April 2014 dosimeter wear period and involved employee working with Y-90 in hot cell. Licensee reported extremity ring badge pierced through the employee's glove resulting in contamination of ring badge. March-April 2014 extremity ring exposure reading of 52,480 mRem. Year-to-date extremity ring exposure at 53,400 mRem. The year-to-date whole body badge exposure is at 51 mRem.

"Licensee reported corrective actions identified and implemented to reduce likelihood of recurrence. Consultant hired to review dose assessment and assist in completing 30-day written report.

"No other details from the licensee at this time.

"The Agency inspector will conduct a site visit. The Agency is awaiting a 30-day written report by the licensee.

"The Agency considers this event to still be OPEN."

Event Docket #: 18-1343

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Agreement State Event Number: 50193
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWEST COMMUNITY HOSPITAL
Region: 3
City: ARLINGTON HEIGHTS State: IL
County:
License #: IL-01094-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/12/2014
Notification Time: 11:30 [ET]
Event Date: 06/10/2014
Event Time: [CDT]
Last Update Date: 06/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following information was received via email from the State of Illinois:

"On June 11, the Radiation Safety Officer/Medical Physicist for Northwest Community Hospital in Arlington Heights, IL called to report a medical event. The previous morning a patient was to be administered approximately 38 milliCi of Y-90 labeled microspheres for treatment of liver cancer in the left lobe of the liver via the hepatic artery. Instead, approximately only 21 milliCi was delivered. Post treatment measurements of the delivery system showed substantially elevated readings at the catheter/vial interface suggesting either blockage or perhaps improper flow allowing the microspheres to coagulate. The physician is considering an increase in dosage for the patient's second treatment which is scheduled in two to three weeks in order that the ideal dose be delivered. However, if that cannot be accomplished, the interventional radiologist does not believe the patient's health to be adversely affected by the under dose. A written report of the event from the licensee is pending at this time."

IL Report Number: IL-14010

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: 50195
Rep Org: U.S. AIR FORCE
Licensee: U.S. AIR FORCE
Region: 1
City: ROSSLYN State: VA
County:
License #: 42-23539-01 A
Agreement: Y
Docket:
NRC Notified By: MAJOR EDWARD KELLY
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/12/2014
Notification Time: 14:19 [ET]
Event Date: 04/21/2014
Event Time: [EDT]
Last Update Date: 06/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GREG WERNER (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

LOST NICKEL-63 ION SCAN SOURCE

"On 21 April 2014, BE [AMDS Bioenvironmental Engineering] received an email from AFRRAD [Air Force Radioactive Recycling and Disposal] with a certification of transfer & receipt indicating that the Ionscan [Model 400/ serial number 10172] received by AFRRAD did not contain radioactive material. BE made a site-visit to 305th APS Passenger Terminal [Building 1706 located in New Jersey on 87 AMDS/SGPB, Joint Base McGuire-Dix-Lakehurst] to assist in searching for the ion scanner source. When the source could not be found, BE emailed a picture of what the component should look like to the URSO [Unit RSO] and his alternate to further assist in searching for the source while also asking for documentation of the last time the source was sent to manufacturer to determine whether the source was removed at that time. Neither the source nor the documentation could be found.

"From 21 April - 21 May 2014, BE maintained communication with the URSO and his alternate and informed them that if they did not find the source by 21 May, a telephonic notification would be made to the RIC [Radioisotope Committee]. During this period, BE communicated the health risks both to 305 APS & 87 AMDS commanders and affected personnel.

"On 21 May, the URSO made it clear that they had exhausted all efforts to find the source. Later that day, BE made telephonic notification to the RIC (Maj Ed Kelly) indicating that the source was missing and could not be found."

Ionscan 400 contains a Ni-63 source with an activity of 15 milliCi. The Sealed Source and Device Registry number (SS&DR) associated with the Ionscan 400 is NR-0163-D-801-G. The device is used to screen passengers for hazardous material. The licensee will be notifying NRC Region IV (Cook)

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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Agreement State Event Number: 50196
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ENERGY SOLUTIONS
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73008
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/12/2014
Notification Time: 15:35 [ET]
Event Date: 06/12/2014
Event Time: 11:30 [EDT]
Last Update Date: 06/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIATION LEVELS ON TRANSPORTATION TRAILER EXCEEDED 200 MR/HR

The following information was received via email from the State of Tennessee:

"The Tennessee Division of Radiological Health was notified on June 12, 2014 by a representative of Energy Solutions that an 'exclusive use' truck shipment was received from Philotechnics of Oak Ridge, TN. The truck was identified to have radiation levels on the bottom surface of the truck of approximately 350 mR/hr.

"The State of Tennessee dispatched an inspector to Energy Solutions."

State of Tennessee notified NRC Region 1(Janda).

TN Report No.: TN-14-120

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Power Reactor Event Number: 50211
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOHN SALVATORE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 06/19/2014
Notification Time: 15:08 [ET]
Event Date: 06/19/2014
Event Time: 08:03 [EDT]
Last Update Date: 06/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAKE WELLING (R1DO)

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

PROCESS RADIATION MONITOR MAINTENANCE

"System affected: Normal and High Range SLCRS [Supplementary Leakage Collection and Release System] ventilation process radiation monitors.

"Actuations and their initiation signals: None.

"Causes: Removed from service for scheduled maintenance.

"Effect of event on plant: None.

"Actions taken or planned: Complete required calibration.

"Additional information: Will be returned to service following maintenance."

The licensee notified the NRC Resident Inspector and applicable State and local agencies.

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Power Reactor Event Number: 50212
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RAUL MARTINEZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/19/2014
Notification Time: 15:19 [ET]
Event Date: 04/22/2014
Event Time: 08:30 [CDT]
Last Update Date: 06/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MICHAEL HAY (R4DO)

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

Event Text

EMERGENCY DIESEL GENERATOR INVALID ACTUATION

"This report describes an invalid actuation of the Unit 2, Train A (2-01) Emergency Diesel Generator (EDG) that occurred on April 22, 2014. This report is being made in accordance with 10CFR50.73(a)(2)(iv)(A). 10CFR50.73(a)(1) states, in part, 'In the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than actuation of the Reactor Protection System (RPS) when the reactor is critical, the licensee may, at its option, provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.'

"On April 22, 2014, Comanche Peak Nuclear Power Plant Unit 2 was in Mode 5 during the 14th refueling outage. At approximately 0830 CDT, while performing a lockout test on EDG 2-01, the Reactor Operator made a place keeping error that resulted in EDG 2-01 starting and rolling up to approximately 300 RPM. The start signal should have been blocked as part of the test. However, a step was skipped due to a place keeping error and this resulted in an inadvertent start of EDG 2-01 during the performance of a subsequent step.

"The specific train and system that actuated was the Unit 2, Train A, Emergency Diesel Generator. During the inadvertent EDG start the system started and functioned correctly, and the EDG only reached 300 RPM before it was shut down.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 50213
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: THOMAS MORSE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 06/19/2014
Notification Time: 17:06 [ET]
Event Date: 06/19/2014
Event Time: 16:28 [EDT]
Last Update Date: 06/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NICK VALOS (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

UNANALYZED CONDITION DUE TO A POSTULATED HOT SHORT THAT COULD AFFECT SAFE SHUTDOWN EQUIPMENT

"A review of industry operating experience regarding the impact of unfused Direct Current (DC) circuits has determined the described condition to be applicable to the Perry Nuclear Power Plant (PNPP) resulting in an unanalyzed condition with respect to fire safe shutdown requirements.

"In the postulated event, a fire induced hot short could adversely impact safe shutdown equipment. The potential exists for a secondary fire to occur due to unfused DC control circuits associated with the Turbine Emergency Bearing Oil Pump, Reactor Feed Pump Turbine 'A' Emergency Lube Oil Pump, Turbine Emergency Seal Oil Pump, and Reactor Feed Pump Turbine 'B' Emergency Lube Oil Pump. These circuits are routed from the respective equipment to other plant areas including the Unit 1 Control Room, Division 1 Cable Spreading, and Division 1 Cable Chase.

"Without overcurrent protection for these circuits, the potential exists that an initial fire event affecting these circuits could cause short circuits without protection that would cause excessive current through the circuit beyond the capacity rating of the conductors. This could lead to a secondary fire in another plant area where these circuits are routed challenging the ability to achieve and maintain safe shutdown.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). Interim compensatory measures (i.e., fire watches) have been implemented for affected areas of the plant.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 50214
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/20/2014
Notification Time: 00:29 [ET]
Event Date: 06/20/2014
Event Time: 00:01 [CDT]
Last Update Date: 06/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MICHAEL HAY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Cold Shutdown

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"The National Weather Service predicts that the Missouri River level at Fort Calhoun Station will exceed 1004 feet above mean sea level on 6/20/14 at approximately 2300 CDT. Fort Calhoun Station will begin a ramp down in power to satisfy technical specification 2.16 which states, 'When the Missouri River level reaches elevation 1004 feet mean sea level, the reactor shall be in a HOT SHUTDOWN condition [Mode 3] and in Cold Shutdown [Mode 4] within 36 hours following entry into Hot Shutdown.' The river level is currently 998 feet 3 inches and rising approximately 0.5 inches per hour. At time 0001 CDT 6/20/14 Fort Calhoun station will initiate a plant shutdown to Hot Standby and will proceed to a Cold Shutdown condition within 36 hours following entry into Hot Shutdown, as required."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 50215
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/20/2014
Notification Time: 01:08 [ET]
Event Date: 06/19/2014
Event Time: 20:35 [CDT]
Last Update Date: 06/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 55 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"At 1435 [CDT] on June 19, 2014 while performing Unit 1 A Train Safeguards Logic Test at power, it was discovered, while testing the Safety Injection Automatic Actuation Relay Logic, that the 1SI-15x, SI RELAY TRAIN A, was not making up the contact to energize 1SI-16x, SI AUX RELAY TRAIN A. As a result, the 8 hour exception for testing allowed under LCO 3.3.2 Condition C no longer applied, and the 6, 12, and 42 hour clocks associated with condition C were entered.

"At 2035 [CDT] on June 19, when the 6 hour time limit to complete Condition C.1 action could not be completed operators began preparation to shutdown Unit 1 to Mode 3 by 0235 on 6/20/14.

"At 2245 [CDT] on June 19, 2014 operators commenced reducing reactor power of Prairie Island Unit 1. As of 0003, June 20, Unit 1 was at 55 percent power and continuing to reduce load.

"This event is reportable per 10CFR50.72(b)(2)(i) - The initiation of any nuclear plant shutdown required by the plant's Technical Specification.

"The protection of the health and safety of the public is not affected by this issue.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, June 20, 2014
Friday, June 20, 2014