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Event Notification Report for September 10, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/09/2014 - 09/10/2014

** EVENT NUMBERS **


49879 50064 50421 50439

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Power Reactor Event Number: 49879
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ADAM PECK
HQ OPS Officer: PETE SNYDER
Notification Date: 03/06/2014
Notification Time: 19:33 [ET]
Event Date: 03/06/2014
Event Time: 09:06 [PST]
Last Update Date: 09/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
TOM ANDREWS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION REGARDING POTENTIAL TORNADO MISSILE DAMAGE TO EMERGENCY DIESEL EXHAUST PLENUM

"The condition described below is being reported as an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B) and per the guidance of NUREG-1022, Rev. 3.

"On 03/06/2014 at 0906 PST, Diablo Canyon Power Plant (DCPP) identified a nonconforming condition involving the Emergency Diesel Generator (EDG) ventilation exhaust plenums installed in Unit 1 and Unit 2. Specifically, the radiator exhaust plenums and exhaust piping need to be re-evaluated to ensure adequate protection against flying debris that could be generated by a tornado.

"The occurrence of such an event is highly unlikely and there is no imminent concern regarding severe weather involving tornados. The EDGs are located inside the power plant structure and are capable of performing their safety function. Compensatory measures are being developed to address the associated nonconformance.

"This event does not adversely affect the health and safety of the public.

"The licensee informed the NRC Resident Inspector."

* * * UPDATE PROVIDED BY RUSS CRUZEN TO JEFF ROTTON AT 2245 EDT ON 09/09/2014 * * *

"This condition does not adversely affect the health and safety of the public.

"Based on an extent of condition review being performed for this event, the issue identified in the original event notification 49879 has also been determined to similarly affect the ventilation systems associated with the Unit 1 and 2 Vital 480 volt AC switchgear and battery/inverter equipment.

"The condition described in this update is being reported as an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B) and as an event or condition that could have prevented the fulfillment of a safety function per 10 CFR 50.72(b)(3)(v)(A).

"Compensatory measures are being developed to address the associated condition.

"The licensee informed the NRC Resident Inspector."

Notified R4DO (Azua)

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Agreement State Event Number: 50064
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: ELEKTA, INC.
Region: 1
City: NORCROSS State: GA
County:
License #: GA 1153-2
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/28/2014
Notification Time: 10:20 [ET]
Event Date: 04/24/2014
Event Time: [EDT]
Last Update Date: 09/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
MARK HAIRE (R4DO)
FSME EVENTS RESOURSE (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT

The following information was received via E-mail:

"On the evening of April 24, 2014 Elekta, (Georgia license - GA 1153-2) working under a Nebraska reciprocity general license, was installing the initial source (9.98 curies of lr-192) into the new Flexitron unit at Saint Francis Medical Center (Nebraska Radioactive Material License # 08-09-01) in Grand Island, Nebraska. During the upload procedure, the source did not completely retract into the safe and became hung-up on the in-drive. The device gave an error stating the source was detached from the cable. Following the manufacturer's recommended emergency procedures, the engineer entered the room to investigate the issue and determined the source cable needed to be cut to remove it from the stuck source drive. The Field Service Engineer (FSE) then quickly cut the exposed source cable and, using pliers, manually inserted the source into the transport container. However, due to the fact that the source cable was short, he could not get it completely into the center of the shielded transport container. The exposure rate at one meter from the transport container was 200 mR/hour. The facility physicist and FSE insured the door to the treatment room was sealed and marked so no one could enter overnight.

"The following morning, April 25, 2014, work began to construct temporary shielding made of lead bricks on a trolley in order to transport the container to the facility hot lab. Additionally, arrangements were made with Elekta's source manufacturer to acquire a type A container of the proper size to house and ship the source transport container to their facility, thus removing it from St. Francis premises.

"Elekta's Radiation Safety Officer failed to notify the State of Nebraska Radioactive Material's Program in a timely manner. The incident occurred after business hours and Friday April 25, 2014 was a State holiday (Arbor Day). No call was made to the emergency call number for the State and the information was only obtained by the Nebraska Program Manager by a series of e-mails and a voicemail after 0800 CDT on Monday, April 28, 2014."

Item Number: NE14003

* * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *

The following information was received via email:

"On April 29, 2014, a special Type A container from Alpha Omega Services (AOS) arrived on site and the source was packaged in it for shipment. On May 1, 2014, source was shipped to AOS. On May 7, 2014, the source was received at AOS facility for safe decay storage before shipping back to Mallinckrodt.

"On May 21 & 22, 2014, the HDR unit involved in the incident was shipped back to Nucleotron B. V. in the Netherlands for investigations. No results as of June 16, 2014."

Notified R4DO (Hay), R1DO (Welling) and FSME Event Resource via email.

* * * UPDATE FROM TRUDY HILL (VIA EMAIL) TO HOWIE CROUCH AT 1123 EDT ON 09/09/14 * * *

The following information was obtained via email:

"As of July 25, 2014 there is still no determination as to the cause of the source hang-up. The HDR unit is still being analyzed at the factory in the Netherlands.

"As of August 27, 2014, Elekta's R & D Department has not uncovered the root cause of the incident. Extensive analysis of the drive and the log files have not been able to reproduce the specific error. R & D are in the final stages of the root cause investigation and should be completed soon.

"On September 8, 2014, Elekta submitted their close out report on the incident. After exhaustive & extensive analysis of the drive and the log files, the R & D Department has not been able to reproduce the specific error and could not uncover the root cause of the incident."

Nebraska considers this report as closed.

Notified R1DO (Jackson), R4DO (Azua) and FSME Events Resource via email.

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Agreement State Event Number: 50421
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: FROEHLING & ROBERTSON
Region: 1
City: JESSUP State: MD
County:
License #: MD-27-083-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/02/2014
Notification Time: 16:40 [ET]
Event Date: 08/27/2014
Event Time: [EDT]
Last Update Date: 09/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED AT CONSTRUCTION SITE

"Our [Froehling & Robertson] technician was using the gauge to test compaction of soils placed for wall backfill. [The technician] placed the nuclear gauge on the sloped hill next to the backfill area and stepped away from the gauge to check on the concrete pour that was happening at the top of the hill. As she was walking away, the backfill crew started using the two drum walk-behind roller. The roller was in vibratory mode and, as it approached the area near the nuclear gauge, the gauge slid down the slope into the path of the roller. The gauge was hit with the roller on the end opposite the rod, damaging the casing and the instrument panel. [The technician] and the roller operator moved the gauge to assess the damage and, when they realized it was damaged, [the technician] cordoned off the area.

"Exposure Readings and Visual Damage Assessment:

"[The RSO] arrived on-site with the survey meter (CD V-700 calibrated 5/9/2014) and checked the area for radiation exposure. No significant readings were recorded (less than 0.1 mrem/hr 5 feet from the gauge). The source rod was fully retracted into the casing and did not appear to be damaged other than the handle was twisted. The gauge appeared to be intact in the vicinity of the Americium source. The gauge was packed and secured in its storage case and transported to Northeast Technical Services for a leak test and damage evaluation.

"Assessment of Cause:

"[The RSO] interviewed the client and [technician] to try to assess a cause for the incident. The client had asked [the technician] to go check on the concrete pour before performing another density test and, instead of properly securing the gauge in the truck or keeping it within arm's reach, [the technician] left the gauge unattended while she walked up the slope. In talking with [the technician], she was aware of the proper procedures for securing the gauge and maintaining control of the gauge but failed to do so in this case.

"Corrective Measures:

"As this is a first offense for [the technician], she will be issued a written warning stating that if involved in another incident like this, she will be terminated. Additionally, she will be asked to take another refresher course on using and transporting nuclear density gauges. [The RSO] will also be holding a safety meeting with all technicians to review this incident and review the F&R Nuclear Gauge Safety material regarding maintaining control of gauges."

Sources: 0.37 GBq Cs-137 and 1.48 GBq Am-241:Be
Make/Model: Troxler 3400
Serial #: 23898

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Part 21 Event Number: 50439
Rep Org: CAMERON MEASUREMENT SYSTEMS
Licensee: CAMERON MEASUREMENT SYSTEMS
Region: 4
City: CITY OF INDUSTRY State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ISAAC RAMSINI
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/09/2014
Notification Time: 18:37 [ET]
Event Date: 09/09/2014
Event Time: [PDT]
Last Update Date: 09/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
TODD JACKSON (R1DO)
SCOTT SHAEFFER (R2DO)
KENNETH RIEMER (R3DO)
RAY AZUA (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT - DEFECTIVE BARTON DIFFERENTIAL PRESSURE SWITCHES

The following is a synopsis of information received via facsimile:

Cameron Measurement Systems has issued a product advisory concerning nuclear qualified versions of Barton Model 288A, 289A, 580A and 581A differential pressure indicating switches and blind switches and spare switch assemblies shipped from the Cameron factory.

The defect being reported is an out of specification thread on the screws that depress the switch operating plunger which can cause a change in the switch setpoint. The maximum change in screw position observed during testing equates to a switch set point change of approximately 8.4 percent of the instrument's factory calibrated span. The screws of concern did not enter the Cameron stock before February of 2014 for the ones used in the Model 580A and 581A instruments and not before June of 2014 for the ones used in Model 288A and 289A instruments.

Cameron recommends that new switch actuator arm assemblies be replaced on any unit that is evaluated to be a concern by their customers.

Notification to NRC provided by ISAAC RAMSINI, Manager Quality and Safety, (562) 321-9158.

Page Last Reviewed/Updated Wednesday, September 10, 2014
Wednesday, September 10, 2014