Event Notification Report for September 19, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/18/2014 - 09/19/2014
EVENT NUMBERS
5047550476504745047150472
Power Reactor
Event Number: 50475
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPCINSKI
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DARRELL LAPCINSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 17:54 [ET]
Event Date: 09/19/2014
Event Time: 13:53 [CDT]
Last Update Date: 11/18/2014
Notification Time: 17:54 [ET]
Event Date: 09/19/2014
Event Time: 13:53 [CDT]
Last Update Date: 11/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BILLY DICKSON (R3DO)
BILLY DICKSON (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNANALYZED CONDITION DUE TO MISSING FIRE BARRIERS
"As part of an extent of condition review related to ENS report 50362 (Unanalyzed Condition Due to Lack of Appropriate Fuse Protection), it was identified that, within the past three years, three additional examples existed of missing fire barriers that could have impacted separation of redundant safe shutdown trains. For the affected areas associated with each of the three missing barriers, compensatory measures (hourly fire watches) had been in place for three years prior to the discovery of the condition. However, it was determined the missing barriers met the reporting criteria for 10 CFR 50.72(b)(3)(ii)(B) as unanalyzed conditions that significantly degraded plant safety.
"The first condition was the use of rodofoam material in Auxiliary Building seismic joint seals. Rodofoam is a combustible foam material and does not provide a fire rating equivalent to the barriers in which it was used. This issue was corrected in a plant modification.
"The second condition is the lack of required fire dampers in ventilation supply ducts to the Aux. Feedwater (AFW) Pump Rooms (Fire areas 31 and 32). An engineering change package has been approved to implement a plant modification to install the required dampers as part of the NFPA-805 transition.
"The third condition is a gap where the ventilation duct passes through the wall from the Bus 150/160 room into the AFW pump room. An engineering change package has been approved to implement a plant modification to correct this condition as part of the NFPA-805 transition.
"The protection of the health and safety of the public was not affected by this issue. In all cases, compensatory measures existed to ensure the protection of safe shutdown equipment.
"The licensee has notified the NRC Senior Resident Inspector."
* * * UPDATE FROM DOUG LARSON TO DANIEL MILLS AT 2122 EST ON 11/18/14 * * *
"Northern States Power Company (NSPM) has determined that the missing fire damper and the wall gap (the second and third identified conditions) are not separating redundant equipment and no longer meet the regulatory definition of an unanalyzed condition. This was identified when it was determined that the redundant pressurizer heater cables credited for safe shutdown were routed through the same fire area. This was reported under EN 50531 (Unanalyzed Condition Due To Missing Fire Barrier). Since the missing fire barrier does not separate redundant equipment, the condition does not degrade plant safety, and is no longer reportable.
"The protection of the health and safety of the public was not affected by this issue.
"The licensee has notified the NRC Resident Inspector."
Notified R3DO (Peterson).
"As part of an extent of condition review related to ENS report 50362 (Unanalyzed Condition Due to Lack of Appropriate Fuse Protection), it was identified that, within the past three years, three additional examples existed of missing fire barriers that could have impacted separation of redundant safe shutdown trains. For the affected areas associated with each of the three missing barriers, compensatory measures (hourly fire watches) had been in place for three years prior to the discovery of the condition. However, it was determined the missing barriers met the reporting criteria for 10 CFR 50.72(b)(3)(ii)(B) as unanalyzed conditions that significantly degraded plant safety.
"The first condition was the use of rodofoam material in Auxiliary Building seismic joint seals. Rodofoam is a combustible foam material and does not provide a fire rating equivalent to the barriers in which it was used. This issue was corrected in a plant modification.
"The second condition is the lack of required fire dampers in ventilation supply ducts to the Aux. Feedwater (AFW) Pump Rooms (Fire areas 31 and 32). An engineering change package has been approved to implement a plant modification to install the required dampers as part of the NFPA-805 transition.
"The third condition is a gap where the ventilation duct passes through the wall from the Bus 150/160 room into the AFW pump room. An engineering change package has been approved to implement a plant modification to correct this condition as part of the NFPA-805 transition.
"The protection of the health and safety of the public was not affected by this issue. In all cases, compensatory measures existed to ensure the protection of safe shutdown equipment.
"The licensee has notified the NRC Senior Resident Inspector."
* * * UPDATE FROM DOUG LARSON TO DANIEL MILLS AT 2122 EST ON 11/18/14 * * *
"Northern States Power Company (NSPM) has determined that the missing fire damper and the wall gap (the second and third identified conditions) are not separating redundant equipment and no longer meet the regulatory definition of an unanalyzed condition. This was identified when it was determined that the redundant pressurizer heater cables credited for safe shutdown were routed through the same fire area. This was reported under EN 50531 (Unanalyzed Condition Due To Missing Fire Barrier). Since the missing fire barrier does not separate redundant equipment, the condition does not degrade plant safety, and is no longer reportable.
"The protection of the health and safety of the public was not affected by this issue.
"The licensee has notified the NRC Resident Inspector."
Notified R3DO (Peterson).
Power Reactor
Event Number: 50476
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: JEREMY SHARKEY
HQ OPS Officer: DANIEL MILLS
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: JEREMY SHARKEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/20/2014
Notification Time: 07:42 [ET]
Event Date: 09/19/2014
Event Time: 23:59 [EDT]
Last Update Date: 09/20/2014
Notification Time: 07:42 [ET]
Event Date: 09/19/2014
Event Time: 23:59 [EDT]
Last Update Date: 09/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
JOHNATHAN LILLIENDAH (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
LOSS OF SECONDARY CONTAINMENT INTEGRITY
"At approximately 2359 EDT a temporary modification plug was found to be removed from a floor drain in the Outboard MSIV Room (Trunnion Room). The purpose of the temporary modification plug is to ensure that secondary containment remains intact during outages where the trunnion room door is required to be open. The trunnion room door was open when the plug was found to be removed. The plug was immediately reinstalled, restoring the safety function of the secondary containment.
"Per [10 CFR] 50.72(b)(3)(v)(C), Oyster Creek is reporting an event that could have prevented the fulfillment of the safety function of a system needed to control the release of radioactive material."
The licensee has notified the NRC Resident Inspector.
"At approximately 2359 EDT a temporary modification plug was found to be removed from a floor drain in the Outboard MSIV Room (Trunnion Room). The purpose of the temporary modification plug is to ensure that secondary containment remains intact during outages where the trunnion room door is required to be open. The trunnion room door was open when the plug was found to be removed. The plug was immediately reinstalled, restoring the safety function of the secondary containment.
"Per [10 CFR] 50.72(b)(3)(v)(C), Oyster Creek is reporting an event that could have prevented the fulfillment of the safety function of a system needed to control the release of radioactive material."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 50474
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAVID LANTZ
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAVID LANTZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 16:35 [ET]
Event Date: 09/19/2014
Event Time: 11:34 [CDT]
Last Update Date: 09/19/2014
Notification Time: 16:35 [ET]
Event Date: 09/19/2014
Event Time: 11:34 [CDT]
Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
TOM ANDREWS (R4DO)
TOM ANDREWS (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNANALYZED CONDITION DUE TO A POSTULATED HOT-SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT
"From review of Event Notification 50468 made by Wolf Creek Nuclear Operating Company on 9/18/2014, which in turn was based on review of INPO Event Report 14-33, 'Direct Current Circuits Challenge Appendix R Fire Analysis,' it was determined that portions of the control circuits for the main turbine-generator direct-current (DC) Emergency Lube Oil Pump and the Emergency DC Seal Oil Pump at Callaway Plant are not properly fused to prevent overload and possible secondary fires. The review found that a fire at the motor starter cabinet in the turbine building could cause specific 'smart' hot shorts that could cause overheating of the control cable and result in secondary fires outside the turbine building, including the Control Building, thereby potentially affecting safe shutdown capability for the plant. Based on this information, it has been determined that this condition is unanalyzed, and on a conservative basis, is reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.
"As compensatory measures, hourly fire watches are in place in the affected areas of the Turbine Building and Control Building. These compensatory measures, in addition to automatic fire detection and suppression capability in these fire areas, ensure protection of the potentially affected equipment.
"The NRC Resident Inspector has been notified."
The licensee continues to evaluate other control circuits to identify if this condition exists elsewhere.
"From review of Event Notification 50468 made by Wolf Creek Nuclear Operating Company on 9/18/2014, which in turn was based on review of INPO Event Report 14-33, 'Direct Current Circuits Challenge Appendix R Fire Analysis,' it was determined that portions of the control circuits for the main turbine-generator direct-current (DC) Emergency Lube Oil Pump and the Emergency DC Seal Oil Pump at Callaway Plant are not properly fused to prevent overload and possible secondary fires. The review found that a fire at the motor starter cabinet in the turbine building could cause specific 'smart' hot shorts that could cause overheating of the control cable and result in secondary fires outside the turbine building, including the Control Building, thereby potentially affecting safe shutdown capability for the plant. Based on this information, it has been determined that this condition is unanalyzed, and on a conservative basis, is reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.
"As compensatory measures, hourly fire watches are in place in the affected areas of the Turbine Building and Control Building. These compensatory measures, in addition to automatic fire detection and suppression capability in these fire areas, ensure protection of the potentially affected equipment.
"The NRC Resident Inspector has been notified."
The licensee continues to evaluate other control circuits to identify if this condition exists elsewhere.
Agreement State
Event Number: 50471
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: FRENCH & PARRELLO
Region: 1
City: WALL TOWNSHIP State: NJ
County:
License #: 507834-RAD110
Agreement: Y
Docket:
NRC Notified By: JACK TWAY
HQ OPS Officer: DANIEL MILLS
Licensee: FRENCH & PARRELLO
Region: 1
City: WALL TOWNSHIP State: NJ
County:
License #: 507834-RAD110
Agreement: Y
Docket:
NRC Notified By: JACK TWAY
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/19/2014
Notification Time: 10:09 [ET]
Event Date: 09/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 10/10/2014
Notification Time: 10:09 [ET]
Event Date: 09/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 10/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The state of New Jersey provided notification that a licensee (French and Parrello) reported a Troxler moisture density gauge (Model 3430, Serial #38931) stolen. The gauge was in the possession of a contractor (employed by Aerotek staffing agency) who has not shown up for work for several days. Attempts have been made to contact the contractor. New Jersey instructed the licensee to contact local law enforcement. The gauge contains 40mCi Am-241 and 8mCi Cs-137.
NJ EVENT: 14-09-19-1107-54
* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 9/19/14 AT 1231 EDT * * *
The gauge operator contacted the Wall Township Police Department to inform them that he was in possession of the gauge and would be returning it to the licensee today.
Notified R1DO (Lilliendahl), FSME Events Resource (email), and ILTAB (email).
* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 10/10/14 AT 1019 EDT * * *
The gauge was, in fact, returned to the licensee on 9/19/14. The State of New Jersey received a written report of the event from the licensee and considers this case closed.
Notified R1DO (Bower), FSME Events Resource (email) and ILTAB (email).
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
The state of New Jersey provided notification that a licensee (French and Parrello) reported a Troxler moisture density gauge (Model 3430, Serial #38931) stolen. The gauge was in the possession of a contractor (employed by Aerotek staffing agency) who has not shown up for work for several days. Attempts have been made to contact the contractor. New Jersey instructed the licensee to contact local law enforcement. The gauge contains 40mCi Am-241 and 8mCi Cs-137.
NJ EVENT: 14-09-19-1107-54
* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 9/19/14 AT 1231 EDT * * *
The gauge operator contacted the Wall Township Police Department to inform them that he was in possession of the gauge and would be returning it to the licensee today.
Notified R1DO (Lilliendahl), FSME Events Resource (email), and ILTAB (email).
* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 10/10/14 AT 1019 EDT * * *
The gauge was, in fact, returned to the licensee on 9/19/14. The State of New Jersey received a written report of the event from the licensee and considers this case closed.
Notified R1DO (Bower), FSME Events Resource (email) and ILTAB (email).
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 50472
Rep Org: MONONGALIA GENERAL HOSPITAL
Licensee: MONONGALIA GENERAL HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: HOWIE CROUCH
Licensee: MONONGALIA GENERAL HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 13:56 [ET]
Event Date: 09/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2015
Notification Time: 13:56 [ET]
Event Date: 09/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHNATHAN LILLIENDA (R1DO)
FSME EVENTS RESOURCE (EMAI)
JOHNATHAN LILLIENDA (R1DO)
FSME EVENTS RESOURCE (EMAI)
BRACHYTHERAPY PATIENT RECEIVED 54% OF PRESCRIBED DOSE
The authorized user determined that, due to scar tissue from a previous procedure, the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.
The investigation into the event is ongoing.
* * * RETRACTION FROM MARK PENA TO HOWIE CROUCH AT 1458 EDT ON 9/30/15 * * *
Upon investigation of the details surrounding the event, it was determined that the patient received greater than 80% of prescribed activity. Therefore, this event no longer meets any regulatory reporting criteria and is being retracted.
Notified R1DO (Bower) and NMSS Events Resource via email.
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.
The authorized user determined that, due to scar tissue from a previous procedure, the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.
The investigation into the event is ongoing.
* * * RETRACTION FROM MARK PENA TO HOWIE CROUCH AT 1458 EDT ON 9/30/15 * * *
Upon investigation of the details surrounding the event, it was determined that the patient received greater than 80% of prescribed activity. Therefore, this event no longer meets any regulatory reporting criteria and is being retracted.
Notified R1DO (Bower) and NMSS Events Resource via email.
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.