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Event Notification Report for December 23, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/22/2014 - 12/23/2014

** EVENT NUMBERS **


50573 50597 50673 50679 50697 50700

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50573
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM MUFFLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2014
Notification Time: 13:54 [ET]
Event Date: 10/29/2014
Event Time: 07:11 [EDT]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 98 Power Operation 98 Power Operation

Event Text

LOSS OF CONTROL ROOM EMERGENCY AIR CONDITIONING SYSTEM OPERABILITY

"At 0711 EDT, Salem Unit 2 entered TSAS [Technical Specification Action Statement] 3.0.3 due to the Salem Unit 1 - 1B Vital instrument bus inverter failing which resulted in a loss of the Unit 1 - 1B Vital instrument bus. The loss of power to the 1B Vital instrument bus resulted in Salem Unit 2 initiating the accident pressurized mode of control room ventilation. All dampers and fans repositioned correctly with the exception of the Unit 1 Control Room Emergency Air Conditioning System (CREACS) intake dampers, 1CAA48, 50, and 51. The 1CAA48 was pinned closed to support Unit 1 - 1A125VDC scheduled maintenance. The 1CAA50 and 51 failed to move to the open position (required for Unit 2 accident pressurized mode) due to the loss of power to the 1B Vital Instrument Bus. With the 1CAA48, 50 and 51 dampers closed, this isolated the Unit 1 CREACS intake in the closed position. For an accident in Unit 2, the CREACS intake for Unit 1 is required to open.

"Salem Unit 2 exited TSAS 3.0.3 at 0822 EDT when the 1CAA50 and 51 were pinned in the open position to implement accident pressurized mode for Salem Unit 2 in accordance with S1/S2.OP-SO.CAV-0001, Control Area Ventilation Operation.

"Salem Unit One is Defueled.

"This event is being reported under the requirements of 10 CFR 50.72(b)(3)(v)(D) as 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of systems that are needed to perform mitigation of the consequences of an accident.'

"The licensee has notified the NRC Resident Inspector. No one was injured as a result of the failure of 1B Vital instrument inverter."

The licensee notified Lower Alloways Township.

* * * RETRACTION FROM BILL MUFFLEY TO HOWIE CROUCH AT 1529 EST ON 12/22/14 * * *

"A subsequent review of the condition reported on 10/29/2014 in EN 50573 determined that the Control Room Emergency Air Conditioning System (CREACS) was operable and capable of performing its safety function. Therefore, there was no reportable condition.

"Circuit analysis identified that the Unit 2 Control Room Intake Isolation (CRIX) Train B circuit remained fully functional and able to respond to a Unit 2 Safety Injection (SI) signal or actuation from radiation monitor 2R1B Channel 1 (radiation levels in the Unit 2 normal Control Area Ventilation intake). The loss of the 1B vital instrument bus did not affect the normal actuation circuitry. The appropriate Unit 1 dampers would have received an open
signal and the appropriate Unit 2 dampers would have received a closed signal, thereby isolating the Unit 2 CREACS intake and opening the Unit 1 CREACS intake. Thus, the CREACS would have been capable of mitigating the consequences of an accident.

"The NRC Resident Inspector has been notified."

Notified R1DO (Ferdas).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50597
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RYAN MEREMA
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/06/2014
Notification Time: 04:30 [ET]
Event Date: 11/05/2014
Event Time: 19:38 [CST]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
DAVE PASSEHL (R3DO)

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

Event Text

SIX UNIT 2 CONTROL ROD DRIVE HYDRAULIC CONTROL UNITS INOPERABLE

"Six (6) U2 CRD [Control Rod Drive] HCU [Hydraulic Control Unit] accumulators were identified with riser brackets that were installed incorrectly. This issue impacts U2 CRD HCU accumulators only. The incorrect riser bracket installation could challenge the ability of the CRD hydraulic control unit to perform its design function during a seismic event.

"Identified U2 control rods associated with HCU accumulators that had riser brackets installed incorrectly were declared inoperable. This condition has been corrected since initial identification, restoring all control rods to operable status. Reference IR 2407342.

"This notification is made pursuant to 10CFR 50.72(b)(3)(v) regarding the reportability of multiple failures that could have prevented fulfillment of a safety function.

"The NRC Resident Inspector will be notified."

* * * RETRACTION FROM MATT SEELEY TO HOWIE CROUCH AT 1144 EST ON 12/22/14 * * *

"The purpose of this notification is to retract the ENS notification made on November 6, 2014 (ENS 50597). An Engineering Evaluation has determined that the function of the affected U2 CRD HCU Accumulators was not affected as discussed in Chapters 6 and 15 of the Updated Final Safety Analysis Report. Therefore, the threshold for reporting the issue as an event or condition that could have prevented the fulfillment of a safety function was not met (NUREG 1022, Revision 3, Event Report Guidelines Section 3.2.7).

"The NRC Resident Inspector has been notified."

Notified R3DO (Dickson).

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Agreement State Event Number: 50673
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: UNIVERSITY OF MARYLAND HELEN DENT CANCER CENTER
Region: 1
City: OLNEY State: MD
County:
License #: MD-31-310-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/12/2014
Notification Time: 14:40 [ET]
Event Date: 12/10/2014
Event Time: [EST]
Last Update Date: 12/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

MARYLAND AGREEMENT STATE REPORT - MISADMINISTRATION OF I-125 SEEDS DURING PROSTATE THERAPY

The following information was obtained from the State of Maryland via email:

"Post implant CT determined that all seeds missed the prostate and were deposited in an unintended area of soft tissue at the base of the patient's penis. A medical determination has been made to not remove the seeds due to the difficulty of removal. The patient will be followed over the next two weeks to determine whether damage to the urethra has occurred. The licensee states that the patient has been informed.

"Preliminary root cause evaluation is that the Medical Center's ultrasound unit used to guide insertion is 12 years old and has a poor (grainy) display. No defect with the Mick applicator has been determined.

"The Maryland Radiation Program will conduct an on-site investigation of this incident."

The patient was administered 53 seeds at a nominal 0.36 mCi I-125 per seed manufactured by Best Industries. Intended dose to the prostate was 108 Gy.

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: 50679
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ECS-MID ATLANTIC, INC.
Region: 1
City: LEESBURG State: VA
County: LOUDOUN
License #: 107-314-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/15/2014
Notification Time: 14:41 [ET]
Event Date: 12/13/2014
Event Time: [EST]
Last Update Date: 12/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following report was received from the Commonwealth of Virginia via email:

"On Saturday, December 13th [2014], a CPN MCIDR moisture/density gauge was run over at a temporary jobsite in Leesburg, Virginia (Battlefield Parkway and Sycolin Road). The licensee's authorized user was performing a test and walked about 20 feet away from the gauge. The general contractor's bulldozer operator did not see the gauge because the bulldozer blade was raised, which obstructed his view when driving the bulldozer up the slope.

"The gauge was completely destroyed with the source in the transmission position. The authorized user contacted the construction testing services manager who then contacted the radiation safety officer. Both individuals arrived on scene and were able to retract the source into the shielded position using a pair of pliers. A radiation survey was performed at 1 meter indicating a reading of 0.4 mrem/hr. The gauge was then placed into the transportation case and returned to storage where a wipe test was performed. The wipe test has been sent to a licensed service provider for analysis and if no contamination is present, the gauge will be returned [pending final resolution].

"The licensee submitted an incident report, which is under review by the [Virginia] Radioactive Materials Program. The incident and suggested corrective actions will also be re-examined during the next inspection."

Event Report ID No.: VA-14-25

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Power Reactor Event Number: 50697
Facility: COOK
Region: 3 State: MI
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/20/2014
Notification Time: 13:39 [ET]
Event Date: 12/20/2014
Event Time: 12:12 [EST]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
AARON MCCRAW (R3DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO OIL LEAK FROM MAIN TURBINE LUBE OIL SYSTEM

"At 1212 EST on December 12, 2014, D.C. Cook notified the State of Michigan and local authorities of an oil leak from the Unit 2 Main Turbine Lube Oil Cooler to Lake Michigan. Approximately 2000 gallons have leaked into Lake Michigan since October 25, 2014. No visible oil or oil sheen is present on Lake Michigan or the shore line. The leak is currently isolated as of 1030 EST on December 20, 2014. Leak repairs will be made to the cooler prior to placing back in service.

"The NRC Resident Inspector was notified.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies."

Notified DOE, EPA, USDA, HHS, and FEMA.

* * * UPDATE FROM PERRY GRAHAM TO HOWIE CROUCH AT 1432 EST ON 12/22/14 * * *

The licensee issued a press release about this event this afternoon.

Notified R3DO (Dickson).

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Power Reactor Event Number: 50700
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: DANIEL HUNT
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/23/2014
Notification Time: 00:57 [ET]
Event Date: 12/22/2014
Event Time: 22:30 [EST]
Last Update Date: 12/23/2014
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):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 30 Power Operation 12 Power Operation

Event Text

UNIT 1 TECHNICAL SPECIFICATION SHUTDOWN DUE TO RCS PRESSURE BOUNDARY LEAKAGE

"On December 22, 2014 at 2230 hours [EST] while performing a containment walkdown due to increased RCS [Reactor Coolant System] unidentified leakage, a leak was identified upstream of 1-RC-68, B Loop Cold Leg Drain Isolation Valve. The source of this leakage cannot be isolated and is considered RCS pressure boundary leakage. [Unit 1] Entered TS LCO 3.4.13 RCS Operational Leakage, Condition B for the existence of pressure boundary leakage. TS 3.4.4 RCS Loops - Modes 1 and 2 condition A, TR 3.4.6 ASME Code Class 1, 2, and 3 components, Condition B. Unit 1 will be taken to Mode 5 for repair.

"This event is reportable in accordance with 10 CFR 50.72(b)(2) for "initiation of plant shutdown required by Technical Specifications" and 10CFR50.72(b )(3)(ii)(A) for "any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded."

The RCS leakage has been quantified as 0.053 gallons per minute from a containment sump in-leakage calculation. The exact location of the leak has not been identified due to the installation of lagging on the RCS components. The licensee anticipates entering Mode 3 (Hot Standby) within the next 30 minutes. There is no safety-related equipment out-of-service at this time.

The licensee will inform Louisa County and has informed the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, December 23, 2014
Tuesday, December 23, 2014