| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
02/04/2015 - 02/05/2015 ** EVENT NUMBERS ** |
 | Power Reactor | Event Number: 50351 | Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNY HUNTER
HQ OPS Officer: HOWIE CROUCH | Notification Date: 08/07/2014
Notification Time: 20:00 [ET]
Event Date: 08/07/2014
Event Time: 17:07 [EDT]
Last Update Date: 02/04/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
REBECCA NEASE (R2DO)
|
| 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 | 90 | Power Operation | 90 | Power Operation | Event Text UNANALYZED CONDITION DUE TO DISCOVERY OF DEGRADED FIRE BARRIER WALLS
"During a fire inspection activity involving inspection of fire walls that serve as Appendix R barriers, degradation of some fire walls was identified that was sufficient to prevent these walls from meeting Appendix R requirements as 3-hour fire barriers. In the event of a postulated fire in the affected areas, both safe shutdown paths on the affected unit could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded conditions can be corrected.
"Condition Reports: 850802, 850819"
In addition to automatic fire protection features, the licensee has posted fire watches as a compensatory measure.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM STANLEY STONE TO DONALD NORWOOD AT 1814 EST ON 11/24/2014 * * *
"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1023 - RPS MG Set Room and Fire Area 1015 - Annunciator Room. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity.
"Condition Report: 898908."
The licensee will notify the NRC Resident Inspector.
Notified R2DO (Ehrhardt).
* * * UPDATE FROM KENNY HUNTER TO DANIEL MILLS AT 1758 EST ON 11/25/2014 * * *
"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1016 - 600 Volt Switchgear Room 1C and Fire Area 1017 - 600 Volt Switchgear Room 1D. In the event of a postulated fire in the affected areas, both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity."
The licensee notified the NRC Resident Inspector.
Notified R2DO (Ernstes).
* * * UPDATE FROM SCOTT BRITT TO DONALD NORWOOD AT 1706 EST ON 12/4/2014 * * *
"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, additional conditions were identified involving multiple fire barriers in the control building that affected both safe shutdown paths on Unit 1 and Unit 2 based on the respective inspection results. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised.
"Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report as required and will be documented in a revised LER at the end of the inspection activity."
The licensee will notify the NRC Resident Inspector.
Notified R2DO (Freeman).
* * * UPDATE AT 1842 EST ON 12/12/2014 FROM G.S. GRIFFIS TO MARK ABRAMOVITZ * * *
"As part of the 'extent of condition' corrective action for the condition identified in EN# 50351, an inspection activity is in progress to inspect the remaining fire walls and associated penetrations for conditions similar to those reported on 08/07/2014. During this inspection, nonconformances of multiple fire barriers were identified that bring into question the functionality of the affected fire barriers that can compromise safe shutdown paths on Unit 1 and 2 based on the respective inspection results. Since additional time is required to further evaluate each nonconformance to conclusively determine if the nonconformance is sufficient to consider the barrier nonfunctional, interim conservative fire actions were taken by considering these fire barriers as nonfunctional. Based on this conservative conclusion, in the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations and fire walls in most of these same fire areas and will remain in place until the barrier(s) are repaired. Additional fire actions were taken as required to address the additional fire areas identified. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.
"Unit 1 is entering a planned outage due to unrelated activities."
Condition Report: 10000607
The licensee notified the NRC Resident Inspector.
Notified the R2DO (Desai).
* * * UPDATE FROM STANLEY STONE TO DONALD NORWOOD AT 2315 EST ON 1/15/2015 * * *
"As part of the 'extent of condition' corrective action for the conditions identified in EN# 50351, an inspection activity was performed of a fire wall for conditions similar to those reported on 12/12/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1008 - Unit 1 AC Inverter Room and Fire Area 0001 to consider the barrier nonfunctional. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity."
Condition Report: 10013077
The licensee notified the NRC Resident Inspector.
Notified the R2DO (Musser).
* * * UPDATE FROM JOHN MITCHELL TO JEFF HERRERA AT 2025 EST ON 1/21/2015 * * *
"During review and closeout of fire barrier and penetration seals work orders and surveillance procedures performed as part of the 'extent of condition' inspection activity initially described in Event # 50351, the following conditions were identified that in the event of a postulated fire in the respective fire areas listed both safe shutdown paths could be compromised.
"Unit 2 Control Bldg. el. 130', gap in the grout around conduit penetration between fire areas 2013 and 2015
"Unit 1 Reactor Bldg. el. 130', open conduit between fire areas 1203C and 1105
"Given this information the determination was made that this condition meets the reporting criteria of 10 CFR 50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in the Unit 2 fire area and will remain in place until the affected barrier areas are repaired. Compensatory measures were established for the Unit 1 areas and will remain in place until the affected barriers areas are repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. Subsequent similar condition(s) found when performing remaining inspections that meet the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.
"Condition Report 10015417
"Condition Report 10015437"
The licensee notified the NRC Resident Inspector.
Notified the R2DO (McCoy).
* * * UPDATE FROM G.S. GRIFFIS TO HOWIE CROUCH AT 1714 EST ON 2/4/15 * * *
"During the review of fire barrier surveillance procedures performed as part of the 'extent of condition' inspection activity for the event initially identified in EN# 50351, some degradation was observed on the east wall of fire area 2006. These nonconforming issues observed on the affected fire wall were identified as affecting both safe shutdown paths for Unit 2. Therefore, in the event of a postulated fire for the affected area, both safe shutdown paths on Unit 2 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).
"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures, in addition to portable fire protection equipment located in adjacent areas, ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this, and any subsequent similar condition(s) that meets the reporting requirements, will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."
CR 10021623
Notified R2DO (HAAG). |
| Agreement State | Event Number: 50770 | Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CANCER CENTER OF GAITHERSBURG MARYLAND
Region: 1
City: GAITHERSBURG State: MD
County:
License #: 31-385-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/27/2015
Notification Time: 14:49 [ET]
Event Date: 01/26/2015
Event Time: 14:30 [EST]
Last Update Date: 01/28/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
| Event Text AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following report was received from the State of Maryland via email:
"On 1/27/15 at 0830 EST, [Maryland Department of the Environment (MDEP) personnel] discussed preliminary findings [with the licensee] regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO [Radiation Safety Officer]. The initial notification came to [the Maryland] RHP [Radiological Health Program] on 1/26/15 at 1600 EST.
"The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878.
"The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR [High Dose Rate].
"The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose.
"[The Licensee] stated no history of previous medical incidents.
"The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray.
"Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur.
"The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed.
"Present at the therapy - Oncologist, Medical Physicist, and Therapist.
"[The Medical Physicist] stated that the licensee will re-examine all quality assurance oversight for HDR therapies.
"Preliminary consideration for corrective actions: All new treatment plans will be given new identities [and] the licensee will explore ways to delete previous treatment plans.
"The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day.
"[The Medical Physicist] was informed that RHP will investigate the incident."
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.
* * * UPDATE FROM ALAN JACOBSON TO JEFF HERRERA ON 01/28/2015 AT 0828 EST * * *
The following information was provided by the State of Maryland via email:
The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci.
Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email). |
| Agreement State | Event Number: 50777 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SIGNET TESTING LABORATORIES, INC.
Region: 4
City: HAYWARD State: CA
County:
License #: 2943-01
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 01/28/2015
Notification Time: 18:08 [ET]
Event Date: 01/27/2015
Event Time: [PST]
Last Update Date: 01/28/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
| Event Text AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following report was received from the State of California via email:
"On 01/28/15, [the licensee] RSO contacted [the California] RHB [Radiologic Health Branch] to notify [the state] of a damaged nuclear gauge incident that occurred on 01/27/15. The gauge involved was a Troxler Model 3440, S/N 21101 containing 9 mCi of Cs-137 and 44 mCi of Am-241. Gauge user had left the gauge on a wheel barrow and walked away [approximately] 25 feet to look for a foreman. User then noticed a CAT scrapper backing off towards the gauge. His attempt to stop the scrapper failed, resulting in a damaged gauge. After the incident, it was noted that the gauge was intact with damage only to the face plate area. The operator contacted the RSO, and then transported the gauge to Instrotek for further testing. Leak tests performed indicated no contamination. The gauge is still at Instrotek for repairs."
California Event: #012815 |
| Power Reactor | Event Number: 50786 | Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RYAN MEYER
HQ OPS Officer: DANIEL MILLS | Notification Date: 02/04/2015
Notification Time: 17:57 [ET]
Event Date: 02/04/2015
Event Time: 09:34 [CST]
Last Update Date: 02/04/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
GEOFFREY MILLER (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 | Event Text CONTROL ROOM VENTILATION INOPERABLE DUE TO MISPOSITIONED VENTILATION INSPECTION PORT
"At 0934 CST hours on Wednesday, February 4, 2015 during a housekeeping inspection, an inspection port (18x18 inch opening) on the Control Room Fresh Air (CRFA) System was discovered open. The opening of the inspection port resulted in the loss of safety function for both trains of CRFA as a loss of control room envelope boundary.
"The cause of the inspection port being open is currently unknown and is under investigation. The Control Room was notified and an operator immediately secured the inspection port returning both trains of CRFA to operable status.
"The reactor was at approximately 100 percent power at the time of the discovery of the event. The Limiting Condition for Operation (LCO) Technical Specification 3.7.3, Control Room Fresh Air (CRFA) System, is two CRFA subsystems shall be OPERABLE. This Technical Specification is applicable in MODES 1, 2, and 3, and during operations with a potential for draining the reactor vessel.
"This condition is reportable as an 8 hour call in accordance with 10 CFR 50.72(b)(3)(v)."
The licensee has notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 50787 | Facility: ZION
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN GIERNOTH
HQ OPS Officer: DANIEL MILLS | Notification Date: 02/04/2015
Notification Time: 19:15 [ET]
Event Date: 02/03/2015
Event Time: 19:01 [CST]
Last Update Date: 02/04/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
72.75(d)(1) - SFTY EQUIP. DISABLED OR FAILS TO FUNCTION
| Person (Organization):
LAURA KOZAK (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Decommissioned | 0 | Decommissioned | | 2 | N | N | 0 | Decommissioned | 0 | Decommissioned | Event Text SAFETY EQUIPMENT DISABLED DUE TO SNOW
"On 2/3/2015 at 1901 [CST], equipment important to safety failed to function as designed: 33 NAC MAGNASTOR systems containing Spent Nuclear Fuel, and 1 NAC MAGNASTOR system containing GTCC [Greater than Class C] waste, had air inlet vent partial blockage, totaling 50 percent or greater, due to environmental conditions, i.e., snow. (Please Note, no VCC systems reached full blockage.)
"NO personnel radiation exposure.
"Actions Taken lAW the NAC FSAR, Rev. 5, which included actions to immediately return the systems to less than 50 percent blockage and ongoing maintenance activities to return all systems to full operability.
"Additional information:
1. On 2/4/2015 at 0445 hrs. All 34 failed systems were restored to less than 50 percent blockage.
2. lAW the NAC FSAR we have 30 days from time of discovery to return each system to full operability.
3. A report will be followed up within 60 days per 10 CFR 72.75.g"
The licensee will notify the NRC Inspector and the State of Illinois. | |