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Event Notification Report for April 16, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/15/2015 - 04/16/2015

** EVENT NUMBERS **


50831 50954 50963 50967 50969 50984 50985 50988

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Power Reactor Event Number: 50831
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/19/2015
Notification Time: 09:55 [ET]
Event Date: 02/19/2015
Event Time: 03:04 [EST]
Last Update Date: 04/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
DAVID HILLS (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

SECONDARY CONTAINMENT BUILDING DECLARED INOPERABLE DUE TO VENTILATION SYSTEM TRIP

"At 0304 EST on February 19, 2015, Fermi 2 experienced a trip of the Reactor Building Ventilation (RB) (HVAC) during plant operations associated with very cold temperatures outside. At the time of the trip, outside air temperature was -1 degrees Fahrenheit and RB HVAC tripped due to a Freeze-Stat actuation [a freeze protection feature].

"The plant Technical Specifications require that Secondary Containment pressure be maintained greater than or equal to -0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1). This specification was not maintained and the highest pressure observed was -0.11 inches of vacuum water gauge. Subsequently, at 0450, during restoration activities, RB pressure degraded again to higher than -0.125 inches of vacuum water gauge for 38 seconds. The lowest observed pressure was -0.11 inches of vacuum water gauge. RB HVAC has been restored by resetting the Freeze-Stat and the Standby Gas Treatment System (SGTS) has been placed back in a standby condition.

"The technical specification requirement is to maintain secondary containment at -0.125 inches of vacuum water gauge for secondary containment operability. Declaring secondary containment inoperable is reportable under 10CFR50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM WARREN PAUL TO DANIEL MILLS AT 1035 ON 4/8/2015 * * *

"After reviewing the events that occurred on February 19, 2015 against the accident analyses in Chapter 15 of the UFSAR and design functions of the Standby Gas Treatment System and Secondary Containment structure, it is concluded that a condition that could have prevented the fulfillment of a safety function to control the release of radioactive material did not occur as a result of momentarily exceeding the Technical Specification for Secondary Containment vacuum after a loss of the normal Reactor Building Ventilation System.

"The Fermi 2 accident analysis for a LOCA does not assume that secondary containment is under vacuum throughout the duration of an accident and contains conservative leakage assumptions to bound the effects of a postulated ground level release. The accident analysis credits the operation of the Standby Gas Treatment System (SGTS); both divisions of SGTS were operable at the time of the event. Although secondary containment was declared inoperable due to exceeding the Technical Specification value for secondary containment vacuum, the structural integrity of the secondary containment was not degraded at the time. Upon receipt of an accident signal, SGTS would have automatically started and restored secondary containment vacuum to within the bounding analyses of Chapter 15 of the UFSAR. Secondary containment was capable of performing its design function of minimizing any ground level release of radioactive material by maintaining boundary integrity so that the SGTS may draw a vacuum in the Reactor Building and filter radioactive material at all times. The event reported in EN # 50831 did not result in a condition that could have prevented the fulfillment of a safety function to control the release of radioactive material. This event report is being retracted."

The licensee informed the NRC Resident Inspector. Notified R3DO (Skokowski).

* * * UPDATE FROM WARREN PAUL TO CHARLES TEAL ON 4/15/15 AT 1348 EDT * * *

"Upon further review of NUREG-1022 section 3.2.7, the original Non-Emergency Event Notification, 50831, remains valid."

The NRC Resident Inspect has been informed. Notified R3DO (McCraw).

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Fuel Cycle Facility Event Number: 50954
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/05/2015
Notification Time: 06:58 [ET]
Event Date: 04/04/2015
Event Time: 11:51 [EDT]
Last Update Date: 04/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
SHAKUR WALKER (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BRIAN SMITH (NMSS)
WILLIAM GOTT (IRD)

Event Text

UNPLANNED CONTAMINATION EVENT

"On April 4,2015, at approximately 1151 [EDT], a chemical reaction occurred in a 2-liter bottle of cleanup materials. The bottle was located in a storage rack. The chemical reaction caused the bottle to breach, releasing some of the contents into the immediate area around the storage rack. There were no individuals in the area where the bottle was stored when the breach occurred. The area has been roped off and is in the process of being cleaned up. There were no personnel injuries or exposures. The event is currently being investigated.

"The licensee notified the NRC Resident Inspector."

* * * UPDATE FROM RANDY SHACKLEFORD TO HOWIE CROUCH AT 1257 EDT ON 4/10/15 * * *

The licensee is also making a courtesy notification for an unplanned chemical reaction in accordance with Information Notice 97-23.

Additionally, on April 7, 2015, the area was cleaned up and access restrictions were removed.

The licensee notified the NRC Resident Inspector.

Notified R2DO (Heisserer), NMSS EO (Habighorst), IRD (Grant) and NMSS Events Notification (E-mail).

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Agreement State Event Number: 50963
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BAYER MATERIALSCIENCE LLC
Region: 4
City: BAYTOWN State: TX
County:
License #: 01577
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/07/2015
Notification Time: 17:31 [ET]
Event Date: 04/07/2015
Event Time: [CDT]
Last Update Date: 04/07/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON A FIXED GAUGE

The following information was received from the State of Texas via fax:

"On April 7, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that they were unable to close the shutter on a Berthold Model LB 300 IRL Type 1 source holder containing three Cobalt - 60 sources. The licensee found the problem during routine checks. The RSO stated they had contacted the manufacturer for assistance. The RSO stated there was no increased risk of exposure to members of the general public or the employees at the facility. This Agency contacted the manufacturer on April 7, 2015 and requested the seal source and device (SSD) data sheet for the device. At 1206 hours [CDT], the Agency received an email from the manufacturer containing the SSD sheet for the gauge. The email also stated the gauge had been repaired and was now operating properly. The specifics of the event were not provided by the RSO as he was still investigating the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9298

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Agreement State Event Number: 50967
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON SUBURBAN HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-099-27
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/08/2015
Notification Time: 10:10 [ET]
Event Date: 03/12/2015
Event Time: [CDT]
Last Update Date: 04/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TREATMENT UNDERDOSE

The following was received from the Commonwealth of Kentucky via email:

"On 19 March 2015, the patient was receiving an HDR cylinder treatment using the HDR Ir-192 source for treatment of her vaginal cuff. The prescribing physician inserted the vaginal cylinder in the patient's vagina until resistance was present, indicating the tip of the cylinder had reached the vaginal cuff. Before each treatment is delivered a radiographic image of the inserted treatment device is reviewed to ensure consistent device location across each fraction (this image is not intended as a placement verification for treatment). Comparison of images taken on 19 March 2015 and 12 March 2015, revealed that the cylinder placement during treatment on 12 March 2015, was 3cm distal to the cylinder placement on 19 March 2015, implying the dose delivered during the patient's first treatment on 12 March 2015 was located 3cm distal to its intended location. The effect of relocating the cylinder to a 3cm distal position has the effect of under dosing the vaginal cuff, while providing additional dose to the vaginal wall in an unintended location. The RHB [Kentucky Radiation Health Branch] has requested additional dose information to the vaginal wall area. Some of the vaginal wall is dosed during this procedure just not in this location. The prescribing physician has deemed the additional dose to the vaginal wall as medically insignificant. Vaginal cuff treatments are planned to deliver a prescribed dose to a reference line located 0.5cm outside the cylinder wall. A new treatment plan depicting the true location of the 12 March 2015, treatment has been generated and a comparison of the dose to the reference line has been made to estimate the extent to which the vaginal cuff has been under dosed. The average dose delivered to the vaginal cuff area was 80% lower than intended. Due to the fact that the dose to the vaginal cuff from the first treatment is so low, the physician has decided to ignore the patient's first treatment and change the patient's prescription to deliver the intended dose over the remaining fractions. The authorized user notified the patient upon completion of her treatment on 19 March 2015. Two possible scenarios have been determined to be the most likely cause of the event:

"1. The first is that the cylinders used for treatment are segmented. Typically 4 segments are locked together into one larger cylinder. The larger cylinder is then attached to a clamping device that allows the cylinder to be locked into position after the authorized user (AU) inserts the device into the patient. During this particular treatment only 3 segments were used to form the cylinder leaving less space for the clamping device to attach to the cylinder. As the AU was inserting the cylinder, the cylinder clamping device may have pushed up against the patient's perineum prematurely causing resistance to further insertion prompting the AU to believe the cylinder had reached the vaginal cuff.

"a. In order to prevent future occurrences from happening, the staff involved will be required to always use all 4 segments when constructing a cylinder.

"2. The other possibility is due to the non-compliance of the patient herself. As the cylinder was being inserted, the patient was having a hard time remaining still. Once the cylinder was locked into place, it is possible that the patient pulled away from the cylinder a small amount causing the change in location. This is believed to be the most likely scenario based on the patient's common reaction and motion upon insertion of the cylinder.

"a. In order to minimize a patient's ability to adjust the cylinder position, staff will be instructed to pay close attention to the patient's movements and additional imaging of the device location will be taken if movement is a concern. A phone call was made to the KY Radiation Health Branch of the incident with intent to meet the notification requirements to the KY RHB. The Physicist had left a phone message but did not report to a person. There is no record of this message however a record of a phone call is noted received 19 March 2015 at 1450 EDT. Upon receipt of an email to the Radiation office, the required 24 hour notification is made to the NRC Headquarters Operations Officer."

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.

Kentucky Incident # 150002

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Agreement State Event Number: 50969
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: MISTRAS GROUP INC
Region: 4
City: DEER PARK State: TX
County:
License #: 06369
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2015
Notification Time: 16:48 [ET]
Event Date: 04/08/2015
Event Time: [CDT]
Last Update Date: 04/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

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

"On April 8, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee's site radiation safety officer (RSO) of a source disconnect. The RSO stated a radiography crew had contacted him [from a field site in Charco, TX] and informed him that after the first exposure of a 62.2 curie Iridium - 192 source, they could not retract the source back into a QSA 880D exposure device. The RSO stated he arrived at the site and found dose rates at the boundaries to be less than 0.5 millirem per hour. The RSO, who is on the license to retrieve a source, detached the guide tube from the camera and using a pair of tongs, lifted the collimator and the source slid out on the ground. The RSO placed bags of lead over the source. The RSO cranked the drive cable through the camera and connected the drive cable to the source. The RSO then retracted the source into the camera locking it in place. The RSO stated he inspected the camera and crankout device in the field and could not find any cause for the disconnect. The maximum dose during the event was received by the RSO who received 24 millirem to his hand and 16 millirem to his chest.

"No member of the general public was exposed as a result of this event.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9299

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Power Reactor Event Number: 50984
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ALLAN BRIESE
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/15/2015
Notification Time: 02:07 [ET]
Event Date: 04/14/2015
Event Time: 19:20 [MST]
Last Update Date: 04/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (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
2 N Y 100 Power Operation 100 Power Operation
3 N N 0 Defueled 0 Defueled

Event Text

OFFSITE NOTIFICATION DUE TO SODIUM HYDROXIDE SPILL ONSITE EXCEEDING REPORTABLE QUANTITY

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"Arizona Public Service Co. made an offsite notification to the National Response Center regarding an approximately 3500 gallon caustic (8% sodium hydroxide) spill due to an improper valve lineup. The spill occurred at the Water Reclamation Facility (produces water for cooling towers and power plant and is located outside the Security Owner Controlled Area) in the area of the Fire Protection tanks (additional liquid was contained in a containment structure at the release location, and in a nearby concrete lined storm ditch on site). The release has been isolated, the immediate area has been barricaded. The quantity released exceeded the Reportable Quantity for sodium hydroxide (RQ of 1,000 pounds) and was therefore reported. Additionally, the state [Arizona] and county [Maricopa] have also been notified. There was no impact to the operation of the power units, aquifer or personnel onsite or offsite.

"The NRC Resident [Inspector] has been notified."

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Power Reactor Event Number: 50985
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BLAS BARTKO
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/15/2015
Notification Time: 07:32 [ET]
Event Date: 04/15/2015
Event Time: 04:11 [EDT]
Last Update Date: 04/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 85 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO THE LOSS OF A CONDENSATE PUMP

"At 0411 EDT on April 15, 2015, Beaver Valley Power Station (BVPS) Unit 1 manually tripped the reactor from approximately 85% power due to the trip of a condensate pump. The unit was performing an emergent power reduction due to a degraded condensate pump prior to the manual reactor trip. An end of cycle Tave coastdown was in progress at the time of the event. All control rods fully inserted into the core. All three auxiliary feed water pumps started as expected and were subsequently secured in accordance [with] station procedures. The main feedwater system remains available and in service. The unit is currently stable in Mode 3.

"Unit 2 was unaffected and remains at full power."

Decay heat removal is via main feedwater system with steam discharge to the main condenser via the steam bypass valves. Unit 1 is in a normal shutdown electrical lineup. No primary or secondary reliefs or safeties lifted during the transient.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 50988
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KARI BENNING
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/16/2015
Notification Time: 01:35 [ET]
Event Date: 04/16/2015
Event Time: 05:00 [CDT]
Last Update Date: 04/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
AARON MCCRAW (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

Event Text

SCHEDULED MAINTENANCE AFFECTING TECHNICAL SUPPORT CENTER HVAC

"On April 16, 2015, Byron Station will remove part of the Technical Support Center (TSC) emergency ventilation system from service to facilitate necessary surveillance work on the fire protection system. This work is expected to last approximately 4 hours. This maintenance affects the ability of the TSC ventilation to maintain adequate habitability during the duration of an emergency. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the potential loss of an emergency response facility because of the unavailability of the ventilation system. An update will be provided once the TSC ventilation has been restored to normal operation."

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Thursday, April 16, 2015
Thursday, April 16, 2015