Event Notification Report for April 29, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/28/2015 - 04/29/2015
Power Reactor
Event Number: 51027
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: EDAN ENGSTROM
HQ OPS Officer: DANIEL MILLS
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: EDAN ENGSTROM
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2015
Notification Time: 21:24 [ET]
Event Date: 04/29/2015
Event Time: 18:11 [PDT]
Last Update Date: 04/30/2015
Notification Time: 21:24 [ET]
Event Date: 04/29/2015
Event Time: 18:11 [PDT]
Last Update Date: 04/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEOFFREY MILLER (R4DO)
GEOFFREY MILLER (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 95 | Power Operation | 95 | Power Operation |
ROD POSITION INDICATOR SYSTEM (RPIS) UNPLANNED OUTAGE
"At 1811 PDT on 04/29/2015, the station declared the RPIS system inoperable when a Control Room panel alarmed the loss of indication. The cause of the equipment loss is under investigation. This unplanned equipment outage is being conservatively reported as a major loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).
"No other safety equipment has been impacted by this event and the plant continues normal operation."
The NRC Resident Inspector has been notified.
"At 1811 PDT on 04/29/2015, the station declared the RPIS system inoperable when a Control Room panel alarmed the loss of indication. The cause of the equipment loss is under investigation. This unplanned equipment outage is being conservatively reported as a major loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).
"No other safety equipment has been impacted by this event and the plant continues normal operation."
The NRC Resident Inspector has been notified.
Fuel Cycle Facility
Event Number: 51024
Facility: WESTINGHOUSE ELECTRIC CORPORATION
Region: 2 State: SC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: CARL SNYDER
HQ OPS Officer: DONALD NORWOOD
Region: 2 State: SC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: CARL SNYDER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/30/2015
Notification Time: 09:30 [ET]
Event Date: 04/29/2015
Event Time: 10:00 [EDT]
Last Update Date: 04/30/2015
Notification Time: 09:30 [ET]
Event Date: 04/29/2015
Event Time: 10:00 [EDT]
Last Update Date: 04/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
FRANK EHRHARDT (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)
FRANK EHRHARDT (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)
VALVE CLASSIFIED AS ITEM RELIED ON FOR SAFETY FAILED TO OPERATE AS DESIGNED
"On April 29, 2015 at 1000 [EDT], it was reported to EH&S [Environmental Health and Safety] that the spring loaded valve on the deionized (DI) water line, which supplies rinse water to an in-line gamma monitor in the conversion scrap recovery area, was found to have the spring-return damaged such that the valve would not automatically return to the closed position when released. This valve is listed as IROFS ADUSCRA-102. While production activities had already ceased in preparation for a Special Nuclear Material (SNM) inventory and planned maintenance outage, liquid wastewater processing activities were on-going.
"Liquid wastewater processing activities were immediately stopped, and EH&S was notified of the event by phone and the 'Redbook' reporting system (Redbook Issue #68460). At no time was there any actual or potential health and safety consequences to the workers, the public, or the environment.
"The safety function of this IROFS is to automatically close when released by hand to prevent possible backflow of Uranium-235 containing wastewater into the DI water supply and potentially to an unfavorable geometry tank. During this time, IROFS ADUSCRP-153, a three-way valve that prevents the commingling of wastewater and DI water, remained available and reliable to prevent potential backflow of the wastewater into the DI water supply. Based on available IROFS, this accident sequence was 'Unlikely' (a failure probability of 10E-3), and not 'Highly Unlikely' (a failure probability of 10E-4 or less), and therefore does not meet the performance requirements of 10 CFR 70.61 [which requires that an accident sequence be 'Highly Unlikely']. The actual configuration remained safe at all times, and no external conditions affected the event. A process upset would have to occur to enable a potential backflow condition, and the remaining IROFS would have had to simultaneously fail.
"Immediate Corrective Actions:
As stated above, the process was shut down, and the upstream DI water valve was locked closed. After evaluation and with EH&S approval, maintenance replaced the valve and a functional test was completed. The event was reviewed in the conversion huddle meetings held before the start of each shift, and operations initiated a check to validate the operability of the spring loaded valve after each use until a long term corrective action is in place. Operating Experience is being shared with the site and industry personnel.
"An Extent of Condition inspection was performed for all safety-significant spring loaded valves. All other valves functioned properly.
"This event has been entered into the facility Corrective Action Prevention And Learning system (CAPAL) #100267824."
"On April 29, 2015 at 1000 [EDT], it was reported to EH&S [Environmental Health and Safety] that the spring loaded valve on the deionized (DI) water line, which supplies rinse water to an in-line gamma monitor in the conversion scrap recovery area, was found to have the spring-return damaged such that the valve would not automatically return to the closed position when released. This valve is listed as IROFS ADUSCRA-102. While production activities had already ceased in preparation for a Special Nuclear Material (SNM) inventory and planned maintenance outage, liquid wastewater processing activities were on-going.
"Liquid wastewater processing activities were immediately stopped, and EH&S was notified of the event by phone and the 'Redbook' reporting system (Redbook Issue #68460). At no time was there any actual or potential health and safety consequences to the workers, the public, or the environment.
"The safety function of this IROFS is to automatically close when released by hand to prevent possible backflow of Uranium-235 containing wastewater into the DI water supply and potentially to an unfavorable geometry tank. During this time, IROFS ADUSCRP-153, a three-way valve that prevents the commingling of wastewater and DI water, remained available and reliable to prevent potential backflow of the wastewater into the DI water supply. Based on available IROFS, this accident sequence was 'Unlikely' (a failure probability of 10E-3), and not 'Highly Unlikely' (a failure probability of 10E-4 or less), and therefore does not meet the performance requirements of 10 CFR 70.61 [which requires that an accident sequence be 'Highly Unlikely']. The actual configuration remained safe at all times, and no external conditions affected the event. A process upset would have to occur to enable a potential backflow condition, and the remaining IROFS would have had to simultaneously fail.
"Immediate Corrective Actions:
As stated above, the process was shut down, and the upstream DI water valve was locked closed. After evaluation and with EH&S approval, maintenance replaced the valve and a functional test was completed. The event was reviewed in the conversion huddle meetings held before the start of each shift, and operations initiated a check to validate the operability of the spring loaded valve after each use until a long term corrective action is in place. Operating Experience is being shared with the site and industry personnel.
"An Extent of Condition inspection was performed for all safety-significant spring loaded valves. All other valves functioned properly.
"This event has been entered into the facility Corrective Action Prevention And Learning system (CAPAL) #100267824."
Agreement State
Event Number: 51025
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: MAYO CLINIC
Region: 3
City: ROCHESTER State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: DANIEL MILLS
Licensee: MAYO CLINIC
Region: 3
City: ROCHESTER State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2015
Notification Time: 11:32 [ET]
Event Date: 04/29/2015
Event Time: 00:00 [CDT]
Last Update Date: 04/30/2015
Notification Time: 11:32 [ET]
Event Date: 04/29/2015
Event Time: 00:00 [CDT]
Last Update Date: 04/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following was received from the State of Minnesota via email:
"Please note the medical event reported today to the Minnesota Department of Health Radioactive Materials Unit by Mayo Clinic in Rochester, MN.
"The licensee reports that on April 29, 2015, a male patient was treated with Y-90 TheraSpheres. The written directive prescribed 62.1 mCi of Y-90 (120 Gy dose). The administration proceeded as expected with the assistance of interventional radiology and nuclear medicine. As part of the procedure, the licensee uses a survey meter to survey the Y-90 microsphere vial to determine that microspheres have been administered to the patient. The procedure was described as 'uneventful' and following the initial flushing the dose rate from the vial/tubing had not decreased to zero. The physician continued with three additional flushes as part of the normal procedure. The vial/tubing dose rate did not reduce to zero.
"The waste material was collected and counted according the manufacturer's instructions. The licensee determined approximately 33% of the Y-90 activity was not delivered to the patient. Administered activity was estimated to be 41.85 mCi (84 Gy). Physicians anticipate no negative impact to the patient since the 'tumoricidal' dose, according to the manufacturer, is 80-150 Gy,
"The patient has been notified. The referring physician was out of town on the day of the event and the licensee notified his fellow.
"The licensee is continuing with an investigation.
"The Minnesota Department of Health considers this investigation open and will provide more information will be as it becomes available."
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 following was received from the State of Minnesota via email:
"Please note the medical event reported today to the Minnesota Department of Health Radioactive Materials Unit by Mayo Clinic in Rochester, MN.
"The licensee reports that on April 29, 2015, a male patient was treated with Y-90 TheraSpheres. The written directive prescribed 62.1 mCi of Y-90 (120 Gy dose). The administration proceeded as expected with the assistance of interventional radiology and nuclear medicine. As part of the procedure, the licensee uses a survey meter to survey the Y-90 microsphere vial to determine that microspheres have been administered to the patient. The procedure was described as 'uneventful' and following the initial flushing the dose rate from the vial/tubing had not decreased to zero. The physician continued with three additional flushes as part of the normal procedure. The vial/tubing dose rate did not reduce to zero.
"The waste material was collected and counted according the manufacturer's instructions. The licensee determined approximately 33% of the Y-90 activity was not delivered to the patient. Administered activity was estimated to be 41.85 mCi (84 Gy). Physicians anticipate no negative impact to the patient since the 'tumoricidal' dose, according to the manufacturer, is 80-150 Gy,
"The patient has been notified. The referring physician was out of town on the day of the event and the licensee notified his fellow.
"The licensee is continuing with an investigation.
"The Minnesota Department of Health considers this investigation open and will provide more information will be as it becomes available."
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.