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Event Notification Report for May 11, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/08/2015 - 05/11/2015

** EVENT NUMBERS **


50998 51006 51024 51025 51031 51032 51060 51061

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Power Reactor Event Number: 50998
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE BRUNSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/20/2015
Notification Time: 21:26 [ET]
Event Date: 08/07/2014
Event Time: 17:07 [EDT]
Last Update Date: 05/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ALAN BLAMEY (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

THIS IS A CONTINUATION OF EN #50351

* * * UPDATE FROM STEVE BRUNSON TO CHARLES TEAL ON 4/20/15 AT 2126 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was found at penetration 1Z43H594D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- Near penetration 1Z43J837D, and approximately 12" south and above 1Z43H837D, gaps were observed in the mortar joint between CMU on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A triangular gap 1" wide, 1" tall and 6" deep was found at penetration 1Z43H592D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A gap 4" tall and 3" wide was found behind Turn Box TB1-1272 which covers penetrations 1Z43H590D, 1Z43H589D, 1Z43H588, and 1Z43H587D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- At the architectural joint between the vertical wall to the horizontal floor/ceiling assembly above door 1C-22, above and to the south of 1Z43H1105D, a gap was observed approximately " tall, 3" wide, and 6" deep on the west wall of the U1 East Cableway Foyer (separating Fire Area 1105 and Fire Area 0014K)

- Gap between the grout and the conduit of penetration 1Z43H778D approximately " tall x 1.5" wide x 6" deep on the east wall of the Unit 1 130' Elevation Control Building Working Floor Hallway (separating Fire Area 0014K and Fire Area 1105)

"The nonconforming conditions observed for the affected fire penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 2. 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 areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensure the safe shutdown paths are preserved until the degraded conditions are repaired.

"CR 10058276; CR 10058278

"The following deficiencies were also observed causing the affected penetrations to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H532D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 0014M)

- A gap 1/8" wide, 1" tall and 6" deep was located at penetration 1Z43H780D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M)

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H781D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M). A " x " defect was also identified at penetration 1Z43H781D on the east wall of the Men's Restroom in the Control Building (separating Fire Area 0014M and Fire Area 1104)

"The nonconforming conditions observed for the affected penetrations were identified as affecting both safe shutdown paths for Unit 1 and Unit 2. 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 areas and will remain in place until the fire barriers are repaired. The presence of compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until degraded conditions are repaired.

"CR 10058277

"The expanded scope 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 has notified the NRC Resident Inspector. Notified R2DO (Blamey).

* * * UPDATE FROM SCOTT BRITT TO DONG PARK ON 4/23/15 AT 1654 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A gap 1/4" wide, 1" tall and 7" deep was found at penetration 1Z43H1138D on the east wall of the U1 RPS MG Set Room (separating Fire Area 1013 and Fire Area 0040). No seal material was seen between the sleeve and the cinderblock on the north side of penetration.

- A void 1" tall, 1" wide, and 7" deep was found in the south upper corner under a concrete beam at column line T12 above penetration 1Z43H941D on the east wall of the U1 RPS MG Set Room (separating Fire Area 1013 and Fire Area 0040).

- At penetration 1Z43H1139D, it appears that combustible neoprene insulation is used around the pipe within the plane of the west wall of the Vertical Cable Chase Room (separating Fire Area 0040 and Fire Area 1013). Combustible materials would not be part of a rated pen seal.

- A gap 1" wide, 1" tall and 7" deep was observed at penetration 1Z43H1138D on the west wall of the Vertical Cable Chase Room (separating Fire Area 0040 and Fire Area 1013).

"The nonconforming conditions observed for the affected fire penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 1. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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 10060228"

The licensee will notify the NRC Resident Inspector. Notified R2DO (Blamey).

* * * UPDATE FROM STANLEY STONE TO DONG PARK ON 4/27/15 AT 2047 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

-An opening in the grout 1/4" wide, 1/2" tall and over 7" deep was found between the wall and the outside sleeve for penetration 2Z43H028D on the west wall of the U2 Transformer Room (separating Fire Area 2019 and Fire Area 2016).

-A 1/4" diameter hole in the grout approximately 2.5" deep was found above conduit 2MI2128 on the west wall of the U2 Transformer Room (separating Fire Area 2019 and Fire Area 2016).

"The nonconforming conditions observed for the affected penetration and fire barrier were identified as affecting both safe shutdown paths for Unit 1 and Unit 2. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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 10061830"

The licensee notified the NRC Resident Inspector. Notified R2DO (Blamey).


* * * UPDATE FROM PAUL UNDERWOOD TO DONG PARK ON 4/28/15 AT 1640 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers in the Unit 2 Control Building 130' elevation to be considered nonfunctional and represented degraded conditions of penetrations through the wall separating the Unit 2 Switchgear Access Hallway - Fire Area 2014, from the U2 West 600 V Switchgear Room - Fire Area 2016.

"The following conditions were located on the south wall of the Unit 2 Switchgear Access Hallway (Fire Area 2014).

1. An opening between the conduit and the wall 1/4" wide, 2" long and probed to be at least 2 1/2" deep was identified for penetration 2Z43H668D. A similar condition exists for this penetration on the opposite side of the wall in Fire Area 2016.
2. An opening between the conduit and the wall 1/4" wide, 1/2" long and probed to be at least 3" deep was identified for penetration 2Z43H667D. A similar condition exists for this penetration on the opposite side of the wall in Fire Area 2016.

The following conditions were located on the opposite side of the same wall. This is the north wall of the U2 West 600V Switchgear Room (Fire Area 2016):
3. An opening between the conduit and the wall 1/8" wide, 1" long and probed to be at least 4" deep was identified for penetration 2Z43H668D.
4. An opening between the conduit and the wall 1/8" wide, " long and probed to be at least 3" deep was identified for penetration 2Z43H667D.
5. An opening between the conduit and the wall 2 1/2" wide, 2 1/2" long and probed to be at least 4" deep was identified around the 2" continuous run conduit located above cable tray penetration 2Z43H031D.
6. An opening between the conduit and the wall 1/4" wide, 3/4" long and probed to be at least 6" deep was identified above a 3/4" continuous run conduit (first of three) located at the ceiling near column line TE.
7. An opening between the conduit and the wall 1/4" wide, 1/2" long and probed to be at least 6" deep was identified above a 3/4" continuous run conduit (second of three) located at the ceiling near column line TE.
8. An opening between the conduit and the wall 1/4" wide, 3/4" long and probed to be at least 5" deep was identified above a 3/4" continuous run conduit (third of three) located at the ceiling near column line TE.

"The nonconforming conditions observed for the affected penetration and fire barrier were identified as affecting both safe shutdown paths for Unit 2. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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 10062254"

The licensee notified the NRC Resident Inspector. Notified R2DO (Ehrhardt).

* * * UPDATE FROM PAUL UNDERWOOD TO DANIEL MILLS ON 4/29/15 AT 1804 EDT * * *

"During an expanded scope inspection, deficiencies in the Unit 2 Control Building 130 foot elevation were observed that caused the affected barriers to be considered nonfunctional and represented degraded conditions of penetrations through the wall separating the Unit 2 West DC Switchgear Room 2A (Fire Area 2018) and the Unit 2 Switchgear Access Hallway (Fire Area 2014).

"The following conditions were located on the west wall of the Unit 2 Switchgear Access Hallway (Fire Area 2014).
1. An opening between the conduit and the wall inch wide, 1 inch long and probed to be greater than 2 inch deep, was identified for penetration 2Z43H673D.
2. There is insufficient masonry material to fill the full depth of the wall above the ductwork that passes through penetration 2Z43H032D. This deficiency affects a small area on the south side of the ductwork and penetrations 2Z43H789D, 2Z43H790D, and 2Z43H791D.
3. An opening between the conduit and the wall inch wide, 1 inch long and probed to be 4 inch deep was identified for penetration 2Z43H671D. A similar condition exists for this penetration on the opposite side of the wall (see Item 5 below).

"The following conditions were located on the east wall of the Unit 2 West DC Switchgear Room 2A (Fire Area 2018).
4. There are openings between the conduits and the wall inch wide and 1 inch long for penetrations 2Z43H789D, 2Z43H790D, and 2Z43H791D. These penetrations are affected in Item 2 above.
5. An opening between the conduit and the wall 1 inch wide, 1 inch long and probed to be greater than 6 inch deep, was identified for penetration 2Z43H671D.
6. An opening between the conduit and the wall inch wide, 1 inch long and probed to be at least 2 inch deep, was identified for penetration 2Z43H673D.
7. An opening between the conduit and the wall inch wide, 1 inch long and probed to be at least 2 inch deep, was identified for penetration 2Z43H676D.

"The nonconforming conditions observed for the affected penetrations were identified as affecting both safe shutdown paths for Unit 2. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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.

"CR10062955"

The licensee notified the NRC Resident Inspector. Notified R2DO (Ehrhardt).

* * * UPDATE FROM JOHN MITCHELL TO HOWIE CROUCH AT 2137 EDT * * *

"During an expanded scope inspection, deficiencies in the Control Building 130' elevation were observed that caused the affected barriers to be considered nonfunctional and represented degraded conditions of the following penetrations through the wall separating the Unit 2 East Cableway (Fire Area 2104) and the Health Physics Hallway and Counting Room (Fire Areas 0014B and 0014G).
- Penetration 2Z43H783D terminates open within a foot of the east wall of the Health Physics Counting Room (Fire Area 0014G)
- Penetration 2Z43H603D contains no visible seal material and is located on the east wall of the Health Physics Hallway (Fire Area 0014B).

"The nonconforming conditions observed for the affected penetrations were identified as affecting both safe shutdown paths for Unit 1 and Unit 2.

"Deficiencies were also observed that caused the affected barriers to be considered nonfunctional and represented degraded condition of the wall separating the Unit 2 East Cableway (Fire Area 2104) from the common East Cableway Foyer (Fire Area 1105).
- Gap near penetration 2Z43H170D between a conduit and the concrete masonry unit (CMU) wall located on the south wall of the Unit 2 East Cableway (Fire Area 2104).

"The nonconforming conditions observed for the affected fire barriers were identified as affecting both safe shutdown paths for Unit 1.

"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 areas but were modified based on the nature of the degradations noted in the condition report and will remain in place until the fire barriers are 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 expanded scope 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.

"CR10063642"

Notified R2DO (Ehrhardt).

* * * UPDATE FROM JOHN MITCHELL TO JOHN SHOEMAKER AT 1638 EDT ON 5/7/15 * * *

"During an expanded scope inspection, deficiencies in the Control Building 147' elevation were observed that caused the affected barriers to be considered nonfunctional. These deficiencies represented degraded conditions of the following penetrations through the wall separating the Unit 1 CO2 Tank Room (Fire Area 0025) and the Computer Room (Fire Areas 0024B) as well as a discrepancy in the affected wall.
- In Fire Area 0024B, a small gap in the foam, approximately 6 [inch] deep was identified in Penetration 1Z43H592F. The adjacent Fire Area is FA 0025.
- In Fire Area 0024B, penetration 1Z43H325F was identified with no sealant for the penetration sleeve. The adjacent Fire Area is FA 0025.
- In Fire Area 0024B, foam sealant was missing in cable-tray, 1Z43H061F. The adjacent Fire Area is FA 0025
- In Fire Area 0024B, a gap was identified in a concrete masonry unit (CMU) wall joint, directly above 1Z43H062F.

"The nonconforming conditions observed for the affected fire barriers were identified as affecting both safe shutdown paths for Unit 1 and Unit 2.

"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 areas and will remain in place until the fire barriers are 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 expanded scope 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.

"CR10066678"

The licensee has notified the NRC Resident Inspector.

Notified the R2DO (Sandal).

* * * UPDATE AT 2151 EDT ON 05/07/15 FROM SCOTT BRITT TO S. SANDIN * * *

"During an expanded scope inspection, a deficiency in the Control Building 147 ft. elevation was observed that caused the affected barrier to be considered nonfunctional. This deficiency represented degraded conditions of the following fire barrier separating the Unit 1 CO2 Tank Room (Fire Area 0025) and the Cable Spreading Room (Fire Areas 0024A).

- A 1/4 inch x 2 inch x approximately 4 inch deep gap in the east CMU wall of Unit 1 CO2 Tank Room above penetration 1Z43H046F.

"The nonconforming condition observed for the affected fire barrier was identified as affecting both safe shutdown paths for Unit 1 and Unit 2. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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.

"CR10066844"

The licensee will inform the NRC Resident Inspector. Notified R2DO (Sandal).

* * * UPDATE AT 2029 EDT ON 05/08/15 FROM SCOTT A. BRITT TO S. SANDIN * * *

"During an expanded scope inspection, deficiencies in the Control Building 147 ft. elevation were observed that caused the affected barrier to be considered nonfunctional. These deficiencies represent degraded conditions of the following fire barrier separating the Cable Spreading Room (FA 0024A) and the CO2 Tank Room (FA 0025).

- Multiple gaps in the caulk at the top of the ceiling of the west wall of the Cable Spreading Room (separating FA 0024A and FA 0025).

"The nonconforming condition observed for the affected fire barrier was identified as affecting both safe shutdown paths for Unit 1 and Unit 2. 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 areas and will remain in place until the fire barriers are 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 expanded scope 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 10067163"

The licensee will inform the NRC Resident Inspector. Notified R2DO (Sandal).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51006
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARK DICKERSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/23/2015
Notification Time: 18:51 [ET]
Event Date: 04/23/2015
Event Time: 10:50 [CDT]
Last Update Date: 05/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
NICK VALOS (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

Event Text

SAFETY SYSTEMS DECLARED INOPERABLE DUE TO EQUIPMENT MALFUNCTION

"At 1050 [CDT] on 4/23/2015, an equipment malfunction resulted in DAEC [Duane Arnold Energy Center] declaring the Division 1 Essential Electrical Bus inoperable. The LPCI [ Low Pressure Coolant Injection] system was inoperable but available as part of a planned evolution at the time of the malfunction. Declaring the Essential Electrical Bus inoperable caused the 'A' Core Spray System to be considered inoperable. LPCI and 'A' Core Spray being inoperable simultaneously constituted a loss of safety function. The 'B' Core Spray system remained operable and available. The equipment malfunction was resolved promptly, allowing the Division 1 Essential Electrical Bus to be returned to an operable status.

"The notification is being made pursuant to 10 CFR 50.72(b)(3)(v)(D).

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

The licensee entered and exited TS LCO 3.5.1 condition B.


* * * RETRACTION FROM BOB MURRELL TO DONALD NORWOOD AT 0835 EDT ON 5/8/2015 * * *

"The purpose of this notification is to retract a previous report made on 4/23/15 at 1851 EDT (EN 51006). Notification to the NRC was initially made as a result of an event or condition that could prevent the fulfillment of the safety function of Emergency Core Cooling System (ECCS) due to an equipment malfunction associated with the Division 1 Essential Electrical Bus Breaker 1A306.

"Subsequent to the initial report, NextEra Energy Duane Arnold (NextEra) has determined that the Division 1 Essential Electrical Bus was fully capable of performing its intended safety function with the malfunction on Bus Breaker 1A306.

"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73.

"The NRC Resident Inspector has been notified."

Notified R3DO (Skokowski).

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Fuel Cycle Facility Event Number: 51024
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
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
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
FRANK EHRHARDT (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

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."

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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
Notification Date: 04/30/2015
Notification Time: 11:32 [ET]
Event Date: 04/29/2015
Event Time: [CDT]
Last Update Date: 04/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

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.

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Agreement State Event Number: 51031
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TERRACON CONSULTANTS
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 05268
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/01/2015
Notification Time: 17:56 [ET]
Event Date: 05/01/2015
Event Time: 10:00 [CDT]
Last Update Date: 05/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEXICO (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN AND RECOVERED MOISTURE DENSITY GAUGE

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

"On May 1, 2015 the licensee's corporate office notified the Agency [Texas Department of State Health Services] that one of its vehicles had been stolen at 10 am today with a moisture density gauge secured on the back of the truck. The gauge was a Troxler 4640 with an 8 millicurie Cesium-137 and 40 millicurie Americium/Beryllium source in the gauge. The truck was stolen at a gas station and local police were immediately called by the driver/technician. The police recovered the vehicle with the gauge still secured in the back of the truck. Details of the event will be provided as the local radiation safety officer and technician are still on-site with the police. Additional information will be provided in accordance with SAE 300."

Texas Incident # I-9309

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

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Agreement State Event Number: 51032
Rep Org: NORTH CAROLINA DEPT OF HHS
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: RALEIGH State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/01/2015
Notification Time: 19:10 [ET]
Event Date: 03/30/2014
Event Time: [EDT]
Last Update Date: 05/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - IODINE 125 SEED LEFT IN PATIENT

The following was received from the State of North Carolina via email:

"During a recent facility inspection at Duke University Medical Center (License# 0247-4), it was discovered that a lost I-125 seed (National NMED Item #140177) was actually found a couple months later still in the patient's breast tissue. The seed was intended for radioactive seed localization (RSL) of a breast lesion and thought to be excised with the targeted tissue during surgery.

"Events as follows:
-Seed was implanted to patient with 213 uCi on 1/23/2014.
-Discovered missing by licensee on 2/27/2014.
-Reported lost to NC on 3/21/2014.
-Found in patient 3/30/2014, no update given to NC.
-Removed from patient breast on 4/1/2014.

"As of 5/1/2015, the licensee maintains that there was only 12.5 rads received to the 250g of breast tissue and not above the 50 rem for medical event reporting. This is currently under investigation by the NC Radioactive Materials Branch as our preliminary numbers suggest the breast tissue dose could be as high as 66 rem in the maximally exposed 100g of tissue.

"The licensee is not concerned with overall adverse reaction to the patient health due to them receiving a subsequent external beam radiation treatment that deposited between 300-1100 rads to the affected breast.

"This possible medical event is tied to the former local NMED Incident# NC 140014 where the source was lost, and it is now being tracked by a new local NMED Incident# NC 150010."

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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Power Reactor Event Number: 51060
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: LUKE HEDGES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/09/2015
Notification Time: 18:19 [ET]
Event Date: 05/09/2015
Event Time: 17:50 [EDT]
Last Update Date: 05/09/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAN SCHROEDER (R1DO)
BILL DEAN (NRR)
ALLEN HOWE (NRR)
DAN DORMAN (R1RA)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO MAIN TRANSFORMER FIRE

"At 1750 EDT [05/09/15,] Indian Point Unit 3 experienced a fire on the 31 Main Transformer resulting in a unit trip. An Unusual Event was declared at 1801 EDT. The onsite fire brigade was mobilized. Offsite fire fighting assistance was requested. The fire was reported extinguished at 1815 EDT. The reactor was shutdown by an automatic trip. Plant response to the trip was as expected with no complications. The 31 and 33 Auxiliary Feed Pumps are operating and feeding the steam generators. Accountability is being performed."

The plant is stable in mode 3, all control rods fully inserted, with normal offsite electrical power, and decay heat is being released to the main condenser. There was no impact on Unit 2 which continues to operate at 100% power.

The licensee has notified the NRC Resident Inspector and state and local authorities.

Notified DHS SWO, FEMA OPS Center, DHS NICC Watch Officer, and Nuclear SSA via email.


* * * UPDATE FROM LUKE HEDGES TO JOHN SHOEMAKER AT 2037 ON 5/9/15 * * *

"Oil from 31 Main Transformer has spilled into the discharge canal and has made its way into the river. Plant personnel are sandbagging drains and release paths. IPEC [Indian Point Energy Center] has contacted its environmental contractor, who is expected onsite at 2100 EDT to assist with cleanup. The National Response Center was notified at 1945 EDT and issued notification number 1116011. A message was left with the Westchester County Department of Health at 1953 EDT. The NY State DEC [Department of Environment Conservation] was contacted at 1955 EDT and issued notification number 1501459."

The licensee has notified the NRC Resident Inspector.

Indian Point Unit 3 remains in an Unusual Event at this time.

Notified R1DO (Schroeder).


* * * UPDATE FROM LUKE HEDGES TO JOHN SHOEMAKER AT 2141 ON 5/9/15 * * *

"Indian Point Unit 3 exited the Unusual Event at 2103 EDT. The basis for exiting the Unusual Event is that the fire is out and field operators report they have been successful in cooling the transformer."

The licensee has notified the NRC Resident Inspector and state and local authorities.

Notified R1DO (Schroeder), R1RA (Lew), NRR (Dean), NRR EO (Morris), NRR EO (Howe), and IRD (Grant).

Notified DHS SWO, FEMA OPS Center, DHS NICC Watch Officer, and Nuclear SSA via email.

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Power Reactor Event Number: 51061
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: JOHN PHILLIPPE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/09/2015
Notification Time: 19:45 [ET]
Event Date: 05/09/2015
Event Time: 18:55 [EDT]
Last Update Date: 05/09/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
PEDERSON (R3RA)
JENNIFER UHLE (NRR)
SCOTT MORRIS (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO STEAM LEAK IN THE TURBINE BUILDING

At 1855 EDT, a steam leak from the #1 moisture separator reheater in the turbine building was reported to the control room. Operators performed a rapid down power to approximately 30% at which time the reactor was manually tripped. At 1910 EDT an Unusual Event was declared. The steam feed rupture control system was manually initiated (this includes actuation of both turbine-driven Auxiliary Feedwater Pumps) and the steam leak was isolated. Station air compressor #2 (non-safety related) tripped. Station air compressor #1 automatically started.

The unit is currently in mode 3 (Hot Standby) and stable. Steam is being discharged through the atmospheric dumps as a means of decay heat removal. There is no known primary to secondary leakage. All systems functioned as expected. There were no reported injuries and personnel accountability is in progress.

The licensee notified state and local agencies and informed the NRC Resident Inspector.

Notified DHS SWO, FEMA Ops Center, NICC Watch Officer and FEMA NWC and NuclearSSA via email.


* * * UPDATE AT 2201 EDT ON 5/9/15 FROM GERRY WOLF TO S. SANDIN * * *

The licensee exited the Unusual Event at 2121 EDT based on the following:

"At 2121 hours EDT, the Unusual Event at the Davis-Besse Nuclear Power Station was terminated. The steam leak has been isolated and plant conditions are stable. Cooling continues to be maintained via the auxiliary feedwater system.

"The initiation of auxiliary feedwater at the start of the event is reportable as a Specified System Actuation per 10CFR50.72(b)(3)(iv)(A)."

The licensee notified state and local agencies and informed the NRC Resident Inspector.

Notified R3DO (Skokowski), NRR EO (Morris) and IRD (Grant).

Notified DHS SWO, FEMA Ops Center, NICC Watch Officer and FEMA NWC and NuclearSSA via email.

Page Last Reviewed/Updated Monday, May 11, 2015
Monday, May 11, 2015