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Event Notification Report for May 12, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/11/2015 - 05/12/2015

** EVENT NUMBERS **


50899 50915 51031 51032 51037 51039 51063 51064 51065 51066 51068

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50899
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: DANA ANTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/17/2015
Notification Time: 02:57 [ET]
Event Date: 03/16/2015
Event Time: 18:20 [CDT]
Last Update Date: 05/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KENNETH RIEMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECT DECLARED INOPERABLE FOLLOWING SCHEDULED MAINTENANCE

"At 1820 on March 16th, 2015, the High Pressure Coolant Injection (HPCI) system steam lines were re-pressurized following scheduled maintenance. Upon restoration, an alarm was received that indicated condensate may exist in the steam line. The system responded as designed but the alarm did not clear as expected. Without assurance that the condensate has been removed from the HPCI steam line, HPCI remains inoperable for reasons other than the planned maintenance. As a result, this condition is being reported under 10CFR50.72(b)(3)(v)(D) as a condition that could have prevented fulfillment of the safety function at the time of discovery.

"The health and safety of the public was maintained as the plant was in a normal condition with no initiating event in progress.

"The NRC Resident Inspector has been notified."

The licensee will also notify the State of Minnesota.

* * * RETRACTION FROM RANDY SAND TO DANIEL MILLS AT 1445 EDT ON 5/11/15 * * *

"On March 16, 2015, Northern States Power Minnesota reported a condition that could have prevented the fulfillment of a safety function under 10 CFR 50.72(b)(3)(v)(D). The High Pressure Coolant Injection (HPCI) System was declared inoperable for a reason other than planned maintenance due to the failure of the HPCI Steam Supply Drain Hi Level Bypass Level Switch to clear the high level alarm subsequent to actuation.

"An engineering evaluation was performed and concluded that the function of the primary pathway to remove condensate remained unchallenged by the condition present on the level switch. This conclusion was also validated via thermography with the HPCI steam supply pressurized and bypass valve open. The verification that the primary pathway was functional provides reasonable assurance that the HPCI steam supply was always clear of condensate supporting the ability of HPCI to perform its required safety function. Therefore, the condition present on the level switch did not render HPCI inoperable. The conclusions of the engineering evaluation provide the basis for retraction of the ENS report made on March 17.

"The NRC Resident Inspector has been notified."

The licensee will also notify the State of Minnesota.

Notified R3DO (Peterson).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50915
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: LEE ROY ANDERSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/21/2015
Notification Time: 13:55 [ET]
Event Date: 03/21/2015
Event Time: 05:37 [CDT]
Last Update Date: 05/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GREGORY ROACH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO CONDENSATION IN STEAM LINE

"At 0537 CDT on March 21, 2015, following the High Pressure Coolant Injection (HPCI) system quarterly pump and valve surveillance, after HPCI was removed from service, an alarm for the HPCI Turbine Inlet High Drain Pot Level did not reset. This indicated that LS-23-90 (HPCI Steam Supply Drain High Level Bypass) did not reset, which could be an indication that condensate exists in the steam line. The system responded as designed but the alarm did not clear as expected. Without assurance that the condensate has been removed from the HPCI steam line, HPCI remains inoperable for reasons other than the planned surveillance. As a result, this condition is being reported under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented fulfillment of the safety function at the time of discovery.

"The health and safety of the public was maintained as the plant was in a normal condition with no initiating event in progress.

"The NRC Resident Inspector has been notified."

The State of Minnesota will be notified.

* * * RETRACTION FROM RANDY SAND TO DANIEL MILLS AT 1445 EDT ON 5/11/15 * * *

"On March 21, 2015, Northern States Power Minnesota reported a condition that could have prevented the fulfillment of a safety function under 10 CFR 50.72(b)(3)(v)(D). The High Pressure Coolant Injection (HPCI) System was declared inoperable for a reason other than planned maintenance due to the failure of the HPCI Steam Supply Drain Hi Level Bypass Level Switch to clear the high level alarm subsequent to actuation.

"An engineering evaluation was performed and concluded that the function of the primary pathway to remove condensate remained unchallenged by the condition present on the level switch This conclusion was also validated via thermography with the HPCI steam supply pressurized and bypass valve open. The verification that the primary pathway was functional provides reasonable assurance that the HPCI steam supply was always clear of condensate supporting the ability of HPCI to perform its required safety function. Therefore, the condition present on the level switch did not render HPCI inoperable. The conclusions of the engineering evaluation provide the basis for retraction of the ENS report made on March 21.

"The NRC Resident Inspector has been notified."

The licensee will also notify the State of Minnesota.

Notified R3DO (Peterson).

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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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Agreement State Event Number: 51037
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: NOT PROVIDED
Region: 4
City: TEMPLE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 11:46 [ET]
Event Date: 04/30/2015
Event Time: [CDT]
Last Update Date: 05/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - RUPTURED IODINE SEED DURING REMOVAL

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

"On May 4, 2015, licensee's Radiation Safety Officer (RSO) reported to the Agency [Texas Department of State Health Services] that he had been notified today that on Thursday, April 30, 2015, a physician had ruptured an I-125 seed during removal from a patient. The seed was used for localization in a breast treatment procedure. The seed activity was 357 microcuries at the time of treatment on 4/30/15. The seed was identified as leaking after removal and in a container in the pathology department. The physician had screened the patient with a probe in the tissue/lesion and no radioactivity was found. No overexposure to the patient or doctor had occurred. The RSO stated he was preparing a full detailed report. Further information will be provided in accordance with SA300 guidelines."

Texas Incident # I-9310

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: 51039
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER, INC.
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 17:52 [ET]
Event Date: 05/01/2015
Event Time: [CDT]
Last Update Date: 05/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED Y-90 DOSE

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

"On May 4, 2015, the Wisconsin Radiation Protection Section received a notice from an Authorized Medical Physicist [AMP] at Gundersen Lutheran Medical Center, Inc., of a medical event that occurred during a Yttrium-90 Therasphere procedure on May 1, 2015. The licensee did not have enough information to determine if the procedure constituted a medical event on May 1, 2015. Upon further evaluation, the AMP determined it was a medical event as of 3 pm CST May 4, 2015. The patient was scheduled to receive two separate Y-90 Therasphere doses to two separate segments of the liver. During the first injection, the overpressure valve opened and filled the overflow vial with the Authorized User applying very little pressure to the saline filled syringe. The patient was to get 147 Gy to Segment 6 of the liver. From residue measurements, the patient received 35.5 percent or 52.2 Gy to Segment 6. The Radiation Protection Section will perform an investigation and update through NMED [Nuclear Material Events Database].

"Event Report ID No.: WI150006"

* * * UPDATE AT 0938 EDT ON 5/18/2015 FROM CAL WALTON TO MARK ABRAMOVITZ * * *

The correct Wisconsin event ID is WI150007.

Notified the R3DO (Peterson) and NMSS (via e-mail).

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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Part 21 Event Number: 51063
Rep Org: BNL INDUSTRIES, INC.
Licensee: BNL INDUSTRIES, INC.
Region: 1
City: VERNON State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: JEFFREY JACOBS
HQ OPS Officer: RICHARD SMITH
Notification Date: 05/11/2015
Notification Time: 13:59 [ET]
Event Date: 05/01/2015
Event Time: [EDT]
Last Update Date: 05/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
HIRONORI PETERSON (R3DO)
BLAKE WELLING (R1DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - DEFECT IDENTIFIED 6 INCH GEAR OPERATED BALL VALVES

The following is excerpted from a reported submitted by BNL Industries, INC.:

"On May 1, 2015 BNL identified a discrepant condition in which material was identified by an audited third-party material testing facility as meeting the requirements of ASME SA-105, despite having a test yield strength of 35.6ksi (vice 36ksi required by the specification).

"The discrepant material has already been manufactured and incorporated into a basic component and shipped to the end users.

"Based on BNL engineering evaluations of the design criteria, code requirements and supplied material, BNL has determined there to be no safety hazard. Engineering evaluations EE-A150217 Rev. 0 and EE-A141009-23 Rev. 0 are being supplied to the purchasers.

"First Energy - Perry - 1 endcap supplied, P/N GBV-B2-60-0020 PC. 3, Serial Number A150217-1-1 (Trace Number 547G-1)

"First Energy - Beaver Valley - 7 endcaps supplied, GBV-B2-60-0112 PC. 3, Serial Numbers A141009-23-3 (2pcs.), A141009-23-4 (2pcs.), A141009-23-5 (2pcs.), A141009-23-6 (1 pc.) (Trace Number 547G-1)"

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Power Reactor Event Number: 51064
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MARK PHILLIPS
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/11/2015
Notification Time: 20:38 [ET]
Event Date: 05/11/2015
Event Time: 16:29 [EDT]
Last Update Date: 05/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAKE WELLING (R1DO)

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

LOSS OF POWER TO DIGITAL RADIATION MONITORING SYSTEM

"At 1629 EDT on May 11, 2015, Beaver Valley Power Station (BVPS) Unit 1 (Mode 6 Refueling) opened circuit breaker PCB-92 to de-energize system service transformer 1A due to an emergent issue with a transformer bushing. This resulted in a loss of power to the ERF [Emergency Response Facility] substation which powers various plant support equipment at both units. The BVPS Unit 2 Digital Radiation Monitoring System (DRMS) was non-functional for approximately 21 minutes. This was a loss of radiation monitor capability to alarm and indicate in the control room. Following power restoration to the ERF substation, the radiation monitor system was restored at 1650 EDT. Both Unit 1 and Unit 2 remain stable.

"Since the BVPS Unit 2 DRMS was non-functional, this event resulted in a loss of emergency assessment capability and is reportable per 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51065
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: SEAN BLOOM
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/12/2015
Notification Time: 05:48 [ET]
Event Date: 05/12/2015
Event Time: 04:30 [EDT]
Last Update Date: 05/12/2015
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):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
4 A/R Y 81 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DUE TO MAIN GENERATOR DIFFERENTIAL TRIP

"This is an non-emergency notification to the NRC [Headquarters] Operations Center in accordance with 10 CFR 50.72(b)(2)(iv)(B) for a valid actuation of the reactor protection system (RPS) (four hour notification) and 10 CFR 50.72(b)(3)(iv)(A) for a valid Engineered Safeguards (ESF) actuation (eight hour notification) due to auxiliary feedwater (AFW) initiation.

"On 5/12/15 at 0430 EDT, Unit 4 experienced an automatic reactor trip due to Generator Differential Trip. Investigation is underway to determine the cause. Auxiliary feedwater automatically initiated as expected. All systems operated correctly in response to the reactor trip. Unit 4 is currently in Mode 3 and stable."

All control rods fully inserted. Normal offsite power is available with decay heat is being removed by the atmospheric steam dumps. There is no known primary to secondary reactor coolant system leakage.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 51066
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: ANDREW MITCHELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/12/2015
Notification Time: 09:08 [ET]
Event Date: 05/12/2015
Event Time: 01:04 [CDT]
Last Update Date: 05/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRIAN BONSER (R2DO)

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

Event Text

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"On May 12, 2015, at 0104 CDT, during performance of 3-SR-3.3.6.1.2(3B), High Pressure Coolant Injection (HPCI) System Steam Supply Pressure Low Functional Test, an inadvertent PCIS Group 4 (HPCI) isolation occurred. All automatic actions occurred as designed. HPCI was declared inoperable and Technical Specification LCO 3.5.1.C was entered with required action to verify immediately that RCIC is operable administratively and to restore HPCI to operable within 14 days. HPCI was returned to service at 0125 CDT, declared operable and TS LCO 3.5.1.C was exited. The cause of the isolation is unknown with an investigation in progress.

"This condition is reportable as an 8-hour ENS notification under 10CFR 50.72(b)(3)(v)(D) due to the failure of a single train system affecting accident mitigation.

"This condition also requires a 60 day written report.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51068
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: DON GREGOIRE
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/12/2015
Notification Time: 22:13 [ET]
Event Date: 04/03/2015
Event Time: [PDT]
Last Update Date: 05/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL VASQUEZ (R4DO)

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

LOSS OF RADIOLOGICAL ASSESSMENT CAPABILITY DUE TO NON-FUNCTIONAL RADIATION MONITOR

"On 4/21/2015, during performance of source check surveillance on the liquid effluent radiation monitor for the Plant Service Water (TSW), a non-radioactive system, it was discovered that the instrument was determined to be nonfunctional. It was determined on 4/25/15 that the failure was due to an incorrect 'as left' setting from testing conducted on 4/3/2015. The instrument was determined to be non-functional from the period 4/03/15 to 4/25/15 when the setting was corrected.

"On 5/12/15 it was recognized that because no compensatory measures were implemented during the time the instrument was non-functional that this condition constituted a major loss of radiation assessment capability which is reportable in accordance with 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident Inspector will be notified."

Page Last Reviewed/Updated Wednesday, May 20, 2015
Wednesday, May 20, 2015