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Event Notification Report for June 29, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/26/2015 - 06/29/2015

** EVENT NUMBERS **


51166 51167 51182 51184 51185 51186 51187

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Agreement State Event Number: 51166
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: COLBY COLLEGE
Region: 1
City: WATERVILLE State: ME
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JEAN GESLIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/19/2015
Notification Time: 12:50 [ET]
Event Date: 08/21/2014
Event Time: [EDT]
Last Update Date: 06/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - THEFT OF FOUR TRITIUM EXIT SIGNS

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

"Colby College reported the theft of four radioluminescent exit signs (Isolite model SLX-60, serial #13-9009, 13-9010, 13-9011, and 13-9013), each containing 229.4 GBq (6.2 Ci) of H-3. The signs were discovered to be missing during an annual inventory performed on 8/21/2014."

This event was reported to the State of Maine on 12/04/2014. An NMED report was submitted on 02/02/2015 [NMED Item Number: 150092].

Maine Report Nr.: ME150001

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: 51167
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINE GENERAL MEDICAL CENTER
Region: 1
City: AUGUSTA State: ME
County:
License #: ME-11623
Agreement: Y
Docket:
NRC Notified By: JEAN GESLIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/19/2015
Notification Time: 12:50 [ET]
Event Date: 03/04/2015
Event Time: [EDT]
Last Update Date: 06/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DURING BRACHYTHERAPY TREATMENT

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

"Maine General Medical Center reported that a patient received less dose than prescribed to the treatment site and dose to an unintended site during HDR (Varian model GammaMed Plus) brachytherapy using an Ir-192 source. The patient was prescribed to receive a 1,350 cGy (rad) boost dose to the vaginal cuff in three weekly fractions of 450 cGy (rad) each. The first fraction was delivered on 2/25/2015 using a 3.5-cm applicator. Post insertion CT images were reviewed by the physician and the first fraction was delivered correctly. During the second fraction on 3/4/2015, a second physician was unable to insert the 3.5-cm applicator due to edema and tenderness. A new treatment plan was developed to deliver the prescribed 450 cGy (rad) dose using a 2.6-cm applicator. Upon review of the previous week's images, the second physician noted that the applicator was approximately 7 cm short of the intended position such that the tip of the applicator did not contact the vaginal cuff. On 3/11/2015, a fraction was correctly delivered using the 2.6-cm applicator. The second physician reviewed the treatment deviation with the patient and recommended that an additional fraction of 450 cGy (rad) be administered, which was scheduled for 3/18/2015. The cause was determined to be human error."

This event was reported to the State of Maine on 03/11/2015. An NMED report was submitted on 03/12/2015 [NMED Item Number: 150165].

Maine Report Nr.: ME150002 and ME150002A

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: 51182
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: QUOC VO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/26/2015
Notification Time: 04:38 [ET]
Event Date: 06/25/2015
Event Time: 22:00 [PDT]
Last Update Date: 06/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
VIVIAN CAMPBELL (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 2 Startup 2 Startup

Event Text

TWO REACTOR VESSEL LEVEL CHANNELS FAILED HIGH

"At 2200 PDT during startup from refueling outage 22, it was discovered that both level instruments used in reactor protection system (RPS) trip system 'A' for initiation of a reactor scram on low reactor pressure vessel (RPV) level were observed to have failed high. This resulted in the inability to generate a full reactor scram on low level (+13 inches). All remaining RPV level indications demonstrated that level was being maintained within normal operating bands. This constitutes a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to shut down the reactor.

"The RPS trip logic at Columbia consists of two trip systems, RPS trip system 'A' and RPS trip system 'B'. There are two level instrument channels in each trip system. Columbia utilizes a 'one-out-of-two taken-twice' trip logic to generate a full scram signal. At least one channel in both trip systems must actuate to generate a full scram signal. With both level instruments in RPS system 'A' failed high, the RPS trip logic was unable to generate a full scram.

"At 2246 [PDT] and in accordance with TS LCO 3.3.1.1 Condition C, a half scram was generated on RPS trip system 'A' to restore full scram capability. The cause of the failure of the two level instruments associated with RPS Trip system 'A' is under investigation."

The level channels are being calibrated prior to changing to mode 1 (power operations). The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 51184
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: NATHAN LITTERST
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/27/2015
Notification Time: 06:40 [ET]
Event Date: 06/26/2015
Event Time: 21:49 [CDT]
Last Update Date: 06/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VIVIAN CAMPBELL (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

Event Text

SEISMIC MONITOR DECLARED NON FUNCTIONAL

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) as an event that will result in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g. significant portion of control room indication, Emergency Notification System or offsite notification system.)

"The emergency preparedness plan requires seismic monitoring instruments to diagnose an earthquake for emergency action levels (EAL) HU6 (Natural or destructive phenomena affecting Protected Area) and HA6 (Natural and destructive phenomena affecting Vital Areas).

"At 2149 CST on June 26, 2015, [the] ACS-8003 seismic monitor was declared non-functional due to having a fault light indicated on the C529 seismic cabinet. [The] ACS-8001 seismic monitor had previously been declared non-functional due to the same condition. With these 2 monitors out of service the seismic alarm capability is not available. ANO procedures provide compensatory measures of using offsite sources to obtain seismic data."

The NRC Resident Inspector has been notified.

* * * UPDATE ON 6/28/15 AT 1552 EDT FROM KENYON MCNEAILL TO DONG PARK * * *

"On 6/28/15 at 1232 CDT, batteries have been replaced in ACS-8001 and ACS-8003 seismic monitors. Both monitors have been restored to a fully functional status. Seismic alarm capability is restored and Emergency Assessment Capability has been restored.

The licensee will notify the NRC Resident Inspector. Notified R4DO (Campbell).

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Power Reactor Event Number: 51185
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: MARK HELLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/27/2015
Notification Time: 07:16 [ET]
Event Date: 06/26/2015
Event Time: 23:35 [EDT]
Last Update Date: 06/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID HILLS (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

BOTH AUX FEEDWATER TRAINS DECLARED INOPERABLE

"On June 26, 2015 at 2335 [EDT], with Auxiliary Feedwater (AFW) train 1 declared inoperable for scheduled surveillance testing, AFW train 2 was declared inoperable as a result of the supply breaker for SW1395, Service Water Loop 2 secondaries isolation valve, being found open, i.e. out of its required position. Limiting Condition for Operation (LCO) 3.7.5 Condition D was entered for two Emergency Feedwater Trains inoperable. AFW Train 1 and the non-safety related motor driven AFW pump were available to provide emergency feedwater if required.

"The breaker was verified to be functioning as required and then closed, restoring the safety function. All associated LCOs were exited by 0133 [EDT] on June 27, 2015."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51186
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: CHRIS ROBINSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/27/2015
Notification Time: 13:19 [ET]
Event Date: 06/27/2015
Event Time: 11:00 [EDT]
Last Update Date: 06/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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

OFFSITE NOTIFICATION MADE AFTER PORTABLE TOILET TIPPED OVER

"On 6/27/2015 at 1100 EDT, a spill to the environment was determined to be reportable to the state environmental and local health agencies. A press release is planned.

"The spill occurred when a portable chemical toilet tipped over and was identified at approximately 0925 EDT. The contents and exact quantity of the spill are unknown, but the toilet has a capacity of 60 gallons. The spill flowed to nearby gravel and two storm drains; one of which discharges to navigable state waters. Rainfall was present when the spill was identified. Cleanup efforts are in progress.

"The NRC Senior Resident Inspector has been notified."

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Power Reactor Event Number: 51187
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHAEL WATSON
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/28/2015
Notification Time: 11:24 [ET]
Event Date: 06/28/2015
Event Time: 09:00 [EDT]
Last Update Date: 06/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN ROGGE (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

CONTROL ROOM ENVIRONMENTAL BOUNDARY DOOR FOUND UNLATCHED

"During Security checks of Control Room doors, a boundary door was found not latched. This door is capable of being manually closed and latched. The door was in this condition for 4 hours and 25 minutes. The door is currently closed and latched. This is being reported as it could have prevented the fulfillment of a safety function to mitigate the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D)."

The NRC Resident Inspector has been notified.

A condition report has been written and the door is posted to require manual checks to ensure it is latched until the door closing mechanism is repaired.

Page Last Reviewed/Updated Monday, June 29, 2015
Monday, June 29, 2015