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Event Notification Report for June 30, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/29/2015 - 06/30/2015

** EVENT NUMBERS **


51028 51166 51167 51169 51190

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51028
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT MELTON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/01/2015
Notification Time: 08:36 [ET]
Event Date: 04/30/2015
Event Time: 23:44 [CDT]
Last Update Date: 06/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GEOFFREY MILLER (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

Event Text

HIGH PRESSURE CORE SPRAY SYSTEM INOPERABLE

"River Bend Station personnel declared the High Pressure Core Spray (HPCS) system inoperable at 2344 CDT on 4/30/2015.

"The HPCS system at River Bend Station includes a test return line to the Condensate Storage Tank (CST). The test return line is isolated by two motor operated valves (E22-MOVF010 and E22-MOVF011), with both having a safety function to close on an ECCS initiation signal to ensure that injection flow is directed to the reactor vessel. There is currently a blind flange installed downstream of these two valves. While the HPCS pump is normally aligned to the CST, the credited source of water for the pump is the suppression pool. Accordingly, the pump suction is realigned to the suppression pool on low level in the CST or when suppression pool level rises to a certain point. While performing maintenance on the downstream test return valve (E22-MOVF011), station personnel identified leakage past the upstream test return valve (E22-MOVF010) which was being used as an isolation boundary. In evaluating this condition, engineering personnel noted that the observed leakage past the upstream isolation MOV might be sufficient to deplete suppression pool inventory such that it would not be capable of performing its specified function for the duration of the 30-day mission time. The issue of concern is that once HPCS is aligned to the suppression pool post-LOCA, pool inventory would be lost due to the leaking upstream isolation valve (E22-MOVF010) and out the disassembled downstream isolation valve (E22-MOVF011).

"Based on that concern, the HPCS pump suction valve from the suppression pool was disabled in the closed position to preserve pool inventory. This action caused the HPCS system to be declared inoperable at 2344 CDT. This action results in a 14 day shutdown LCO and is reportable to the NRC in accordance with 10CFR50.72(b)(3)(v)D.

"The HPCS pump remained available with its suction aligned to the CST.

"Message has been left with NRC Senior Resident Inspector."

* * * RETRACTION AT 1009 EDT ON 6/29/2015 FROM MICHAEL BRANSCUM TO MARK ABRAMOVITZ * * *

"The licensee is retracting the report for Event No. 51028.

"On April 28, the High Pressure Core Spray System (HPCS) was inoperable to support planned maintenance. During repairs on the HPCS pump test return valves, leakage through the upstream isolation valve was observed when the downstream valve was disassembled. At 2315 [CDT] on April 30, it was conservatively determined that the leakage represented a potential challenge to the 30-day inventory of the suppression pool, and the pool was declared inoperable. At 2344 [CDT] on April 30, the HPCS pump suction valve to the suppression pool was closed to isolate that potential leakage path until the maintenance could be completed. This action returned the suppression pool to an operable status.

"On June 24, a quantitative leak rate test was performed on the upstream isolation valve (E22-MOVF010). That test determined that the leakage through the valve was not of such magnitude to have had the potential to deplete the 30-day inventory of the suppression pool during post-accident operation of the HPCS system. Additionally, when the HPCS pump suction valve on the suppression pool was closed on April 30, the system was already in a planned outage that commenced on April 28. As such, this condition need not have been reported."

The licensee notified the NRC Resident Inspector.

Notified the R4DO (Campbell).

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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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Agreement State Event Number: 51169
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: NUCOR-YAMATO STEEL COMPANY
Region: 4
City: BLYTHEVILLE State: AR
County:
License #: ARK-0722-0312
Agreement: Y
Docket:
NRC Notified By: SUSAN ELLIOTT
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/22/2015
Notification Time: 11:29 [ET]
Event Date: 06/18/2015
Event Time: 12:30 [CDT]
Last Update Date: 06/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR FIXED GAUGE DAMAGED

The following report was provided by the Arkansas Department of Health via email:

"Nucor-Yamato Steel Company, Arkansas Radioactive Materials Licensee Number ARK-0722-03120, notified the Arkansas Department of Health, Radioactive Materials Program, via phone on Friday, June 19, 2015, at 1000 [CDT], of damage to one of their fixed gauges, manufacturer Ronan, Model #SA-1-F37, Serial #1224CG with a 5 Curie CS-137 source. The event occurred on June 18, 2015 at approximately 1230 [CDT]. Licensee reported a wash-out of liquid steel which came into contact with the gauge. There was approximately 30 tons of molten rock (2800 F) flowing onto the floor of the plant which caused a fire. Surrounding gauges were not affected.

"The Licensee immediately closed the shutter, but was not sure if it was completely shut. The RSO indicated the only radiation levels were from the top of the gauge, nothing was measured on the sides. A steel plate was placed on top of the gauge to reduce radiation levels. The area was roped-off at 2 mR/hr to prevent public exposures. Chase Environmental Consulting was notified of the damaged gauge and arrived on Friday, June 19, 2015 to investigate and remove the gauge out-of-service.

"The gauge is currently in storage awaiting the manufacturer (Ronan) to arrive to package for shipment on Friday, June 26, 2015.

"The State is awaiting a written report from the licensee and will continue to investigate this event. The State will update this event as more information becomes available.

"Arkansas Event Number: ARK-2015-008"

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Part 21 Event Number: 51190
Rep Org: ABB, INC.
Licensee: ABB, INC.
Region: 1
City: CORAL SPRINGS State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DENNIS BATOVSKY
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2015
Notification Time: 17:16 [ET]
Event Date: 06/29/2015
Event Time: [EDT]
Last Update Date: 06/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
KATHLEEN O'DONOHUE (R2DO)
LAURA KOZAK (R3DO)
NEIL OKEEFE (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 NOTIFICATION OF DEVIATION REGARDING COM-5 PROTECTIVE RELAY DEFECTIVE FRAME ASSEMBLY

The following information was provided by ABB via fax:

"This letter provides notification of a deviation for Class IE COM-5 (Long Time Overcurrent Relays) styles 1326D81A01, 1326D81A02, and 326D81A09.

"On April 30, 2015, ABB received a customer complaint regarding a COM-5 relay received with a bracket (ABB Part Number #3518A17H01) detached from the relay frame assembly (ABB Part Number #1456C92G01).

"ABB's investigation determined that the bracket, which is spot-welded to the frame, can be detached from the frame using a relatively small amount of force. If the weld fails, the Indicating Contactor Switch (ICS) unit held by the bracket could inadvertently close, causing a false trip. The affected frame assemblies were manufactured by ABB on 9/25/2014 (Lot#: 45001414115) by an operator who incorrectly followed the inspection procedure required to verify the integrity of the resistance spot welds.

"ABB records show a total of 11 suspect relays were provided to two customers as detailed in attachment 1 [BELOW].

"ABB does not have the capability to perform the evaluation to determine if a defect exists, thus we are notifying the purchasers or affected licensees of this determination so that they may evaluate the deviation, pursuant to 10 CFR 21.21(b).

"ABB recommends that the affected licensees evaluate their specific application and determine whether the deviation described in this notice affects their design basis. If it is determined that it does, the licensees should contact ABB to determine appropriate corrective action. ABB is conducting the following actions:
- ABB has improved existing inspection processes used to verify resistance spot welds.
- ABB has performed an extent of condition evaluation and determined that this issue is limited to this process.

"If you have any questions regarding this notice, please contact ABB Technical Support at +1-954-752-6700 or+ 1-800-222-1946

"Very truly yours,

"Dennis Batovsky - Managing Director

"ATTACHMENT 1

"Customer List for 1326D81A01, 1326D81A02 and 1326D81A09 COM-5 Relays

"Exelon Business Services Corporation, Chicago, IL - Clinton Nuclear Station

"ORDER / CUSTOMER PO / DATE / STYLE / SERIAL NO. / QTY

"ENW0716 / 00531032 Rev 001 / 9-26-2014 / 1326D81A01 / 12910-12912 / 3
"ENW0742 / 00541813 Rev 002 / 3-3-2015 / 1326D81A01 / 12938, 12939 / 2

"Westinghouse Electric Corporation, New Stanton, PA

"ORDER / CUSTOMER PO / DATE / STYLE / SERIAL NO. / QTY

"VEP10980 / 4500653421 Rev 1 / 12-8-2014 / 1326D81A02 / 12928, 12929 / 2
"VEP10976 / 4500653398 Rev 1 / 12-8-2014/1326D81A02 / 12925-12927 / 3
"VEP11168 / 4500657304 rev 1 / 1-20-2015 / 1326D81A09 / 12919 / 1"

Page Last Reviewed/Updated Tuesday, June 30, 2015
Tuesday, June 30, 2015