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Event Notification Report for October 5, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/02/2015 - 10/05/2015

** EVENT NUMBERS **


50472 51424 51439 51440 51444 51445 51447 51448 51449

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 50472
Rep Org: MONONGALIA GENERAL HOSPITAL
Licensee: MONONGALIA GENERAL HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 13:56 [ET]
Event Date: 09/19/2014
Event Time: [EDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHNATHAN LILLIENDA (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

BRACHYTHERAPY PATIENT RECEIVED 54% OF PRESCRIBED DOSE

The authorized user determined that, due to scar tissue from a previous procedure, the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.

The investigation into the event is ongoing.

* * * RETRACTION FROM MARK PENA TO HOWIE CROUCH AT 1458 EDT ON 9/30/15 * * *

Upon investigation of the details surrounding the event, it was determined that the patient received greater than 80% of prescribed activity. Therefore, this event no longer meets any regulatory reporting criteria and is being retracted.

Notified R1DO (Bower) and NMSS Events Resource via email.

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: 51424
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ODH PUBLIC HEALTH LEAD INVESTIGATION PROGRAM
Region: 3
City: CHILLICOTHE State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/25/2015
Notification Time: 09:14 [ET]
Event Date: 09/23/2015
Event Time: [EDT]
Last Update Date: 09/25/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
CANADA (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN GENERAL LICENSED MATERIAL

The following information was provided by the State of Ohio via email:

"Sometime between 2330 EDT pm on 9/22/15 and 0430 EDT on 9/23/15, a vehicle maintained by a staff member of the ODH [Ohio Department of Health] Public Health Lead Investigation Program was broken into at their residence in Chillicothe, Ohio. A NITON X-Ray Fluorescence (XRF) lead-based analyzer (SN 92956) containing a Cadmium-109 radioactive source with a maximum activity of 50 mCi [was stolen]. The XRF device was in a locked pelican case in the locked trunk of the vehicle. The theft was reported to local law enforcement and to the Ohio State Highway Patrol. The device has not been recovered as of the date of this report (9/25/15)."

OH Reference Number: 2015-014

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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Power Reactor Event Number: 51439
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: LAUREL KETCHAM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/02/2015
Notification Time: 10:27 [ET]
Event Date: 10/02/2015
Event Time: 09:05 [CDT]
Last Update Date: 10/03/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
NICK TAYLOR (R4DO)
MARC DEPAS (RA)
BILL DEAN (NRR)
BRIAN HOLIAN (NSIR)
ROB LEWIS (NSIR)
DARYL JOHNSON (ILTA)
WILLIAM GOTT (IRD)
BERN STAPLETON (NSIR)

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

NOTIFICATION OF UNUSUAL EVENT

At 0905 CDT on 10/02/15, Ft. Calhoun Station declared a Notification of Unusual Event based on criteria in the site security plan.

The licensee notified State and local agencies and the NRC Resident Inspector.

Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.

* * * UPDATE FROM LAUREL KETCHAM TO DANIEL MILLS AT 1214 EDT ON 10/02/15 * * *

At 1136 CDT, the Unusual Event was terminated based on the fact that criteria for entry into the site security plan no longer exists.

The licensee notified State and local agencies and the NRC Resident Inspector.

Notified R4DO (Taylor), R4RA (Dapas), NRR ET (Dean), NSIR ET (Holian), NSIR (Lewis, Stapleton), ILTAB (Johnson), IRD MOC (Gott).

Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.

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Power Reactor Event Number: 51440
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: CHRIS ROBINSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/02/2015
Notification Time: 14:50 [ET]
Event Date: 10/02/2015
Event Time: 08:25 [EDT]
Last Update Date: 10/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
STEVE ORTH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

LOOSE SAFETY RELIEF VALVE DISCHARGE FLANGE BOLTS

"On October 2nd, at approximately 0825 EDT, maintenance technicians were performing as-found torque checks on the discharge flange of the 'B' Safety Relief Valve (SRV). 12 of the 16 bolts were not adequately torqued. The 'B' Safety Relief Valve is credited for Remote Shutdown. The as-found condition of inadequate torque potentially impacts the seismic qualification of the 'B' SRV.

"An investigation and extent of condition review is ongoing. The NRC Resident Inspector has been notified."

Before the outage, there were no abnormal indications of leakage as indicated by a rise in drywell temperature or pressure. The SRVs had been cycled under pressure with no abnormal indications.

The four bolts that were tight were in a diagonal pattern. The looses bolts were described as "finger tight." The licensee is determining the actions to take regarding the remaining 14 SRVs.

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Power Reactor Event Number: 51444
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN RASMUSSEN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/03/2015
Notification Time: 12:02 [ET]
Event Date: 10/03/2015
Event Time: 10:00 [CDT]
Last Update Date: 10/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
NICK TAYLOR (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 47 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DURING SHUTDOWN FOR A REFUELING OUTAGE

"During the scheduled Unit 2 down power to start 2RF15, Steam Generator 3 Feed Control Valve failed to control in Automatic or Manual resulting in excessive feedwater flow. Control Room Operators manually tripped the reactor and aligned Auxiliary Feedwater. No automatic RPS or ESF actuations occurred. Plant conditions are stable."

All control rods fully inserted on the trip and no safety or relief valves lifted. The plant is supplying water to the steam generators with auxiliary feedwater and removing decay heat through the main condenser. The unit is in its normal shutdown electrical lineup. There was no effect on unit-1.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 51445
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JOSH MCGUIRE
HQ OPS Officer: DANIEL MILLS
Notification Date: 10/03/2015
Notification Time: 14:46 [ET]
Event Date: 10/03/2015
Event Time: 10:25 [EDT]
Last Update Date: 10/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
FRED BOWER (R1DO)

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

FITNESS FOR DUTY - CONFIRMED POSITIVE FFD TEST

A non-licensed supervisory employee had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The employee's access to the plant has been restricted.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51447
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: LEIA MILSTER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/04/2015
Notification Time: 03:51 [ET]
Event Date: 10/03/2015
Event Time: 23:07 [CDT]
Last Update Date: 10/04/2015
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):
NICK TAYLOR (R4DO)

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

AUTOMATIC REACTOR TRIP

"At 2307 CDT Waterford 3 experienced an automatic reactor trip and all Control Element Assemblies (CEAs) inserted into the core. The cause of the automatic reactor trip is currently under investigation.

"The plant is currently in Mode 3 [Hot Standby] and stable with Main Feedwater feeding and maintaining both Steam Generators. Main Feedwater Pump 'A' tripped subsequent to the reactor trip. Emergency Feedwater actuated following the plant trip as expected, but was not required to maintain Steam Generator level.

"The plant entered the Emergency Operating Procedure for an uncomplicated reactor trip and has now transitioned to the normal operating shutdown procedure."

Unit 3 is in a normal post trip electrical lineup. The Main Condenser is in-service removing decay heat..

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 51448
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: FRED PERKINS
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/04/2015
Notification Time: 10:03 [ET]
Event Date: 10/04/2015
Event Time: 09:32 [EDT]
Last Update Date: 10/04/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
FRED BOWER (R1DO)
SCOTT MORRIS (NRR)
MICHELE EVANS (NRR)
DAN DORMAN (R1RA)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

UNUSUAL EVENT DECLARED DUE TO IDENTIFIED RCS LEAKAGE > 25 GPM

At 0932 EDT on 10/4/15, the licensee declared an Unusual Event for identified RCS [Reactor Coolant System] leakage exceeding 25 gallons per minute [GPM], per EAL BU2, due to a relief valve leaking on the Shutdown Cooling System common header. The RCS leakage was within the capacity of the Charging System. At 0954 EDT the RCS leakage was terminated by isolating the Shutdown Cooling System. The cause of the relief valve failure is unknown and under investigation.

The RCS cooldown was terminated and both RCS loops were restored to service for decay heat removal using both Steam Generators and the Main Condenser. Current RCS temperature is 248 degrees F with RCS pressure at 248 psig. All offsite power and EDGs [Emergency Diesel Generators] are available.

The licensee intends to repair the relief valve to resume the RCS cooldown using the shutdown cooling system..

The licensee informed State and local agencies and the NRC Resident Inspector.

Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.

* * * UPDATE AT 1115 EDT ON 10/04/15 FROM FRED PERKINS TO S. SANDIN * * *

The licensee terminated the Unusual Event at 1100 EDT, based on verification that the RCS leakage was stopped.

The licensee informed State and local agencies and the NRC Resident Inspector.

Notified R1DO (Bower), NRR EO (Morris), and IRD (Gott).

Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.

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Power Reactor Event Number: 51449
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/04/2015
Notification Time: 14:16 [ET]
Event Date: 10/04/2015
Event Time: 09:56 [EDT]
Last Update Date: 10/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
STEVE ORTH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

SECONDARY CONTAINMENT INOPERABLE WITH THE POTENTIAL TO DRAIN THE REACTOR VESSEL

"On October 4th, at approximately 0956 EDT, 'Operations with the Potential to Drain the Reactor Pressure Vessel' (OPDRV) was unintentionally initiated without secondary containment operable. Operators promptly identified the condition and immediately initiated actions to identify and suspend the source of the drain path. At approximately 1120 EDT the source of the OPDRV was isolated. Reactor cavity water level and spent fuel pool level remained constant throughout the event. An investigation is in progress.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, October 05, 2015
Monday, October 05, 2015