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Event Notification Report for October 6, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/05/2015 - 10/06/2015

** EVENT NUMBERS **


50472 51424 51427 51444 51450 51451 51453 51454 51455 51456

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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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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Agreement State Event Number: 51427
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: INVISTA CHEMICAL MANUFACTURING CO.
Region: 1
City: WILMINGTON State: NC
County:
License #: 065-2518-0G-I
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/28/2015
Notification Time: 17:29 [ET]
Event Date: 09/24/2015
Event Time: [EDT]
Last Update Date: 09/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (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 - EIGHT MISSING TRITIUM EXIT SIGNS

The following is a summary of information received from the State of North Carolina via email:

Eight new Tritium exit signs were reported missing to the State of North Carolina by the licensee. The new signs were placed in a temporary storage location during building renovations. They were discovered missing when the licensee was preparing to return old signs back to the manufacturer for disposal. The licensee believes the new signs were inadvertently discarded as trash.

All eight signs were manufactured by Isolite Corporation and each contained approximately 6.22 Curies of Tritium. The serial numbers of the missing signs are: 1203962, 1203964, 1203966, 1203961, 1203900, 1203963, 1203902, and 1203897.

North Carolina will be citing the licensee for loss of radioactive material.

NC Item Number: NC 150025

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: 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: 10/05/2015
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
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.

* * * UPDATE AT 1848 EDT ON 10/05/15 FROM JOHN RASMUSSEN TO JEFF HERRERA * * *

The licensee added 10 CFR 50.72(b)(3)(iv)(A) to the 10 CFR codes reporting section. No other text was modified.

Notified the R4DO (Taylor).

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Power Reactor Event Number: 51450
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LINDSAY GREEN
HQ OPS Officer: VINCE KLCO
Notification Date: 10/05/2015
Notification Time: 08:41 [ET]
Event Date: 10/05/2015
Event Time: 01:05 [CDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVE ORTH (R3DO)

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

Event Text

SPECIFIED SYSTEM ACTUATIONS

"Braidwood Unit 2 was performing a planned plant shutdown for refueling outage A2R18. In accordance with plant shutdown procedures while in Mode 1 (Power Operations) at approximately 15% power, operators attempted to start the Start Up Feedwater (SFWP) pump and the pump immediately tripped on Phase A Overcurrent. The 2A Motor Driven Feedwater pump (MDFWP) was manually started to maintain Steam Generator Water Level during the shutdown and subsequent plant cooldown. While in Mode 3 (Hot Standby) at [550 Degree-F], the 2A MDFWP was manually secured due to pump inboard journal bearing temperature exceeding its [200 Degree-F] operating limit. At 0105 [CDT] an anticipated automatic Auxiliary Feedwater actuation signal was generated on low Steam Generator level (36.3%) and both the 2A and 2B Auxiliary Feedwater pumps (AFP) auto-started. Also at 0105 [CDT] a Reactor Protection System (RPS) Reactor trip signal was received due to low Steam Generator level (36.3%) with the reactor not critical. Both Auxiliary Feedwater trains operated as designed with the Main Steam Dumps in service and the Main Condenser providing the heat sink.

"All systems operated as designed with the exception of the SFWP and the MDFWP described above.

"The plant is currently stable in Mode 5 with both AFPs secured.

"This report is being made per 10 CFR 50.72(b)(3)(iv)(A) for automatic actuation of the (1) RPS Reactor Trip with the reactor not critical and (6) Auxiliary Feedwater System, 8 hour notification."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51451
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN MICHAEL
HQ OPS Officer: VINCE KLCO
Notification Date: 10/05/2015
Notification Time: 10:00 [ET]
Event Date: 08/07/2015
Event Time: 19:19 [EDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DAVID AYRES (R2DO)

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

60-DAY OPTIONAL TELEPHONE NOTIFICATION FOR AN INVALID CONTAINMENT ISOLATION ACTIVATION

"This 60-day telephone notification is being submitted in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to report an invalid actuation of the Unit 2, Train B Containment Ventilation Isolation (CVI) at Sequoyah Nuclear Plant.

"At 1919 EDT on August 7, 2015, during planned performance of a Unit 2 containment vent, the Train B CVI actuated due to an invalid Hi Rad signal from 2-RM-90-131, Containment Vent Radiation Monitor. In addition to the Train B CVI alarm, unexpected alarms were received for 2-RM-90-106, Lower Containment Radiation Monitor and 2-RM-90-112, Upper Containment Radiation Monitor instrument malfunctions as they isolated for the CVI and 2-RM-90-131 Hi Rad alarm. Prior to the invalid Hi Rad alarm, all radiation monitors were stable at their normal values. All required automatic actuations occurred as designed. Upon investigation, the cause of the invalid Hi Rad alarm was due to an exposed shield wire at the 2-RM-90-131 detector. Preventative maintenance had been performed the week prior to the CVI and it is believed the damage occurred at that time.

"Control Room Operators performed Annunciator Response actions and verified by diverse indications that the subject condition was an invalid Hi Rad signal. There were no indications of degraded reactor coolant system parameters or fuel failure. Applicable Technical Specification (TS) Limiting Condition for Operations (LCOs) were entered and the radiation monitors declared inoperable. No Emergency Response criteria were applicable with the subject radiation monitors inoperable. Radiological surveys performed in the vicinity of 2-RM-90-131 verified no abnormal radiological conditions.

"Radiation Monitor 2-RM-90-131 was removed from service, the shield wire was repaired and returned to service with no issues. Radiation Monitors 2-RM-90-106 and 2-RM-90-112 were tested and returned to service. The applicable TS LCOs were exited. At the time of the event, plant conditions for a Hi Rad alarm did not exist; therefore, the CVI was invalid.

"The NRC Resident Inspector was notified."

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Power Reactor Event Number: 51453
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JUSTIN E. CROCKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/05/2015
Notification Time: 15:01 [ET]
Event Date: 10/05/2015
Event Time: 08:15 [EDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BRICE BICKETT (R1DO)

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

Event Text

TWO REACTOR VESSEL HEAD PENETRATIONS COULD NOT BE DISPOSITIONED AS ACCEPTABLE

"On 10/5/2015, during the Beaver Valley Power Station Unit No. 2 (BVPS-2) refueling outage, while performing planned ultrasonic examinations (UT) on the 66 reactor vessel head penetrations, it was determined, that two penetrations could not be dispositioned as acceptable per ASME [American Society of Mechanical Engineers] Code Section XI in a Reactor Coolant System pressure boundary. The indications of a degraded condition, on these two penetrations, are not through wall, as no leak path was identified. The examinations are being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D), and ASME Code Case N-729-1, to find potential flaws/indications well before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. All 66 reactor vessel head penetrations are scheduled to be examined during the current refueling outage.

"The plant is currently shutdown and in Mode 6. The reactor vessel head is not currently installed. Repairs are currently being planned and will be completed prior to startup.

"This is reportable, pursuant to 10 CFR 50.72(b)(3)(ii)(A) since the as found indications did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-1 to remain in-service without repair.

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 51454
Rep Org: AZZ/NUCLEAR LOGISTICS INC
Licensee: AZZ/NUCLEAR LOGISTICS, INC.
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/05/2015
Notification Time: 17:47 [ET]
Event Date: 10/05/2015
Event Time: [CDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
NICK TAYLOR (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 - ELECTRONIC POSITION CONTROLLER FAILED INTERNAL COMPONENT

The following was excerpted from a fax received from the licensee:

"NLI manufactured the reverse engineered units to replace the existing obsolete electronic position controller NLI Model: NLI-10A-LM-P.

"The failed component within the controller was sized based on the original published ratings of the original components installed. The unit had an internal component that was subjected to a current value that was higher than the rating for the component. The actual applied current value was not originally provided to NLI when the units were being designed. NLI and the affected plant has been in communication regarding the component condition since the first reported failure.

"Three of units that initially failed in the plant have already been returned to NLI for failure analysis and design modifications. These units were modified by installing a larger bridge rectifier and wire wound resistor onto the revision 0 circuit board. The modified versions, quantity of three, S/N: NLI-10A-LM-P-1003- 0, NLI-10A-LM-P-1004-0 and NLI-10A-LM-P-1006-0 have been returned to Calloway under purchase orders 689233 SR and 694253 SR and have been accepted and installed into the plant and are working with no reported issues.

The model number NLI-10A-LM-P, has been redesigned with a larger bridge rectifier of a higher rating and wire wound resistor that will withstand the applied current in the intended application. The parent circuit board has also been revised to revision 1 to accept the larger bridge rectifier without impacting other components on the board.

The remaining unmodified revision 0 units that were originally supplied have not yet been returned to NLI for incorporation of the design modification. NLI recommends that at the plant's earliest convenience, the remaining units be returned to NLI to be retrofitted with the latest design configuration (revision 1 circuit board)."

The affected plant is Callaway.

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Power Reactor Event Number: 51455
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ALBERTO SANCHEZ
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/05/2015
Notification Time: 21:47 [ET]
Event Date: 10/05/2015
Event Time: 21:15 [EDT]
Last Update Date: 10/06/2015
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
BRICE BICKETT (R1DO)
DAN DORMAN (RA)
ALLEN HOWE (NRR)
BILL DEAN (NRR)
WILLIAM GOTT (IRD)

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

ALERT DECLARATION DUE TO FIRE IN THE AUXILIARY BUILDING

"At 2115 [EDT] on 10/05/15, an Alert was declared due to a fire in the Auxiliary building affecting DC-P-1A [Decay closed cooling pump 1A] and A-Train safety equipment. The fire is out."

The licensee reported the fire was extinguished at approximately 2201 EDT. The fire did not hamper operations personnel responding to the fire. Offsite fire assistance was requested.

The NRC Resident Inspector will be notified.

The licensee notified the York Haven Power Station, PEMA (Pennsylvania Emergency Management Agency), and the counties of Cumberland, Lebanon, Lancaster, York, and Dauphin.

Notified DHS, FEMA, USDA, HHS, DOE, DHS NICC, EPA EOC, FEMA NWC (via email), FDA EOC (via email) and Nuclear SSA (via email).

* * * UPDATE AT 0015 EDT ON 10/06/15 FROM JAMES CREIGHTON TO S. SANDIN * * *

The licensee is terminating the Alert at 0009 EDT on 10/06/15 based on the following:

"At 2115 [EDT] on 10/05/15, an Alert (HA3) was declared due to a fire in the Decay Closed Cooling Water Pump '1A' motor and breaker. The fire was extinguished at 2201 [EDT].

"Following inspection by electrical maintenance the 'P' 480V bus was re-energized at 2305 [EDT] and restoration of previously running loads is in progress.

"Station (TMI) is in a 72-hour LCO for repairs to the Decay Closed Cooling Water Pump '1A' (DC-P-1A).

"TMI (Three Mile Island) is terminating the event based upon the above information."

The licensee notified the York Haven Power Station, PEMA (Pennsylvania Emergency Management Agency), and the counties of Cumberland, Lebanon, Lancaster, York, and Dauphin. The licensee will issue a press release.

The licensee informed the NRC Resident Inspector. Notified R1DO (Bickett), NRR (Howe) and IRD (Gott).

Notified DHS, FEMA, USDA, HHS, DOE, DHS NICC, EPA EOC, FEMA NWC (via email), FDA EOC (via email) and Nuclear SSA (via email).

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Power Reactor Event Number: 51456
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KENNETH GRACIA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/05/2015
Notification Time: 21:48 [ET]
Event Date: 10/05/2015
Event Time: 17:25 [EDT]
Last Update Date: 10/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BRICE BICKETT (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

SAFE SHUTDOWN ANALYSIS FOR FIRE EVENT - OPEN ITEM WITH POTENTIAL TO IMPACT CAPABILITY TO OPERATE MOTOR OPERATED VALVES

"At 1725 [EDT] on Monday, October 5, 2015, while updating the site fire safe shutdown analysis report, Pilgrim Nuclear Power Station (PNPS) identified vulnerabilities in two (2) specific fire areas that required a compensatory fire watch. The compensatory fire watches have already been established.

"The specific concern involves the unlikely scenario that fire forces evacuation of the control room. In addition, it is postulated that motor operated valves cannot be operated from their alternate control location due to spurious operation caused by hot shorts in control wiring. The specific failure mode is described in NRC Information Notice (IN) 92-18.

"Engineering modifications are under development and scheduled for implementation to address this specific IN 92-18 concern.

"Based on the above, the condition is reportable to the NRC as an unanalyzed condition that significantly degrades plant safety. As such the condition is reportable under 50.72(b)(3)(ii)(B), and requires an 8 hour notification.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Tuesday, October 06, 2015
Tuesday, October 06, 2015