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Event Notification Report for October 23, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/22/2015 - 10/23/2015

** EVENT NUMBERS **


51355 51453 51468 51469 51470

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51355
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/27/2015
Notification Time: 20:39 [ET]
Event Date: 08/27/2015
Event Time: 13:47 [EDT]
Last Update Date: 10/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PAUL KROHN (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

BRIEF LOSS OF SECONDARY CONTAINMENT DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY

"On 8/27/2015 at 1347 [EDT], a cart and personnel were being traversed through an airlock in the Unit 2 reactor building and both airlock doors were inadvertently opened at the same time for a brief period of time (approximately one minute).

"Secondary Containment differential pressure was maintained throughout the time period that the doors were opened. The doors serve as a Secondary Containment boundary and at least one in series is required to be closed at all times for Secondary Containment Operability.

"This event is being reported under 10 CFR 50.72(b)(3)(v) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

The licensee notified the NRC Resident Inspector.

* * * RETRACTED ON 10/22/15 AT 1645 EDT FROM ALEX MCLELLAN TO DONG PARK * * *

"NUREG-1022, Revision 3, Section 3.2.7, 'Event or Condition that Could Have Prevented Fulfillment of a Safety Function,' states, in part, that 'events covered in paragraph (b)(3)(v) of this section may include one or more procedural errors, equipment failures, and/or discovery of design, analysis, fabrication, construction, and/or procedural inadequacies.'

"The level of judgment for reporting an event or condition under this criterion is a reasonable expectation of preventing fulfillment of a safety function. A SSC [System, Structure, and/or Component] that has been declared inoperable is one in which the SSC capability has been degraded to the point where it cannot perform with reasonable expectation or reliability. For SSCs within the scope of this criterion, a report is required when:
- There is a determination that the SSC is inoperable in a required mode or other specified condition in the TS [Technical Specification] applicability,
-The inoperability is due to one of more personnel errors, including procedure violations; equipment failures; inadequate maintenance; or design, analysis, fabrication, equipment qualification, construction, or procedural deficiencies, and
-No redundant equipment in the same system was operable.

"Subsequent to the reporting of this condition, Susquehanna Nuclear, LLC performed an investigation of the event. Below are the results.

"When the airlock doors were opened at the same time, they were being operated as designed. Each individual had a 'green' light, which allowed them to open each door. Based on the investigation, the doors were open at the same time for approximately one second. In summary, the inoperability of Secondary Containment was not due to personnel error or a procedure violation.

"At the time of the event, both airlock doors were operable. No equipment failures, inadequate maintenance, or design, analysis, fabrication, equipment qualification, construction, or procedural deficiencies were identified.

"In summary, based on the above, the identified condition is not reportable in accordance with 10 CFR 50.72(b)(3)(v), for an event or condition, that at the time of discovery, could have prevented the fulfillment of a safety function. As such, this 8-hour event notification is being retracted."

The licensee has notified the NRC Resident Inspector. Notified R1DO (Gray).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 10/22/2015
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."


* * * RETRACTION FROM DAN SCHWER TO STEVEN VITTO ON 10/22/2015 AT 1039 EDT * * *

"The Beaver Valley Power Station Unit 2, FirstEnergy Nuclear Operating Company (FENOC) is retracting the 8-hour non-emergency notification made on 10/05/2015 (EN 51453). This retraction is based on additional examinations and subsequent engineering assessments completed that concluded the penetrations meet the requirements of ASME Code Case N-729-1 as amended by 10CFR50.55a(g)(6)(ii)(D) and no repairs are required.

"The two reactor head penetration indications, are therefore not reportable, pursuant to 10CFR50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been notified."

R1DO(Gray) has been notified.

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Agreement State Event Number: 51468
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BASF CORPORATION
Region: 4
City: FREEPORT State: TX
County:
License #: 01021
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/14/2015
Notification Time: 09:09 [ET]
Event Date: 10/13/2015
Event Time: 13:00 [CDT]
Last Update Date: 10/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - STUCK OPEN SHUTTER ON VESSEL LEVEL GAUGE

The following report was received from the Texas Department of State Health Services via email:

"On October 13, 2015, the licensee [BASF Corporation] reported to the Agency [Texas Department of State Health Services] that during routine gauge inspection and shutter checks, its [BASF Corporation] staff found the shutter on one of its Ronan SA-1 gauges, containing a 10 milliCurie cesium-137 source, was stuck in the open position. The gauge normally operates with the gauge in the open position and due to its location on the side of a vessel there is no risk of exposure. The licensee has contacted the manufacturer to schedule repairs. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.

"Gauge/source Information: Gauge: Ronan model SA-1 -- (no unique serial number for the source holder)
"Source: 10 mCi cesium-137 -- SN: 6727GK"

Texas Incident Number: I-9347

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Agreement State Event Number: 51469
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: SAINT FRANCIS HEALTH SYSTEM
Region: 4
City: TULSA State: OK
County:
License #: OK-07163-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/15/2015
Notification Time: 12:01 [ET]
Event Date: 10/15/2015
Event Time: 10:30 [CDT]
Last Update Date: 10/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

OKLAHOMA AGREEMENT STATE REPORT - PACKAGE RECEIVED WITH EXTERNAL CONTAMINATION

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

"The State of Oklahoma Department of Environmental Quality [DEQ] was notified by Saint Francis Health System (OK-07163-01) that they have received a package with removable contamination on the exterior. The dose rate when surveyed is reported at 70 mR/hr, the wipe count was 400,000 cpm. The package contained an unknown amount of Sirtex Y-90 SirSpheres. The microsphere container is reported to be intact, and it appears that the contamination was spilled on the package after it was closed. The licensee is analyzing the wipe on an MCA [multi channel analyzer] to determine if the contamination is Y-90 or another nuclide."

The carrier who delivered the package is unknown at this time.

* * * UPDATE PROVIDED BY KEVIN SAMPSON TO JEFF ROTTON AT 1632 EDT ON 10/16/2015 * * *

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

"The contamination on the package has been identified as Tc-99m, not Y-90. The contamination was limited to a [common carrier shipping] label applied to the package at the [common carrier] facility in Boston, MA. The package was transported from Boston to Dallas, TX by [common carrier airline], then by truck from Dallas to Saint Francis. The trucking company was contacted by the licensee and the truck driver was scanned at a local hospital in Dallas yesterday; results were negative. Wipe tests of the interior of the package confirm no contamination. The package was surveyed today by DEQ inspectors and the dose rate was 2 Mr/hr. The package is being held for decay in storage at the licensee facility."

Notified R4DO (Miller) and NMSS Events Notification group via email.

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Agreement State Event Number: 51470
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO828-01
Agreement: Y
Docket:
NRC Notified By: CARRIE ROMANCHEK
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/15/2015
Notification Time: 13:55 [ET]
Event Date: 10/14/2015
Event Time: 14:30 [MDT]
Last Update Date: 10/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

COLORADO AGREEMENT STATE REPORT - PATIENT RECEIVED 40 PERCENT LESS THAN PRESCRIBED DOSE

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

"The [licensee] RSO reported that a patient received 40 percent less than the prescribed dose during a TheraSphere (Y-90) treatment on 10/14/2015. The exact cause is still under investigation.

"Initial written direction was for 120 Gy. However, due to unavailability of this dose the written directive was amended to 140 Gy and the dose was ordered.

"The AU [Authorized User] reported that stasis was not reached and it was believed the patient received the entire dose. The associated survey meter was reading 0 and the AU flushed the system 3 times - the meter continued to read 0. The procedure ended around 1430 MDT.

"After the procedure the AMP [Authorized Medical Physicist] reviewed the paperwork, took waste measurements and performed calculations. At this point 40 Gy was found in the waste. The RSO was notified at 1545 MDT."

At this time, it is not known if the patient has been notified.

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.

Page Last Reviewed/Updated Friday, October 23, 2015
Friday, October 23, 2015