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Event Notification Report for December 2, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/01/2015 - 12/02/2015

** EVENT NUMBERS **


51565 51574 51576 51577

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Agreement State Event Number: 51565
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MERCY-HEALTH - EASTGATE MEDICAL CENTER
Region: 3
City: CINCINNATI State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/24/2015
Notification Time: 15:00 [ET]
Event Date: 07/24/2014
Event Time: [EST]
Last Update Date: 11/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"The licensee performed a prostate Iodine-125 (I-125) seed implant on July 24, 2014. The prescribed dose of 144 Gray (Gy) to 90 percent of the prostate gland (D90) was not within 20 percent of prescribed dose [144 Gy prescribed, 86.1 Gy administered]. The post plan performed on August 12, 2014, demonstrated that the prostate D90 was 59.79 percent, not within 20 percent limit of the prescribed dose. The licensee did not notify the Ohio Department of Health of this occurrence as a medical event. The medical event was discovered as a result of an inspection conducted on 10/28/15.

"A Notice of Violation for the medical event and failure to report the medical event has been issued to the licensee. The investigation is ongoing."

Ohio Report: OH150012

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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Part 21 Event Number: 51574
Rep Org: UNITED CONTROLS INTERNATIONAL
Licensee: UNITED CONTROLS INTERNATIONAL
Region: 1
City: NORCROSS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROB HALE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/01/2015
Notification Time: 14:53 [ET]
Event Date: 10/12/2015
Event Time: [EST]
Last Update Date: 12/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
OMAR LOPEZ (R2DO)
HEATHER GEPFORD (R4DO)
PART 21/50.55 REACTO ()

Event Text

PART 21 REPORT - IMPROPER SILVER PLATING DURING REFUBISHMENT OF AK-25 TYPE CIRCUIT BREAKERS

The following information is a synopsis of information received via E-mail:

During refurbishment of General Electric AK-25 type circuit breakers (P/N's: AK-2A-25-1, AK-3A-25-1, and AK-7A-25-1) by United Controls International (UCI), non-current carrying/non-copper based components of the upper stud assembly were silver plated. Bubbling of the silver plating was later noted which is an indication that the plating material was not adhering to the base metal. Flaking of the silver plating material may occur and may introduce conductive foreign material into the host circuit breaker. Introduction of this conductive material could create the possibility of a short circuit of the current sensor terminal board for circuit breakers configured with RMS-9 trip units and subsequent failure of the circuit breaker.

Fort Calhoun Nuclear Station is the only known recipient of affected breakers. Fort Calhoun received 18 breakers that contained improperly silver plated components. 14 of these 18 circuit breakers have been returned to UCI. Four of the 18 circuit breakers have been installed at Fort Calhoun and UCI is currently awaiting the return of these four circuit breakers.

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Power Reactor Event Number: 51576
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JASON WILLIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/01/2015
Notification Time: 16:07 [ET]
Event Date: 12/01/2015
Event Time: 12:45 [EST]
Last Update Date: 12/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
WILLIAM COOK (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

SECONDARY CONTAINMENT INOPERABLE DUE TO REACTOR BUILDING AIRLOCK DOORS BEING OPENED SIMULTANEOUSLY

"On December 1, 2015 at 1245 EST, Secondary Containment became inoperable due to the failure to meet a Surveillance Requirement (SR 3.6.4.1.3) on Unit 2.

"The inoperability was caused when RB [Reactor Building] airlock doors were inadvertently opened simultaneously.

"Secondary Containment was restored December 1, 2015 at 1246 EST when the doors were closed.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) 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.

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Power Reactor Event Number: 51577
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: DAN GENEVA
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/01/2015
Notification Time: 20:25 [ET]
Event Date: 12/01/2015
Event Time: 18:20 [EST]
Last Update Date: 12/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
WILLIAM COOK (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP AFTER STEAM GENERATOR FEED PUMP TRIP

"On 12/01/2015 at 1820 EST, the Main Control Room received a 22 Steam Generator Feed Pump trip. The 22 Steam Generator Feed Pump was not able to be reset and the Main Control Room manually tripped the Unit 2 Reactor. The licensee entered Emergency Operating Procedure (EOP)-0, 'Post Trip Immediate Actions' and all safety functions were met.

"At 1833, Unit 2 transitioned into EOP-1, 'Uncomplicated Reactor Trip.'

At 1841, Unit 2 transitioned into Operating Procedure #4 , 'Plant Shutdown from Power to Hot Stand-by.'

"The plant is stable in Mode 3."

All control rods inserted fully on the reactor trip. No primary or secondary safety relief valves lifted. The steam generators are being fed by the 21 steam generator feed pump and decay heat is being dumped to the condenser via the steam dumps. The electric plant is in a normal shutdown electrical lineup and there was no impact on Unit 1. Unit 1 continues to operate at 100 percent power. The cause of the 22 steam generator feed pump trip is still under investigation.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, December 02, 2015
Wednesday, December 02, 2015