United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > February 29

Event Notification Report for February 29, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/26/2016 - 02/29/2016

** EVENT NUMBERS **


51391 51743 51744 51745 51746 51751 51757 51760

To top of page
Power Reactor Event Number: 51391
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: CHRIS ROBINSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/14/2015
Notification Time: 02:46 [ET]
Event Date: 09/13/2015
Event Time: 23:05 [EDT]
Last Update Date: 02/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
PATTY PELKE (R3DO)
SCOTT MORRIS (NRR)
JEFFERY GRANT (IRD)

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

Event Text

MANUAL SCRAM DUE TO LOSS OF TURBINE BUILDING CLOSED COOLING WATER

"At 2305 EDT on September 13, 2015, a manual scram was initiated in response to a loss of all Turbine Building Closed Cooling Water (TBCCW). All control rods fully inserted. The lowest Reactor Water Level (RWL) reached was 137 inches. All isolations and actuations for RWL 3 occurred as expected. Decay heat was initially being removed through the Main Turbine Bypass System to the Main Condenser, however, as a result of the loss of TBCCW, the Main Feed Pumps lost cooling and had to be secured. At 2310, Standby Feedwater was initiated and Main Feedwater was secured.

"The loss of TBCCW also caused all Station Air Compressors (SACs) to trip on loss of cooling. The loss of SACs caused the Instrument Air header pressure to degrade to the point at which the Secondary Containment isolation dampers drifted closed. This resulted in the Reactor Building vacuum exceeding the Technical Specification limit. At 2325, operators started the Standby Gas Treatment system and manually initiated a Secondary Containment isolation signal. Secondary Containment vacuum was promptly restored to within Technical Specification limits. Additionally, Operators were monitoring for expected MSIV drift due to the degraded Instrument Air header pressure. When outboard MSIVs were observed to be drifting, Operators closed the outboard and inboard MSIVs at 2345. At 2352, Safety Relief Valves (SRVs) reached the Low-Low Setpoint and began cycling to control reactor pressure.

"RWL is currently being maintained in the normal level band with the Standby Feedwater and Control Rod Drive systems. Reactor Pressure is being controlled with Safety Relief Valves. Operators are currently in the Emergency Operating Procedure for Reactor Pressure Vessel control. Investigation into the loss of TBCCW continues.

"No safety-related equipment was out of service at the time of the event. All offsite power sources were adequate and available throughout the duration of the event.

"The NRC resident inspector has been notified."

* * * UPDATE AT 0555 EDT AT 09/14/15 FROM CHRIS ROBINSON TO JEFF HERRERA * * *

"At 0409 EDT the Reactor Core Isolation Cooling (RCIC) system was placed in service due to identification of an unisolable leak in the Standby Feedwater System. Reactor water level and pressure is now being controlled though the RCIC system and Safety Relief Valves. This event update is reportable as a valid manual initiation of a specified safety system under 10CFR50.72(b)(3)(iv)(A).

"The NRC resident inspector has been notified."

The leak rate was reported as approximately 5-10 gallons per minute from a weld on the standby feedwater pump header drain valve F326. The licensee reported the leak stopped once RCIC was placed into service. The licensee is still investigating the issue.

Notified the R3DO (Pelke), IRD Manager (Grant), NRR EO (Morris).

* * * UPDATE PROVIDED BY CHRIS ROBINSON TO JEFF ROTTON AT 2135 EDT ON 09/14/2015 * * *

"At 1847 EDT on September 14, 2015, a valid automatic Reactor Protection System (RPS) actuation occurred due to Reactor Water Level 3 while shutdown in MODE 3. Operators were manually controlling Reactor Pressure Vessel (RPV) level and pressure with Reactor Core Isolation Cooling (RCIC) and Safety Relief Valves (SRV). While operators were cycling SRVs, the RPV level went below the Level 3 setpoint. Operators promptly restored RPV level by manual operation of RCIC. The Level 3 actuation and associated isolations were verified to operate properly.

"The scram signal has been reset. Fermi 2 remains in MODE 3 controlling RPV Level and Pressure through manual operation of RCIC and SRVs.

"This is the second occurrence of a valid specified safety system actuation reportable under 10CFR50.72(b)(3)(iv)(A) for this ongoing event.

"The NRC Resident Inspector has been notified."

Notified R3DO (Riemer), IRD Manager (Grant), and NRR EO (Morris)

* * * UPDATE FROM BRETT JEBBIA TO JOHN SHOEMAKER AT 1446 EST ON 2/27/16 * * *

"This update provides clarification of the applicable reporting criteria for this Event associated with primary containment isolation actuations.

"Upon the manual reactor scram at 2305 EDT on September 13, 2015, Reactor Protection System (RPS) Level 3 actuated and Primary Containment Isolation System (PCIS) Groups 4, 13 and 15 actuated as expected. The applicable reporting criterion for these actuations is 10 CFR 50.72(b)(3)(iv)(A).

"The applicable reporting criterion for the manual closure of the inboard and outboard main steam isolation valves at 2345 EDT on September 13, 2015, is also 10 CFR 50.72(b)(3)(iv)(A). In addition, the manual closures of all MSIV lead to a loss of condenser vacuum which resulted in the actuation of PCIS Group 1 at 0001 EDT on September 14, 2015, as expected. The applicable reporting criterion for this actuation is also 10 CFR 50.72(b)(3)(iv)(A).

"Upon reaching Level 3 at 1847 EDT on September 14, 2015, PCIS Groups 4, 13 and 15 actuated as expected. The applicable reporting criterion for this actuation is 10 CFR 50.72(b)(3)(iv)(A).

"The licensee informed the NRC Resident Inspector."

Notified the R3DO (Stone).

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Part 21 Event Number: 51743
Rep Org: NUCLEAR LOGISTICS INC
Licensee: NUCLEAR LOGISTICS INC
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/18/2016
Notification Time: 18:29 [ET]
Event Date: 02/18/2016
Event Time: [CST]
Last Update Date: 02/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
GLENN DENTEL (R1DO)
SHANE SANDAL (R2DO)
ROBERT ORLIKOWSKI (R3DO)
GREG WERNER (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 - CONTACTOR MAKING NOISE

The following was received via fax:

"Initial notification of a potential 10 CFR Part 21 condition.

"Pursuant to the rules of 10 CFR 21.21 this initial notification is being submitted to the NRC to identify a potential reportable condition that is currently under evaluation.

"FPL [Florida Power & Light] Turkey Point has identified a contactor that was making a considerable amount of noise that was not expected. The unit was continuing to functionally operate, however the source of the noise is cause for investigation.

"The contactors are a non-standard Size 3 and Size 4 Freedom Series Starter/Contactor. These units are currently under evaluation and review by NLI [Nuclear Logistics Inc.] to determine the root cause of the identified condition to determine if the contactor contains a defect.

"To date there have been no reported failures of this item to perform the intended safety function. These components were first supplied in September 2002 to Duke Oconee with no reported issues identified. The units reported by FPL Turkey point were supplied in May and December 2011. They have been installed into other facilities including the Duke Shearon Harris plant in December 2013. Although the increased noise is undesirable, it is not presenting a significant condition adverse to quality that could create a substantial safety hazard. Preliminary testing has confirmed that the safety related performance characteristics have not been degraded. However, due to the number of utilities which may have these components in service, this notification is being submitted to identify the condition to the industry.

"NLI plans to have the completed report submitted by 3/15/2016."

* * * RETRACTION FROM TRACY BOLT TO JOHN SHOEMAKER AT 1847 EST ON 2/26/16 * * *

This retraction is a brief summary from a report received from Nuclear Logistics Inc. via email:

"This retraction is being submitted to the NRC to provide additional information for the initial notification provided on 2/18/2016. After evaluating the identified condition, it has determined that there is no defect within the contactor that if left uncorrected would create a substantial safety hazard. This issue is not considered reportable per the rules of 10 CFR Part 21."

Notified R1DO (Ferdas), R2DO (Shaeffer), R3DO (Stone), R4DO (Whitten), and Part 21/50.55 Reactors via email.

To top of page
Agreement State Event Number: 51744
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: INTERNATIONAL PAPER
Region: 1
City: GEORGETOWN State: SC
County:
License #: 060
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/19/2016
Notification Time: 11:38 [ET]
Event Date: 02/18/2016
Event Time: 21:27 [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TWO UNUSED PROCESS GAUGES SENT TO SCRAP YARD

International Paper performed an inventory of their sources and realized that while performing demolition work at their facility, two unused process gauges were removed from the site. The removal of the gauges was outside the scope of the demolition work. The two process gauges were located on long poles, were removed from the site using a crane, and were sent to a nearby scrap yard. The South Carolina Division of Health and Environmental Control sent an inspector to the scrap yard and he was able to find and recover both gauges. The shutter on one gauge had remained closed and the second gauge shutter was partially open and reading 50 mR/hour on contact. The first gauge was recovered at 1220 EST and the second gauge was recovered at 1315 EST and the shutter was shut. Wipe tests on both gauges were negative. The gauges were returned to International Paper and are locked in a secure location. No personnel exposures were expected from this incident.

Gauges:
Cs-137
50 mCi each (in 1988)
TN Tech Model 5219
Serial Numbers: TNB61 and TNB64

To top of page
Agreement State Event Number: 51745
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: 21ST CENTURY ONCOLOGY
Region: 1
City: PLANTATION State: FL
County:
License #: 2499-1
Agreement: Y
Docket:
NRC Notified By: KELLIE ANDERSON
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/19/2016
Notification Time: 12:35 [ET]
Event Date: 08/27/2015
Event Time: [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following was received via email:

"On August 27th 2015, a patient with 21st [Century] Oncology who was prescribed a 67.13 mCi dose of Sm-153 received an 86.9 mCi dose. The resulting over dose was more than 29.5 [percent] of the prescribed dose. The error was discovered through discrepancies in their pharmacies inventory when a new order was created for a new patient.

"On Feb 15, 2016, [21st Century Oncology] were preparing an order for Sm-153 for a new patient. The nurse referred to the last administered Samarium case (August 27, 2015) for information on activity, patient weight and pricing. In order to clarify the relation between dosage and patient weight, he asked the physics staff to perform a second check of the records. When the requested check was done the following error was discovered.

"Upon re-evaluation of the treatment procedure, the physics staff determined that the dosage of 91 mCi received from the pharmacy was not correctly calculated for the patient weight that was specified on the original order. The pharmacy was then requested to fax back the original order (Form J). The fax which they sent confirmed the correct weight of the patient (148 lbs). For this weight a correct calculation would have indicated an activity of 67.13 mCi. Instead the pharmacy had shipped the (incorrect) activity of 91 mCi. The resulting delivered dosage was 29.5 [percent] more than the prescribed dose. Thus [the staff] concluded that a medical event had occurred.

"The Radiation Oncologist notified the referring physician on February 16, 2016. The Radiation Oncologist also will note this communication in the patient's chart."

Florida Incident Number: FL 16-029

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.

To top of page
Agreement State Event Number: 51746
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UF HEALTH SHANDS CANCER HOSPITAL
Region: 1
City: GAINESVILLE State: FL
County:
License #: 3157-1
Agreement: Y
Docket:
NRC Notified By: KELLIE ANDERSON
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/19/2016
Notification Time: 17:06 [ET]
Event Date: 02/19/2016
Event Time: [EST]
Last Update Date: 02/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received via email:

"On February 19th, 2016, a patient was prescribed and administered a 1.87 GBq Yttrium-90 [Thera-Sphere] treatment. The patient only received 0.28 GBq. [There are] no details as to the cause of the misadministration. [The Radiation Safety Officer] will provide a detailed report next week."

Florida Incident # FL16-033

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.

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51751
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY PATE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/23/2016
Notification Time: 20:45 [ET]
Event Date: 02/23/2016
Event Time: 17:00 [CST]
Last Update Date: 02/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JACK WHITTEN (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION INVOLVING NORMALLY OPEN BATTERY ROOM DOORS

"At CPNPP [Comanche Peak Nuclear Power Plant], eyewash stations are located just outside of the Class 1E battery rooms. The battery room doors are normally open and if a MELB [Moderate Energy Line Break] occurred on the demineralized water line connected to the eyewash station, the water could potentially spray onto the Class 1E safety related batteries. If this occurred, an electrical short could potentially cause a loss of both the batteries and the associated battery chargers.

"This condition has been conservatively determined to be reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. Currently, the demineralized water lines on the battery room eyewash stations for both Units 1 and 2 have been isolated, therefore, all safety related equipment is currently operable. Comanche Peak Engineering is performing a past operability review of this condition.

"The NRC Resident Inspector has been notified."

* * * RETRACTION AT 1821 EST ON 02/27/2016 FROM DANNY BRADFORD TO JEFF HERRERA * * *

"On February 23, 2016 at 2045 [EST], Comanche Peak reported an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B). Specifically, the reported condition involved eyewash stations that are located just outside of the Class 1E battery rooms. The battery room doors are normally open and if a Moderate Energy Line Break (MELB) occurred on the demineralized water line connected to the eyewash station, the water could potentially spray onto the Class 1E safety related batteries. If this occurred, an electrical short could have potentially caused a loss of both the batteries and the associated battery chargers. This condition was conservatively determined to be reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. The demineralized water lines on the battery room eyewash stations for both Units 1 and 2 were isolated, and Comanche Peak Engineering initiated a past operability evaluation of this condition.

"The past operability evaluation has been completed and shows that there are no operability concerns regarding a MELB impact on the Class 1E batteries, DC bus or Class 1E battery chargers. Therefore, Comanche Peak requests that the February 23, 2016, 10 CFR 50.72(b)(3)(ii)(B) reportable event for Units 1 & 2 be retracted."

The NRC Resident Inspector has been notified.

Notified the R4DO (Whitten).

To top of page
Fuel Cycle Facility Event Number: 51757
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: CALVIN MANNING
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/26/2016
Notification Time: 12:32 [ET]
Event Date: 02/25/2016
Event Time: 11:45 [PST]
Last Update Date: 02/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Event Text

POTENTIAL COMMON MODE FAILURE OF ITEM RELIED ON FOR SAFETY

"While processing liquid effluent, process operators noticed that a set of uranium monitors, IROFS [Item Relied On For Safety] for the process system, registered a negative value. The process operators shut down process flows and contacted maintenance to come and check the uranium monitors. The uranium monitors checked out to be functioning correctly. The process was resumed until the condition repeated. The process operator then contacted maintenance again and shut the process down at 0300 [PST] pending further evaluation.

"It appears that an interference material (likely copper or nickel) is masking some of the uranium present in the effluent causing the uranium monitors, which are based on colorimetry, to read low.

"At 1145 PST on 2/25/16, AREVA Richland Reliability Engineering and EHS[and]L staff confirmed that this condition had not been anticipated in the ISA [Integrated Safety Analysis] and had the potential to cause a common mode failure of two IROFS.

"The waste tank that contains the process effluent is a 30,000 gallon tank and currently contains about 3,000 gallons and based on laboratory analysis of a sample of the tank contents contains about 136 grams of low enriched (<5 wt. [percent] U235) uranium. A total of 2 kg has been processed through the tank since the last NCS [Nuclear Criticality Safety] required emptying and clean out of the tank.

"Although the IROFS were degraded, it was determined that the IROFS were available and reliable to perform their function. However, this event meets the criteria in 10CFR70 Appendix A 24 hour reporting item 1, in that this condition had not been anticipated in the ISA and had the potential to cause a common mode failure of IROFS."

The NRC Regional Office will be notified.

To top of page
Power Reactor Event Number: 51760
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RICHARD MEISTER
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2016
Notification Time: 09:20 [ET]
Event Date: 02/26/2016
Event Time: 19:45 [CST]
Last Update Date: 02/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JACK WHITTEN (R4DO)
FFD GROUP (EMAI)

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

Event Text

CONFIRMED POSITIVE TEST FOR ALCOHOL

A contract employee supervisor had a confirmed positive for alcohol during follow up FFD testing. The employee's access to all Entergy plants has been terminated.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, February 29, 2016
Monday, February 29, 2016