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Event Notification Report for April 1, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/31/2016 - 04/01/2016

** EVENT NUMBERS **


51818 51822 51837 51838 51840

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Non-Agreement State Event Number: 51818
Rep Org: BOTSFORD CANCER CENTER
Licensee: BOTSFORD CANCER CENTER
Region: 3
City: FARMINGTON HILLS State: MI
County:
License #: 21-08892-01
Agreement: N
Docket:
NRC Notified By: MISBAH GULAM
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/23/2016
Notification Time: 16:12 [ET]
Event Date: 03/22/2016
Event Time: [EDT]
Last Update Date: 03/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

BRACHYTHERAPY EQUIPMENT MALFUNCTION

On 3/22/16, a medical event occurred from a high dose rate brachytherapy treatment of the prostate. After the first catheter was delivered, the treatment console reported an error. The medical physicist went inside the treatment room with the survey meter to verify that the source retracted and the connections were fine.

The vendor was called out to the facility, and parts had to be replaced. The treatment was stopped, and the patient was 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.

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Agreement State Event Number: 51822
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: SHAW INDUSTRIES GROUP, INC
Region: 1
City: CHICKAMAUGA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MONICA JOHNSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/24/2016
Notification Time: 16:13 [ET]
Event Date: 03/24/2016
Event Time: [EDT]
Last Update Date: 03/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED INDUSTRIAL GAUGE SHUTTER BROKEN

The following information was received via e-mail:

"On Thursday, March 24, 2016, it was reported to the Department [Georgia Department of Radioactive Materials] by Shaw Industries Group, Inc., Plant SI in Chickamauga, GA that the shutter on a fixed industrial gauge is broken. The gauge was shielded, removed from its fixed location, and transferred to a secure storage location. The manufacturer has been contacted and will repair the gauge. A complaint has been opened in CTS [ Complaint Tracking System] and our office [Georgia Department of Radioactive Materials] has an ongoing investigation."

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Power Reactor Event Number: 51837
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: BILL RAYBURN
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/31/2016
Notification Time: 00:14 [ET]
Event Date: 03/30/2016
Event Time: 17:15 [EDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
PATTY PELKE (R3DO)

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

Event Text

DEGRADED CONDITION DUE TO DISCOVERY OF PRESSURE BOUNDARY LEAKAGE

"On March 30, 2016, at 1715 EDT, with the Unit shutdown and in Mode 6 for refueling, evidence of leakage was identified on a 3/4-inch flexible braided piping connection on Reactor Coolant Pump (RCP) 1-1, and this issue was determined to be reactor coolant system pressure boundary leakage. This flexible piping is for RCP 1-1 first stage seal cavity vent line, and is categorized as ASME Section III Class 2 piping. The leakage was identified due to the discovery of a small amount of boric acid (approximately 1/2 teaspoon) on the welded end connection of the flexible piping. No active leakage was identified at the time of discovery with the Reactor Coolant System depressurized and approximately 110 degrees F.

"Technical Specification (TS) Limiting Condition for Operation (LCO) 3.4.13, 'RCS Operational Leakage,' does not apply in the current plant condition (Mode 6). The cause and resolution of the leakage are under evaluation. This event is reportable within 8 hours per 10 CFR 50.72(b)(3)(ii)(A). The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51838
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: LONNIE CRAWFORD
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 12:45 [ET]
Event Date: 03/31/2016
Event Time: 06:03 [EDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

VALID ISOLATION SIGNAL DUE TO A HUMAN PERFORMANCE ERROR

"On March 31, 2016 at 0603 [EDT], with Susquehanna Unit 1 in its 19th Refueling and Inspection Outage, Unit 1 received a valid isolation signal. Preliminary investigation indicates the isolation signal was the result of a human performance error.

"The systems affected by the isolation signal responded as designed for the current shutdown plant conditions.

"This isolation of multiple primary containment isolation systems is being reported under 10CFR50.72(b)(3)(iv)(A) and per the guidance of NUREG 1022, Rev. 3, section 3.2.6 as a system actuation."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51840
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: PAUL FINHOLM
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 16:12 [ET]
Event Date: 03/31/2016
Event Time: 03:24 [CDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 40 Power Operation 40 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - PROHIBITIED ITEM IN THE PROTECTED AREA

"On 3/31/2016 at approximately 0342 CDT, a worker within the Protected Area self-reported a can of beer had been packed in the worker's lunchbox. The worker reported after opening the can and taking a sip it was discovered to be a beer. This event is reportable under 10 CFR 26.719(b)(1).

"The worker notified Security who immediately escorted the worker from the Protected Area and disposed of the beer. The worker is not an Operator or a Supervisor. The investigation of this event is in progress.

"The public health and safety are not impacted.

"The NRC Resident Inspector was notified."

Page Last Reviewed/Updated Friday, April 01, 2016
Friday, April 01, 2016