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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/25/2016 - 05/26/2016
** EVENT NUMBERS **
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| Agreement State |
Event Number: 51937 |
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: JOHN STROGER HOSPITAL
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01768-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: KARL DIEDERICH |
Notification Date: 05/17/2016
Notification Time: 11:54 [ET]
Event Date: 05/13/2016
Event Time: [CDT]
Last Update Date: 05/17/2016 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JIM WHITNEY (EMAI) |
| This material event contains a "Less than Cat 3 " level of radioactive material. |
Event Text
AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE
The following was reported verbally and via email from the Illinois Bureau of Radiation Safety:
"On Friday, May 13, 2016, the licensee's radiation safety officer (RSO) contacted the Agency [Illinois Bureau of Radiation Safety] to advise that one source from a Medi+Physics sealed source brachytherapy device [44 mCi, Cs-137, Model Number CDCT1, Serial Number GA301] was missing following the treatment of a patient. During the unloading of the applicator that afternoon, only 2 of the 3 sources were recovered. Surveys were immediately conducted of the patient, the patient's room, the trash, bed and linen that remained present as well as several potential paths to and from the hot lab where the sources are stored. The facility expanded its surveys to additionally include dumpsters, roll off containers of biohazard waste and soiled linen storage without retrieving the source. Interviews with attending nursing staff showed that the patient had been cooperative throughout the 3 day treatment, did not have any visitors and had no complications where she had been found out of bed or otherwise unattended. Agency representatives were sent to the facility the following Monday to conduct confirmatory measurements of the same areas and equipment and expanded the search again to other outlying areas of the facility with no unexpected elevated readings detected in any area. Waste processing facilities were contacted and advised of the potential of a missing radioactive source in their waste stream beginning on the previous Wednesday. All indicated that they had functioning portal detection units for incoming trash/waste and that no anomalous readings had been noted.
"The Agency is continuing its investigation at this time and conducting additional surveys at out lying waste facilities. Hospital staff have been made aware of the event and been given a description of the source and appropriate action to take should it be discovered. This item remains open at this time."
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 |
| Power Reactor |
Event Number: 51956 |
Facility: VOGTLE
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT FRECK
HQ OPS Officer: STEVE SANDIN |
Notification Date: 05/25/2016
Notification Time: 04:54 [ET]
Event Date: 05/25/2016
Event Time: 02:06 [EDT]
Last Update Date: 05/25/2016 |
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):
EUGENE GUTHRIE (R2DO) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
A/R |
Y |
100 |
Power Operation |
0 |
Hot Standby |
Event Text
AUTOMATIC REACTOR TRIP ON LOWERING STEAM GENERATOR WATER LEVEL
"At 0206 EDT 5/25/16, Vogtle Unit 2 tripped from 100% when SG [Steam Generator] #1 Level began to lower for an unknown reason. Cause for level issue is under investigation. All control rods fully inserted and AFW [Auxiliary Feedwater] and FWI [Feedwater Isolation] actuated as expected.
"Unit 2 is in Mode 3 and stable with decay heat being removed by Aux Feedwater."
Prior to the trip, I & C [Instrumentation & Calibration] was performing a loop #1 narrow range instrument calibration. Unit 2 is in a normal post trip electrical lineup with all source of offsite power available.
The licensee informed the NRC Resident Inspector. |
| Power Reactor |
Event Number: 51958 |
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM LYNDE
HQ OPS Officer: HOWIE CROUCH |
Notification Date: 05/25/2016
Notification Time: 16:00 [ET]
Event Date: 05/25/2016
Event Time: 13:00 [CDT]
Last Update Date: 05/25/2016 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION |
Person (Organization):
MICHAEL KUNOWSKI (R3DO) |
| 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
DISCOVERY OF NON-CONFORMING CONDITIONS DURING TORNADO HAZARDS ANALYSIS
"On May 25, 2016, during evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Byron Station identified non-conforming conditions in the plant design such that specific TS equipment on both units is considered to not be adequately protected from tornado missiles. Each of the following reportable conditions is postulated by tornado missiles entering openings through the wall that separates the Auxiliary Building and the Turbine Building:
"The following items could be impacted by tornado missiles entering the 0A and 0B [common] MCR [main control room] turbine building intake openings: Main control room pressurization, main control room ductwork and dampers, chilled water to the VC [control room ventilation] coils, main control room radiation monitors.
"The following items could be impacted by tornado missiles entering the Division 11 and 21 MEER [miscellaneous electrical equipment rooms] rooms: Exhaust from the MEER (affects room cooling and MCR pressure), exhaust from a battery room, conduits and cabinets associated with the battery chargers and DC bus.
"The following items could be impacted by tornado missiles entering the Division 12 and 22 MEER rooms: Exhaust from the MEER (affects room cooling and MCR pressure), MEER supply fan and ductwork, battery room exhaust, and the instrument inverter cabinets.
"The RWST [refueling water storage tank] roof access opening Bilco hatch is fabricated from sheet metal that is not designed to prevent all postulated tornado missiles from entering the tank. The tank pressure boundary is 24" thick concrete and is designed to withstand an external tornado missile impact. Thus a missile that enters the tank will not adversely impact the tank pressure boundary. The following items could be impacted by tornado missiles entering the RWST roof access: The 6" RWST recirculation pipe, 3" overflow pipe, and 24" suction pipe. This piping is located inside the tank and they are approximately 130 degrees around the tank away from the hatch opening.
"This condition creates a potential LOSF [loss of safety function] with the Byron Essential Service Water Cooling Towers (UHS) [ultimate heat sink] with the discovery that the power and control cables to four of eight cooling tower fans can be damaged by tornado missiles penetrating through wall openings.
"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and per 10 CFR 50.72(b)(3)(v)(D) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"These conditions are being addressed in accordance with EGM 15-002 and DSS-ISG-2016-01 [enforcement discretion and interim guidance documents]. The licensee has notified the NRC Resident Inspector." |
| Power Reactor |
Event Number: 51959 |
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RYAN WITCOFSKI
HQ OPS Officer: HOWIE CROUCH |
Notification Date: 05/25/2016
Notification Time: 17:10 [ET]
Event Date: 05/25/2016
Event Time: 14:15 [CDT]
Last Update Date: 05/25/2016 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION |
Person (Organization):
MICHAEL KUNOWSKI (R3DO) |
| 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
DISCOVERY OF NON-CONFORMING CONDITIONS DURING TORNADO HAZARDS ANALYSIS
"On May 25, 2016, during evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Braidwood Station identified non-conforming conditions in the plant design such that specific TS equipment on both units is considered to not be adequately protected from tornado missiles. Each of the following reportable conditions is postulated by tornado missiles entering openings through the wall that separates the Auxiliary Building and the Turbine Building:
"The following items could be impacted by tornado missiles entering the 0A and 0B [common] MCR [main control room] turbine building intake openings: Main control room pressurization, main control room ductwork and dampers, chilled water to the VC [control room ventilation] coils, main control room radiation monitors.
"The following items could be impacted by tornado missiles entering the Division 11 and 21 MEER [miscellaneous electrical equipment rooms] rooms: Exhaust from the MEER (affects room cooling and MCR pressure), exhaust from a battery room, conduits and cabinets associated with the battery chargers and DC bus.
"The following items could be impacted by tornado missiles entering the Division 12 and 22 MEER rooms: Exhaust from the MEER (affects room cooling and MCR pressure), MEER supply fan and ductwork, battery room exhaust, and the instrument inverter cabinets.
"The Auxiliary Feed Diesel exterior exhaust stacks (which extend from the roofline) could be impacted by tornado missiles. While we have analyses on these impacts, they do not use a NRC accepted methodology to evaluate the impact and effects.
"The RWST [refueling water storage tank] roof access opening Bilco hatch is fabricated from sheet metal that is not designed to prevent all postulated tornado missiles from entering the tank. The tank pressure boundary is 24" thick concrete and is designed to withstand an external tornado missile impact. Thus a missile that enters the tank will not adversely impact the tank pressure boundary. The following items could be impacted by tornado missiles entering the RWST roof access: The 6" RWST recirculation pipe, 3" overflow pipe, and 24" suction pipe. This piping is located inside the tank and they are approximately 130 degrees around the tank away from the hatch opening.
"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and per 10 CFR 50.72(b)(3)(v)(D) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"These conditions are being addressed in accordance with EGM 15-002 and DSS-ISG-2016-01 [enforcement discretion and interim guidance documents]. The licensee has notified the NRC Resident Inspector."
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