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Event Notification Report for August 8, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/05/2016 - 08/08/2016

** EVENT NUMBERS **


52090 52131 52134 52135 52153 52154 52156 52157 52159

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Fuel Cycle Facility Event Number: 52090
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: NANCY PARR
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/14/2016
Notification Time: 18:49 [ET]
Event Date: 07/13/2016
Event Time: [EDT]
Last Update Date: 08/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
DANIEL RICH (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

DEGRADED SAFETY ITEMS CAUSED BY URANIUM BUILDUP

"On July 13, 2016, it was determined by the Environment, Health and Safety (EH&S) department that scrubber clean-out material, found in the S-1030 scrubber transition section during the annual maintenance shutdown that occurred in late May, potentially exceeded the uranium mass limit for the scrubber transition.

"(IROFS [Items Relied on for Safety] VENT-S1030-110) requires annual inspection and removal of significant solids buildup in the transition section. Upon inspection, significant buildup was found, and the ductwork was opened to permit extensive cleanout. 36 containers of material with a total gross weight of 210.4 kg was removed from the inlet transition during the cleanout on May 28th to May 29th. Grab samples were subsequently taken from each container and analyzed for uranium concentration. On July 13th, the EH&S department was made aware that the grab sample results averaged 47.8% U. Although the exact uranium mass cannot be determined until the material is dissolved and representatively sampled, available evidence suggests that the mass limit of 29 kg U in the inlet transition was exceeded. The 29 kg U limit is based on an optimally moderated, fully reflected spherical geometry which very conservatively bounds the conditions in the inlet transition of the scrubber. IROFS remained to limit the quantity of uranium available to the scrubber (IROFS VENT-S1030-101, -102, -103 & -104), which are physical barriers designed to minimize uranium in the airflow entering the transition area. Continuous liquid spraying in the inlet transition section to limit solids accumulation (IROFS VENT-S1030-109) was also in place.

"The inlet transition and scrubber were thoroughly cleaned, and the uranium bearing solids were placed into favorable geometry containers. Also, the inspection and cleanout of the transition frequency was increased to monthly.

"Based on available but degraded IROFS, this accident sequence was unlikely. Therefore, this mass accident sequence does not meet the performance requirements of 10CFR70.61. The actual configuration remained safe at all times. Also, no external conditions affected the event.

"Immediate Corrective Actions:
NRC Region II personnel, who were onsite at the CFFF [Columbia Fuel Fabrication Facility], were made aware of the discovery.

"The Conversion area was shutdown to plan for a second extensive scrubber clean-out to validate that the accumulation of solids is a slow buildup over time. The last extensive cleanout was performed in 2009.

"An extent of condition was performed to determine if other scrubbers potentially had significant uranium buildup. Inspection data indicated that this material accumulation issue was limited to the S-1030 scrubber.

"This event has been entered into the facility Corrective Action Prevention And Learning system (CAPAL) #100397353."

* * * UPDATE PROVIDED BY NANCY PARR TO JEFF ROTTON AT 1025 EDT ON 07/26/2016 * * *

"Onsite chemical analysis confirmed that uranium mass limit for the scrubber transition piece was exceeded. The accumulated material contained 87 kgs of Uranium.

"The Criticality Safety Evaluation for this system was revised and implemented on July 20, 2016 to add Items Relied on For Safety to prevent recurrence of a mass exceedance while the causal analysis and additional corrective actions are completed."

Notified R2DO (Nease) and NMSS Events Notification Group via email.

* * * UPDATE PROVIDED BY NANCY PARR TO HOWIE CROUCH AT 1749 EDT ON 07/31/2016 * * *

"On July 31, 2016, it was determined by the Environment, Health and Safety (EH&S) department that clean-out material found in the S-1030 scrubber packing and floor also potentially exceeded the uranium mass limit for the scrubber criticality safety evaluation. Over years of operations, the same available but degraded mass prevention and inspection/clean-out IROFS did not prevent exceedance of the mass limit.

"This report is being upgraded to a 1 Hour Event Notification based on 10CFR70 Appendix A(a)(4).

"There was no consequence to the public, the workers or the environment.

"The scrubber process will remain in a safe shutdown mode until further investigation and corrective actions are completed."

Notified R2DO (Rose), IRD (Grant), NMSS EO (Kotzalas) and NMSS Events Notification via email.

* * * UPDATE FROM JOHN HOWELL TO VINCE KLCO AT 1620 EDT ON 8/7/2016 * * *

"On August 6, 2016 at 1700, it was reported to the Environment, Health and Safety (EH&S) department that residual material located within the abandoned S-1056 scrubber was sampled and confirmed to contain Uranium.

"24 Hour Event Notification based on 10CFR70 Appendix A(b)(1) 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10CFR70.61.'

"The S-1056 is an out-of-service scrubber. When operational, it scrubbed the acid fumes from the Conversion area. It currently is an unanalyzed system without IROFS or controls. The reported volume of approximately 15 kg is well within safety margins.

"It was taken out of service in 2002, when the S-1030 scrubber replaced it. The material in the S-1056 was discovered as an extent of condition for the S-1030 event.

"The discovery and sampling were documented in Redbook 71409. At no time was there any actual or potential health and safety consequence to the workers, the public, or the environment."

The licensee notified the NRC Regional Inspector (Lopez).

Notified the R2DO (Suggs), R2RA (Haney) and NMSS Events Notification Group via email.

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Agreement State Event Number: 52131
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WA-M048
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/28/2016
Notification Time: 20:00 [ET]
Event Date: 07/27/2016
Event Time: [PDT]
Last Update Date: 07/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN THE PRESCRIBED DOSE OF I-131

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

"At approximately 3:50 pm [PDT] on Thursday, July 28th 2016, the Director of Radiology of Virginia Mason Medical Center called the radioactive materials section [WA Office of Radiation Protection] to report a medical event. The event occurred on the previous day, July 27th 2016, but was not noticed until the 28th . A patient was supposed to receive 120.8 mCi of I-131 in the form of two capsules for thyroid treatment. However, the patient only received one capsule resulting in the patient only receiving 53 mCi of the 120.8 mCi. The event was discovered (8:45 am [on] July 28, 2016) when an I-131 capsule was returned to the pharmacy on the 28th and it was noticed that the patient did not get both capsules as intended."

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 52134
Rep Org: ADVANCED RADIOLOGY CONSULTING
Licensee: ADVANCED RADIOLOGY CONSULTING
Region: 1
City: TRUMBULL State: CT
County:
License #: 06-16869-01
Agreement: N
Docket:
NRC Notified By: DAVID WISHKO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/29/2016
Notification Time: 15:18 [ET]
Event Date: 07/28/2016
Event Time: [EDT]
Last Update Date: 08/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - WRONG RADIOPHARMACEUTICAL FORMULATION ADMINISTERED TO PATIENT

A nuclear technologist ordered and administered 25 mCi of Technetium 99m-methyl diphosphonate (99mTc MDP) to a patient undergoing a gastric emptying scan. 99mTc MDP is a radioisotope used especially for bone scans. The formulation that should have been ordered and administered is 500 microCuries of Tc 99m Sulfur colloid, which is generally used for the gastric study.

Both the patient and prescribing physician have been notified. The dose received by the patient is under evaluation at this time. No harmful effects to the patient are expected.

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.

* * * RETRACTION FROM DAVID WISHKO TO DANIEL MILLS AT 1323 EDT ON 08/02/2016 * * *

Upon further analysis, the dose administered to the patient did not exceed the limits listed in 10 CFR 35.3045, and therefore this event is not reportable.

Notified R1DO (Kennedy) and NMSS (email).

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Non-Agreement State Event Number: 52135
Rep Org: US AIR FORCE
Licensee: US AIR FORCE
Region: 1
City: FALLS CHURCH State: VA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/29/2016
Notification Time: 15:27 [ET]
Event Date: 06/03/2016
Event Time: [EDT]
Last Update Date: 07/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LOSS OF GENERAL LICENSED MATERIAL CHECK SOURCES

On June 3, 2016, the US Air Force determined that two (2) check sources containing Thorium-232 (45 nCi and 13 nCi) were missing at the Aviano Air Base located in Italy. These two generally licensed sources are used as check sources for the ADM-300 survey meter.

The licensee contacted NRC RIV (Michelle Simmons) who recommended that the licensee report the loss per 10 CFR 31.5(c)(10).

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

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Power Reactor Event Number: 52153
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: LORI KIFFMEYER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/04/2016
Notification Time: 22:04 [ET]
Event Date: 08/04/2016
Event Time: 14:15 [CDT]
Last Update Date: 08/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD SKOKOWSKI (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

Event Text

BATTERY ROOM FIRE DETECTION SYSTEM INOPERABLE

"At 1415 CDT on August 4, 2016, while performing a scheduled fire protection surveillance, it was discovered that a component within fire panel FZCP-7, BATTERY ROOM FIRE DETECTION had failed resulting in the inability of the installed fire detectors to detect a fire within the Division 1 and Division 2, 125 VDC battery rooms as well as the Division 2, 250 VDC battery room. This is being reported under 10 CFR 50.72(b)(3)(xiii) for a Loss Of Emergency Assessment Capability as the Control Room would not receive automatic notification of a fire in these areas for evaluation of HU2.1 and HA2.1 for fire within impacted battery rooms which are located within the Protected Area. There is no impact to the health and safety of the public. A 15 minute fire watch has been established for the affected fire zones.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM MARTIN RAJKOWSKI TO DANIEL MILLS AT 1050 EDT ON 08/05/2016 * * *

"Event Notification 52153 completed at 2204 EDT on 8/4/2016 shown above contains an error. The failure of FZCP-7, BATTERY ROOM FIRE DETECTION, resulted in the inability to detect a fire within the Division 1 and Division 2 125 VDC battery rooms as well as the Division 1 250 VDC battery room. The Division 2 250 VDC battery room was not affected by this issue. Additionally, the State of Minnesota was notified of this issue. The NRC Resident Inspector has been notified of this update."

Notified R3DO (Skokowski)

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Power Reactor Event Number: 52154
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: WILLIAM STANG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/05/2016
Notification Time: 06:26 [ET]
Event Date: 08/04/2016
Event Time: 22:40 [CDT]
Last Update Date: 08/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (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

Event Text

UNANALYZED FIRE BARRIER

"At 2240 CDT on August 4, 2016, it was discovered that the floor between the cable spreading room and the plant administration building (PAB) basement is not a credited Appendix R fire barrier. Because the cable spreading room and the plant administration building are located in the same fire area, a fire in the PAB could spread to the cable spreading room requiring evacuation of the control room. The travel path used to access the Alternate Shutdown Panel following control room evacuation traverses the same fire area in the PAB. Therefore, this event is being reported under 10 CFR 50.72(b)(3)(ii) for Degraded or Unanalyzed Condition as a fire in the PAB could have the potential to impact Division 1 equipment as well as impede the Operators ability to access Division 2 safe shutdown equipment. Fire watches have been established. There is no impact to the health and safety of the public.

"The NRC Resident Inspector has been notified."

The licensee will notify the State of Minnesota.

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Power Reactor Event Number: 52156
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KIM HOFFMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/05/2016
Notification Time: 13:58 [ET]
Event Date: 08/05/2016
Event Time: 10:14 [CDT]
Last Update Date: 08/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD SKOKOWSKI (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

Event Text

OFFSITE NOTIFICATION DUE TO DRINKING WATER EXCEEDING LIMITS

"On 8/5/2016 at 1014 [CDT], the Monticello Nuclear Generating Plant (MNGP) was notified by the Minnesota Department of Health (MDH) of a notice of violation for exceeding the drinking water limit for carbon tetrachloride in the drinking water well that supplies the Security Access Facility. Additionally the MDH will be notifying the Minnesota Pollution Control Agency regarding the violation. As a result, this issue is being reported under 10CFR50.72(b)(2)(xi) for notifications to other offsite government agencies. There was no impact to the health and safety of the general public as a result of this issue. The drinking fountains in the Security Access Facility have been isolated. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52157
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHARLES BAREFIELD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/05/2016
Notification Time: 20:55 [ET]
Event Date: 08/05/2016
Event Time: 12:09 [CDT]
Last Update Date: 08/06/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LADONNA SUGGS (R2DO)

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

Event Text

FIRE DETECTION PANEL FAILURE AND LOSS OF ASSESSMENT CAPABILITY

"At 1209 CDT on 8/5/16, during testing of Unit 2 Auxiliary Building Pre-action Sprinkler Systems, all zones on the Unit 2 Pyrotronics Fire Detection Panel went into an alarm state and were unable to be reset. This condition is reportable per 10 CFR 50.72(b)(3)(xiii) as a Major Loss of Assessment capability.

"The NRC Resident has been notified."

The licensee has initiated all necessary compensatory and corrective actions.

* * * UPDATE FROM BLAKE MITCHELL TO VINCE KLCO AT 1718 EDT ON 8/6/2016 * * *

"At 1600 CDT on 8/6/16, the Unit 2 Pyrotronics Fire Detection Panel was declared functional following repair of master override reset test switch and supply fuse. The Pyrotronics Fire Detection Panel was successfully tested following maintenance. The emergency assessment capability for the site's Emergency Plan has been fully restored.

"The NRC Resident has been notified"

Notified the R2DO (Suggs).

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Power Reactor Event Number: 52159
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARIAZ DAVIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/07/2016
Notification Time: 04:45 [ET]
Event Date: 08/07/2016
Event Time: 01:01 [EDT]
Last Update Date: 08/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SILAS KENNEDY (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

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"HPCI [high pressure coolant injection] governor valve did not respond as expected.

"During performance of a planned HPCI valve functional test the HPCI governor valve (FD-FV-4879) did not reposition as expected. The HCPI system has been declared inoperable based on the response per Technical Specification 3.5.1 action C.1. All other emergency core cooling systems and the reactor core isolation cooling (RCIC) system remain operable. The unit remains at 100% power.

"The station has initiated an event response team to identify and correct the cause of the failure. No personnel injuries resulted from the event.

"The licensee notified the NRC Resident Inspector and the Lower Alloways Creek Dispatch."

Page Last Reviewed/Updated Monday, August 08, 2016
Monday, August 08, 2016