Event Notification Report for September 01, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/31/2016 - 09/01/2016
EVENT NUMBERS
5221552216522175237552237
Non-Agreement State
Event Number: 52215
Rep Org: INTEGRITY TESTLAB
Licensee: INTEGRITY TESTLAB
Region: 1
City: NEW CASTLE State: DE
County:
License #: 07-30791-01
Agreement: N
Docket:
NRC Notified By: WILLIAM BATTING
HQ OPS Officer: STEVEN VITTO
Licensee: INTEGRITY TESTLAB
Region: 1
City: NEW CASTLE State: DE
County:
License #: 07-30791-01
Agreement: N
Docket:
NRC Notified By: WILLIAM BATTING
HQ OPS Officer: STEVEN VITTO
Notification Date: 09/01/2016
Notification Time: 13:11 [ET]
Event Date: 09/01/2016
Event Time: 11:15 [EDT]
Last Update Date: 09/01/2016
Notification Time: 13:11 [ET]
Event Date: 09/01/2016
Event Time: 11:15 [EDT]
Last Update Date: 09/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
UNABLE TO RETRACT SOURCE INTO SHIELDED POSITION
"At 1122 [EDT], the RSO [Radiation Safety Officer] for Integrity Testlabs [ITL], LLC, received a telephone notification from the field radiographer at the client's location that he was unable to retract the source fully into the shielded position. The radiographer attempted to retract the source twice. The radiographer realized the source was not going to get shielded because he noticed that the control cable housing was laying on equipment which was later determined to be approximately 500 degrees F. This melted the control cable housing and in turn prevented the complete retraction of the source into the shielded position. The radiographer kept the source to the fully exposed position within the 4HVL collimator and proceeded to extended the posted radiation area boundaries to 2mR/hr or less, then contacted the RSO at 1122 [EDT]. The RSO was approximately 50 miles away and stated he was on his way to assist in the recovery process. The company and RSO are authorized to perform recovery of sources.
"The radiographer then contacted his supervisor, who was the senior radiographer onsite. The supervisor also attempted to retract the source into the shielded position. The supervisor contacted the RSO and explained the situation. By direction from the RSO via telephone communication, the supervisor was able to disconnect the control housing at the remote control crank and pull the control cable so that the source was retracted into the shielded position. The radiography operations were terminated for the day. Surveys were performed after the source was shielded with no unusual readings. All equipment was returned to ITL's facility.
"The following self-reading pocket dosimeter readings were recorded at the conclusion of this event. The radiographer and assistant radiographer had performed 6 exposures for the day. The 6 exposures included the event.
Radiographer 100mR
Assistant 20mR
Supervisor 23mR during the recovery process
No radiographic personnel or member of the pubic was overexposed during the entire event.
"The affected equipment will be inspected, repaired or replaced, as needed.
"A follow report will be submitted to Region I as soon as practical.
"Equipment: QSA Global Model 880s #S1667 w/ IR-192 #32053G - 56.5Curies
25Ft Extreme Control Cables with two extreme guide tubes, each guide tube 7ft long and the outer most guide stop having a source stop.
One - 4HVL Tungsten collimator"
"At 1122 [EDT], the RSO [Radiation Safety Officer] for Integrity Testlabs [ITL], LLC, received a telephone notification from the field radiographer at the client's location that he was unable to retract the source fully into the shielded position. The radiographer attempted to retract the source twice. The radiographer realized the source was not going to get shielded because he noticed that the control cable housing was laying on equipment which was later determined to be approximately 500 degrees F. This melted the control cable housing and in turn prevented the complete retraction of the source into the shielded position. The radiographer kept the source to the fully exposed position within the 4HVL collimator and proceeded to extended the posted radiation area boundaries to 2mR/hr or less, then contacted the RSO at 1122 [EDT]. The RSO was approximately 50 miles away and stated he was on his way to assist in the recovery process. The company and RSO are authorized to perform recovery of sources.
"The radiographer then contacted his supervisor, who was the senior radiographer onsite. The supervisor also attempted to retract the source into the shielded position. The supervisor contacted the RSO and explained the situation. By direction from the RSO via telephone communication, the supervisor was able to disconnect the control housing at the remote control crank and pull the control cable so that the source was retracted into the shielded position. The radiography operations were terminated for the day. Surveys were performed after the source was shielded with no unusual readings. All equipment was returned to ITL's facility.
"The following self-reading pocket dosimeter readings were recorded at the conclusion of this event. The radiographer and assistant radiographer had performed 6 exposures for the day. The 6 exposures included the event.
Radiographer 100mR
Assistant 20mR
Supervisor 23mR during the recovery process
No radiographic personnel or member of the pubic was overexposed during the entire event.
"The affected equipment will be inspected, repaired or replaced, as needed.
"A follow report will be submitted to Region I as soon as practical.
"Equipment: QSA Global Model 880s #S1667 w/ IR-192 #32053G - 56.5Curies
25Ft Extreme Control Cables with two extreme guide tubes, each guide tube 7ft long and the outer most guide stop having a source stop.
One - 4HVL Tungsten collimator"
Part 21
Event Number: 52216
Rep Org: ENERSYS
Licensee: ENERSYS
Region: 1
City: READING State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: WILLIAM ROSS
HQ OPS Officer: STEVEN VITTO
Licensee: ENERSYS
Region: 1
City: READING State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: WILLIAM ROSS
HQ OPS Officer: STEVEN VITTO
Notification Date: 09/01/2016
Notification Time: 14:51 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EDT]
Last Update Date: 09/02/2016
Notification Time: 14:51 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EDT]
Last Update Date: 09/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
RAY POWELL (R1DO)
JONATHAN BARTLEY (R2DO)
BILLY DICKSON (R3DO)
GREG WARNICK (R4DO)
PART 21/50.55 REACT (EMAI)
RAY POWELL (R1DO)
JONATHAN BARTLEY (R2DO)
BILLY DICKSON (R3DO)
GREG WARNICK (R4DO)
PART 21/50.55 REACT (EMAI)
PART 21 - POTENTIAL FAILURE OF BATTERY SYSTEM CONNECTIONS
"This letter will serve as notification from EnerSys to the United States Nuclear Regulatory Commission of an identified deviation in published literature information. The literature defines requirements for resistance in both cell to cell and cell to terminal connections in supplied battery systems. High connection resistance causes increased cell voltage drop and a potential failure to meet run time requirements.
"Internal investigation by EnerSys confirms that no defects exist in systems tested before shipment to customer utilities as internal documented procedures define correct parameters. However, the potential of less than desired performance exists if the values noted in the literature are used during installation and test at utility sites.
"EnerSys does not have the ability to evaluate if a defect exists at customer utilities so per the provisions of Part 21, notification is being made to both the Commission and affected EnerSys customers."
POC: 800-538-3627 ext. 1974
* * * UPDATE FROM WILLIAM ROSS TO STEVEN VITTO AT 1339 EDT on 09/02/2016 * * *
"The literature in question is the EnerSys Safety, Storage, Installation, Operation and Maintenance Manual for Flooded Lead-Acid Batteries C, D, E, F and G, number US-FL-IOM-002 dated January 2007. The errors are located in Section 7.4.3.8c line 2. The current wording of '... connection is more than 30 percent or 5 Mohms above the average...' should read 'connection is more than 10 percent or 5 micro-ohms, whichever is greater, above the average'."
Licensees affected are Dominion North Anna, Dominion Surry Nuclear Power Plant, Energy Northwest Columbia Generating Station, Entergy Nuclear Operations IP2, First Energy Beaver Valley NPP, NextEra Energy Point Beach Nuclear Plant, Perry Nuclear Power Plant, and San Onofre Nuclear Generating Station.
Notified R1DO(Powell), R2DO (Bartley), R3DO (Dickson), R4DO (Warnick), and Part 21Group via email.
"This letter will serve as notification from EnerSys to the United States Nuclear Regulatory Commission of an identified deviation in published literature information. The literature defines requirements for resistance in both cell to cell and cell to terminal connections in supplied battery systems. High connection resistance causes increased cell voltage drop and a potential failure to meet run time requirements.
"Internal investigation by EnerSys confirms that no defects exist in systems tested before shipment to customer utilities as internal documented procedures define correct parameters. However, the potential of less than desired performance exists if the values noted in the literature are used during installation and test at utility sites.
"EnerSys does not have the ability to evaluate if a defect exists at customer utilities so per the provisions of Part 21, notification is being made to both the Commission and affected EnerSys customers."
POC: 800-538-3627 ext. 1974
* * * UPDATE FROM WILLIAM ROSS TO STEVEN VITTO AT 1339 EDT on 09/02/2016 * * *
"The literature in question is the EnerSys Safety, Storage, Installation, Operation and Maintenance Manual for Flooded Lead-Acid Batteries C, D, E, F and G, number US-FL-IOM-002 dated January 2007. The errors are located in Section 7.4.3.8c line 2. The current wording of '... connection is more than 30 percent or 5 Mohms above the average...' should read 'connection is more than 10 percent or 5 micro-ohms, whichever is greater, above the average'."
Licensees affected are Dominion North Anna, Dominion Surry Nuclear Power Plant, Energy Northwest Columbia Generating Station, Entergy Nuclear Operations IP2, First Energy Beaver Valley NPP, NextEra Energy Point Beach Nuclear Plant, Perry Nuclear Power Plant, and San Onofre Nuclear Generating Station.
Notified R1DO(Powell), R2DO (Bartley), R3DO (Dickson), R4DO (Warnick), and Part 21Group via email.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 52217
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN ALEXANDER
HQ OPS Officer: STEVEN VITTO
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN ALEXANDER
HQ OPS Officer: STEVEN VITTO
Notification Date: 09/01/2016
Notification Time: 18:39 [ET]
Event Date: 09/01/2016
Event Time: 10:25 [CDT]
Last Update Date: 10/27/2016
Notification Time: 18:39 [ET]
Event Date: 09/01/2016
Event Time: 10:25 [CDT]
Last Update Date: 10/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GREG WARNICK (R4DO)
GREG WARNICK (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 |
UNANALYZED CONDITION ON TURBINE DRIVEN AUXILIARY FEEDWATER PUMP
"During a review of ongoing analyses related to postulated tornado missiles, a question was raised about the sentinel valve on the turbine driven auxiliary feedwater pump (TDAFW). The sentinel valve is designed as a warning system on steam equipment to warn personnel of increased back pressure. The valve is not an ASME component and its operation is not required to support TDAFW operation.
"The draft analysis predicts the TDAFW exhaust stack could be partially crimped by a tornado missile and the resultant back pressure on the turbine would increase to approximately 40 psi. This is higher than the set point for the sentinel valve (nominally 27 and 29 psi for Units 1 and 2, respectively). Therefore, in a design basis tornado with a design basis tornado missile striking the TDAFW exhaust stack, and in a condition where the TDAFW is demanded to run, the sentinel valve is expected to lift and allow steam to flow into the room.
"Vendor correspondence indicates that at approximately 40 psi the sentinel valve will conservatively pass 600 lbm/hr. Thus, it is conservatively considered operation of the TDAFW under such conditions would create an adverse steam environment which would be beyond that which the TDAFW pump has been analyzed to operate. Actions planned to alleviate the above condition would eliminate the potential for adverse environmental conditions.
"The steam supplies to the TDAFW have been isolated to affect repairs, which are expected to be limited to removal of the sentinel valve from each Unit and installation of a plug. Said activities are expected to be completed within the Allowed Out-of-Service Time (AOT) of the TDAFW of seventy-two hours per Technical Specification 3.7.5."
NRC Resident Inspector has been informed.
* * * RETRACTION ON 10/27/2016 AT 1353 EDT FROM DANNY BRADFORD TO BETHANY CECERE * * *
"On 09/01/2016 Comanche Peak reported an ENS Report (no. 52217) related to unanalyzed conditions related to the sentinel valve on the turbine driven auxiliary feedwater pump (TDAFW) during postulated tornado-based scenarios and non-tornado based scenarios. The technical concern was the potential for the sentinel valve to release steam into the TDAFW room and result in adverse environmental conditions within the room and potentially external to the TDAFW room for both tornado-based and non-tornado based scenarios.
"Subsequent investigations by Engineering have determined the sentinel valve would not be demanded to open during tornado based scenarios and would not result in adverse environmental conditions internal or external to the TDAFW room in any design bases scenario."
The licensee has notified the NRC Resident Inspector. Notified the R4DO (Farnholtz).
"During a review of ongoing analyses related to postulated tornado missiles, a question was raised about the sentinel valve on the turbine driven auxiliary feedwater pump (TDAFW). The sentinel valve is designed as a warning system on steam equipment to warn personnel of increased back pressure. The valve is not an ASME component and its operation is not required to support TDAFW operation.
"The draft analysis predicts the TDAFW exhaust stack could be partially crimped by a tornado missile and the resultant back pressure on the turbine would increase to approximately 40 psi. This is higher than the set point for the sentinel valve (nominally 27 and 29 psi for Units 1 and 2, respectively). Therefore, in a design basis tornado with a design basis tornado missile striking the TDAFW exhaust stack, and in a condition where the TDAFW is demanded to run, the sentinel valve is expected to lift and allow steam to flow into the room.
"Vendor correspondence indicates that at approximately 40 psi the sentinel valve will conservatively pass 600 lbm/hr. Thus, it is conservatively considered operation of the TDAFW under such conditions would create an adverse steam environment which would be beyond that which the TDAFW pump has been analyzed to operate. Actions planned to alleviate the above condition would eliminate the potential for adverse environmental conditions.
"The steam supplies to the TDAFW have been isolated to affect repairs, which are expected to be limited to removal of the sentinel valve from each Unit and installation of a plug. Said activities are expected to be completed within the Allowed Out-of-Service Time (AOT) of the TDAFW of seventy-two hours per Technical Specification 3.7.5."
NRC Resident Inspector has been informed.
* * * RETRACTION ON 10/27/2016 AT 1353 EDT FROM DANNY BRADFORD TO BETHANY CECERE * * *
"On 09/01/2016 Comanche Peak reported an ENS Report (no. 52217) related to unanalyzed conditions related to the sentinel valve on the turbine driven auxiliary feedwater pump (TDAFW) during postulated tornado-based scenarios and non-tornado based scenarios. The technical concern was the potential for the sentinel valve to release steam into the TDAFW room and result in adverse environmental conditions within the room and potentially external to the TDAFW room for both tornado-based and non-tornado based scenarios.
"Subsequent investigations by Engineering have determined the sentinel valve would not be demanded to open during tornado based scenarios and would not result in adverse environmental conditions internal or external to the TDAFW room in any design bases scenario."
The licensee has notified the NRC Resident Inspector. Notified the R4DO (Farnholtz).
Agreement State
Event Number: 52375
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: B. BRAUN MEDICAL GROUP, INC.
Region: 1
City: ALLENTOWN State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: HOWIE CROUCH
Licensee: B. BRAUN MEDICAL GROUP, INC.
Region: 1
City: ALLENTOWN State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/18/2016
Notification Time: 10:20 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EST]
Last Update Date: 11/18/2016
Notification Time: 10:20 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
AGREEMENT STATE REPORT - POLONIUM-210 STATIC ELIMINATOR GAUGE MISSING
The following information was obtained from the Commonwealth of Pennsylvania via email:
"Event Description: During an inventory record check on September 1, 2016, the general licensee discovered that the static eliminator gauge was missing. Its last known use was during the first six months of the year 2011. The general licensee was unaware of its reporting responsibility.
"Gauge info:
Radionuclide: Polonium-210
Manufacturer: NRD, Inc.
Model: P-2021-5000
Device SN#: A2HM769
Activity: 10.2 milliCuries
"Cause of the Event: Unknown at this time, the general licensee believes that the equipment was lost when the company reconfigured its machinery at some point during 2012.
"Actions: A reactive inspection is planned by the Department [PA Department of Environmental Protection]. More information will be provided upon receipt. Note: Given that over 13 half-lives have transpired since the gauge was lost, there is no current public health and safety hazard."
PA Event Report ID: PA160035
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
The following information was obtained from the Commonwealth of Pennsylvania via email:
"Event Description: During an inventory record check on September 1, 2016, the general licensee discovered that the static eliminator gauge was missing. Its last known use was during the first six months of the year 2011. The general licensee was unaware of its reporting responsibility.
"Gauge info:
Radionuclide: Polonium-210
Manufacturer: NRD, Inc.
Model: P-2021-5000
Device SN#: A2HM769
Activity: 10.2 milliCuries
"Cause of the Event: Unknown at this time, the general licensee believes that the equipment was lost when the company reconfigured its machinery at some point during 2012.
"Actions: A reactive inspection is planned by the Department [PA Department of Environmental Protection]. More information will be provided upon receipt. Note: Given that over 13 half-lives have transpired since the gauge was lost, there is no current public health and safety hazard."
PA Event Report ID: PA160035
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
Agreement State
Event Number: 52237
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: EPHRATA COMMUNITY HOSPITAL
Region: 1
City: EPHRATA State: PA
County:
License #: PA-0038
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JEFF HERRERA
Licensee: EPHRATA COMMUNITY HOSPITAL
Region: 1
City: EPHRATA State: PA
County:
License #: PA-0038
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/13/2016
Notification Time: 11:00 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2016
Notification Time: 11:00 [ET]
Event Date: 09/01/2016
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAN COLLINS (NMSS)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAN COLLINS (NMSS)
AGREEMENT STATE REPORT - PATIENT DOSE TO THE SKIN THAT EXCEEDED 50 REM
The following report was received from the Pennsylvania DEP Bureau of Radiation Protection via email:
"On September 12, 2016, the Department [Pennsylvania Department of Environmental Protection] was notified by Ephrata Community Hospital that while injecting technetium-99m (Tc-99m) into a patient, a leak occurred in the delivery system resulting in skin contamination and a dose to the patient's skin estimated to be greater than 50 rem. It is reportable per 10 CFR 35.3045(a)(3).
"A 29 millicurie (mCi) Tc-99m dose was ordered for a patient bone scan. While injecting the dose into the patient's IV port the technologist noticed leakage and immediately stopped the injection. The patient's arm was wiped and cleaned with gauze several times. Ephrata Hospital estimates the skin contamination from that (unknown) residual activity to be approximately 15.8 mCi, resulting in a dose to the patient's skin greater than 50 rem."
Event Report ID No.: PA160025
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.
The following report was received from the Pennsylvania DEP Bureau of Radiation Protection via email:
"On September 12, 2016, the Department [Pennsylvania Department of Environmental Protection] was notified by Ephrata Community Hospital that while injecting technetium-99m (Tc-99m) into a patient, a leak occurred in the delivery system resulting in skin contamination and a dose to the patient's skin estimated to be greater than 50 rem. It is reportable per 10 CFR 35.3045(a)(3).
"A 29 millicurie (mCi) Tc-99m dose was ordered for a patient bone scan. While injecting the dose into the patient's IV port the technologist noticed leakage and immediately stopped the injection. The patient's arm was wiped and cleaned with gauze several times. Ephrata Hospital estimates the skin contamination from that (unknown) residual activity to be approximately 15.8 mCi, resulting in a dose to the patient's skin greater than 50 rem."
Event Report ID No.: PA160025
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.