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Event Notification Report for October 28, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/27/2016 - 10/28/2016

** EVENT NUMBERS **


52217 52304 52305 52308 52311 52320 52321 52324

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
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

Event Text

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).

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Agreement State Event Number: 52304
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/19/2016
Notification Time: 10:34 [ET]
Event Date: 10/17/2016
Event Time: [EDT]
Last Update Date: 10/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via fax:

"Radiation Safety Staff from a hospital in New York called on 10/18/2016 to report that for a patient who was treated with SIR Spheres [containing Y-90] on 10/17/16, it was estimated that about 22.5% less than intended had been delivered. 4.05 mCi was ordered. Assayed at 4.2 mCi. Post treatment survey of the device and residuals showed 1.06 mCi left over. Which means 3.14 mCi was administered, instead of the intended 4.05 mCi. They will mail a report within a week."

New York state Event #NYDOH-NY-16-07

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: 52305
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST JULIEN PARTNERS LLC
Region: 4
City: BOULDER State: CO
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/19/2016
Notification Time: 15:23 [ET]
Event Date: 10/18/2016
Event Time: 15:51 [MDT]
Last Update Date: 10/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the State of Colorado via email:

"During the time the St Julien [Hotel and Spa] was under construction, the fire marshal indicated additional exit signs were needed. The subcontractor working as the intermediary service provider was Riviera Electric. They ordered 3 tritium exit signs to be used on the property. After several discussions, it was determined the tritium exit signs posed a hazard and liability issues. The final decision was not to install them on the property. The disposition of the 3 tritium exit signs is unknown. They are being reported as lost. Riviera Electric is no longer in business."

Event Report ID No.: CO16-I16-22

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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Agreement State Event Number: 52308
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ACUREN INSPECTION, INC.
Region: 4
City: COMMERCE CITY State: CO
County:
License #: CO 997-01
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/19/2016
Notification Time: 18:25 [ET]
Event Date: 10/19/2016
Event Time: [MDT]
Last Update Date: 10/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following was received from the State of Colorado via email:

"The radiography source disconnect occurred on 10/19/2016 at a metal fab yard in Berthoud, CO. No members of the public are believed to have been exposed to radiation from the incident at this time. The source isotope was Ir-192 with an activity of 40 Ci. The source was successfully retrieved by the licensee. The licensee reported the following dose estimates for those involved in the incident.

"Radiation Safety Officer: 50 mR
"Radiographer: 28 mR
"Assistant: 10 mR

"A written report from the licensee is pending; and will be followed-up by a formal investigation."

Event Report ID No.: CO16-I16-23

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Agreement State Event Number: 52311
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: THE NEBRASKA MEDICAL CENTER
Region: 4
City: OMAHA State: NE
County:
License #: 01-88-01
Agreement: Y
Docket:
NRC Notified By: BRYAN MILLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/20/2016
Notification Time: 15:16 [ET]
Event Date: 10/13/2016
Event Time: [CDT]
Last Update Date: 10/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - DIAGNOSTIC RADIOACTIVE SOURCE MISSING

On the morning of 10/13/16, a patient received a diagnostic 0.297 mCi I-125 seed implant to characterize a breast lesion. That afternoon, the tissue and implanted seed were removed and sent to pathology for assessment. The bio-waste was received in pathology as a non-radioactive sample contrary to hospital procedures. A subsequent search of the pathology lab could not locate the missing source.

The State of Nebraska was notified of the incident on 10/19/16.

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: 52320
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF YEAGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/27/2016
Notification Time: 00:49 [ET]
Event Date: 10/26/2016
Event Time: 23:00 [EDT]
Last Update Date: 10/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 98 Power Operation 98 Power Operation

Event Text

SECONDARY CONTAINMENT TECHNICAL SPECIFICATION NOT MET

"On October 26, 2016, at 2300 EDT, high wind conditions encountered on site resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met numerous times. The duration of time that the secondary containment Technical Specification was not met was approximately one second for each instance.

"All plant equipment responded as required to the changing environmental conditions and Reactor Building HVAC returned secondary containment pressure within TS limits. At 2300 EDT, secondary containment vacuum was greater than the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) and steady, and the LCO was exited. There were no radiological releases associated with this event. A review indicates that this condition occurred earlier this shift during the high wind condition.

"Declaring secondary containment inoperable is reportable under 10CFR50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material.

"The licensee has notified the NRC Resident Inspector ."

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Power Reactor Event Number: 52321
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: RYAN TREGRE
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/27/2016
Notification Time: 08:26 [ET]
Event Date: 10/27/2016
Event Time: 00:21 [CDT]
Last Update Date: 10/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby

Event Text

LOSS OF CHARGING AND LETDOWN SYSTEMS FROM THE REACTOR COOLANT SYSTEM

"At 0021 [CDT] on 10/27/16, Waterford 3 (WF3) experienced a loss of the charging and letdown systems from the Reactor Coolant System (RCS). Technical Specification (TS) 3.0.3 was entered due to the loss of all three charging pumps. Charging Pump AB was restored and aligned to replace Charging Pump A and WF3 exited TS 3.0.3 at 0055 on 10/27/16.

"The cause of the loss of charging pumps was due to Refueling Water Storage Pool to Charging Pumps Suction Isolation, CVC-507, not opening as expected following a loss of Static Uninterruptible Power Supply (SUPS) 014AB during electrical troubleshooting. The cause of CVC-507 not opening is being investigated. Power was restored to SUPS 014AB at 0022.

"WF3 is currently stable in Mode 3 with decay heat being removed by the Steam Bypass Control System. Pressurizer Level was maintained throughout the event. WF3 was previously shut down for reasons unrelated to this event.

"The NRC Resident Inspector has been notified."

Valve CVC-183 closed when the power supply was lost. CVC-183 is the Volume Control Tank outlet isolation valve. Waterford 3 will remain in mode 3 until the issue has been corrected.

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Part 21 Event Number: 52324
Rep Org: EMERSON FISHER CONTROLS INTL LLC
Licensee: EMERSON FISHER CONTROLS INTL LLC
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KIM SAGAR
HQ OPS Officer: DANIEL MILLS
Notification Date: 10/27/2016
Notification Time: 16:43 [ET]
Event Date: 08/30/2016
Event Time: [CDT]
Last Update Date: 10/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
BLAKE WELLING (R1DO)
EUGENE GUTHRIE (R2DO)
PATTY PELKE (R3DO)
THOMAS FARNHOLTZ (R4DO)
PART 21/50.55 REACT (EMAI)
PART 21 MATERIALS (EMAI)

Event Text

PART 21 - POTENTIAL ISSUE WITH SEISMIC QUALIFICATION OF TYPE 546NS ELECTRO-PNEUMATIC TRANSDUCERS

The following was received via email:

"Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International LLC ('Fisher') is providing required written interim notification of a potential failure to comply concerning Type 546NS Electro-Pneumatic Transducer Qualification Reports.

"On August 30, 2016, Fisher became aware of a potential issue with the past qualification of the Type 546NS Transducers. Fisher's published seismic literature and certifications, based on testing by a 3rd party laboratory, exhibit inconsistencies when compared to more recent testing completed by Fisher. Regardless of these discrepancies, the Type 546NS Transducer remains qualified to perform before and after seismic loading. The scope of this investigation pertains only to operability during seismic events.

"An extent-of-condition investigation is underway and 546NS testing data is being evaluated to determine if further testing is required. Fisher will complete the investigation by November 27, 2016 and, if necessary, will complete additional testing by February 10, 2017.

"Should there be any further questions concerning this matter, please contact Benjamin Ahrens, Manager, Quality by email at Benjamin.Ahrens@Emerson.com or via phone at 641-754-2249."

Page Last Reviewed/Updated Friday, October 28, 2016
Friday, October 28, 2016