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Event Notification Report for February 9, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/08/2017 - 02/09/2017

** EVENT NUMBERS **


52517 52520 52521 52524 52525 52537 52539 52542 52543 52544

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52517
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN CARTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/29/2017
Notification Time: 16:30 [ET]
Event Date: 01/29/2017
Event Time: 02:09 [CST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
JESSE ROLLINS (R4DO)

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

Event Text

LOSS OF BOTH DIVISIONS OF CONTROL BUILDING CHILL WATER AND VENTILATION SYSTEM

"At 0209 CST, on January 29, 2017, while the plant was in MODE 4 for a refueling outage, the main control room crew removed the AC/DC inverter in the Division 1, 120 VAC electrical distribution system from service due to an equipment malfunction. Removing the inverter from service caused a loss of the associated 120 VAC instrument buss. This instrument buss loss caused a trip of the Division 1 Control Building Chill Water and Ventilation system. The Division 2 Control Building Chill Water and Ventilation System was locked out for surveillance testing at the time of the equipment failure. This condition rendered both divisions of Control Building Chill Water and Ventilation Systems unable to perform the support function for cooling Division 1 and 2 AC and DC power distribution systems. These systems are required to support the operability of two required divisions of shutdown cooling. Division 2 Shutdown Cooling System was in service and remained in service through out the event.

"The Division 2 Control Building Chill Water and Ventilation System was returned to service at 0220 CST on January 29, 2017.

"Division 1 Control Building Chill Water remains inoperable pending restoration with the installed backup Division 1 DC/AC inverter. Actions are ongoing to place this component in service and restore the associated 120 VAC instrument buss.

"The equipment malfunction was limited to the Division 1 inverter. The investigation of the inverter failure is ongoing. This condition is being reported in accordance with 10 CFR 50.72(b)(3)(v)(B).

"The NRC Senior Resident Inspector has been notified."

* * * RETRACTION ON 2/8/17 AT 1617 EST FROM STEVEN CARTER TO DONG PARK * * *

"Engineering has previously performed an evaluation for a loss of Control Building Chill Water and Ventilation, reference Engineering Change-58699. Based on the evaluation, it can be determined that in the event of a Loss of Coolant Accident with a loss of Offsite Power, a loss of all Control Building cooling the Inverter, Battery, and Switchgear Rooms will not exceed 122 deg. F for 2.80 hours or greater with no operator actions required. The 2.8 hours is based on the switchgear room inverters operating which is bounding for the case where the DC equipment room inverters are operating. The 122 deg. F criterion is significant because that is the manufacturer ambient maximum temperature for the Division 3 DC Equipment Room. This is the limiting temperature for the Battery, Inverter, and Switchgear Rooms.

"During the event, operators performed the dedicated actions of AOP-0060 Loss of Control Building Ventilation and restored Division II Chill Water and Ventilation in 11 minutes. All required actions are in the Control Building, either in the Main Control Room or on the 98 foot Elevation. There are no radiological concerns in the Control Building, such as high radiation areas or contaminated areas. Per Engineering Change-58699, assuming a single operator error, the total time to recover from a single operator error and to complete the standby chiller realignment and start is 76 minutes ([approximately] 1.3 hours) which is less than half of the 2.8 hours established in Engineering Change-58699. Therefore, there was no loss of safety function for Control Building Chill Water and Ventilation."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Warnick).

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Non-Agreement State Event Number: 52520
Rep Org: WASHINGTON UNIVERSITY
Licensee: WASHINGTON UNIVERSITY
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-0016711
Agreement: N
Docket:
NRC Notified By: SUSAN M. LANHORST
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/31/2017
Notification Time: 10:15 [ET]
Event Date: 04/08/2016
Event Time: [CST]
Last Update Date: 01/31/2017
Emergency Class:
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

PATIENT DELIVERED RADIATION DOSE TO RIGHT LOBE OF LIVER VERSUS LEFT LOBE

The following was received via email:

"On 4/8/2016 a patient was being treated with Y-90 TheraSpheres. Written directive prescribed 4.15 GBq (117 mCi) Y-90 TheraSpheres to the left liver lobe. The catheter placement was confirmed by the Interventional Radiologist with an angiogram to administer the microspheres to the left liver lobe. The dose of 4.07 GBq of Y-90 TheraSpheres was administered. This patient was part of a study to image the location of the Y-90 TheraSpheres using a PET/MRI unit. The PET/MRI images were taken on 4/15/2016 and were read by a Radiation Oncology Authorized User on 4/16/2016. The PET/MRI images indicated that the majority of the microspheres were deposited in the right liver lobe. The Radiation Safety Officer (RSO) was immediately notified. Evaluation of the incident in accordance with the 'Yttrium-90 Microsphere Brachytherapy Sources and Devices TheraSphere and SIR-Spheres Licensing Guidance' (February 12, 2016, Revision 9) event reporting criteria was done by the RSO, Radiation Safety Committee (RSC) Chairman, Management and Radiation Oncology and the incident was judged not to be a medical event due to unintentional patient intervention. The patient and the physician were notified of the incident.

"The RSO has been discussing this incident with the University's NRC Region III Lead Inspector [Gattone] over the past few weeks. The Inspector let the RSO know that NRC Headquarters and Region III had determined that the incident is a medical event. The Inspector requested on 1/30/2017 that the RSO report the medical event to the NRC Operations Center."

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: 52521
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: NDE SOLUTIONS, LLC
Region: 4
City: BRYAN State: TX
County:
License #: L05879
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/31/2017
Notification Time: 15:05 [ET]
Event Date: 01/30/2017
Event Time: [CST]
Last Update Date: 01/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following report was received via e-mail:

"We [Oklahoma Department of Environmental Quality] have just been informed of an incident which occurred yesterday (1/30/2017) involving the failure of an industrial radiography source to retract. The licensee was NDE Solutions, LLC (TX license L05879) operating out of Bryan, TX. The incident occurred at a temporary job site near Checotah, OK. The licensee was working in Oklahoma under reciprocity. According to the report the drive cable failed, it isn't clear whether the source just wouldn't retract or became disconnected. The source was retrieved yesterday. The drive cable has been removed from service and is being returned to Texas."

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Non-Agreement State Event Number: 52524
Rep Org: HENRY FORD HOSPITAL
Licensee: HENRY FORD HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: 21-04109-16
Agreement: N
Docket:
NRC Notified By: ALAN JACKSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/01/2017
Notification Time: 15:13 [ET]
Event Date: 01/31/2017
Event Time: 10:51 [EST]
Last Update Date: 02/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

POTENTIAL MEDICAL EVENT

A patient at the Henry Ford Hospital Interventional Radiology Department was prescribed a Y-90 Theraspheres treatment of 60 Gray to the left lobe of the liver. The Interventional Radiologist administered 46 Gray total to both the right and the left lobe of the liver. The referring physician has been notified and the licensee has notified the patient. It is believed that this event will not result in any harm to the patient. The licensee is in the process of determining corrective action to prevent reoccurrence.

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: 52525
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: OLSSON ASSOCIATES
Region: 4
City: OMAHA State: NE
County:
License #: 02-34-01
Agreement: Y
Docket:
NRC Notified By: LARRY HARISIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/01/2017
Notification Time: 15:41 [ET]
Event Date: 02/01/2017
Event Time: 11:00 [CST]
Last Update Date: 02/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST/FOUND MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on February 1, 2017, by a representative from Olsson Associates, of a loss and subsequent return of licensed material from the back of a pickup truck on Wednesday, February 1, 2017, in Omaha, Nebraska. The licensed material is a Troxler 3400 series moisture density gauge, serial number 19309, containing 9 mCi of Cs-137 and 44 mCi of Am:Be. The licensee reported to the State that an employee placed the licensed material on the back of the pickup truck and not in the yellow shipping case, and drove away from a temporary jobsite. While the employee made a right hand turn, the Troxler gauge fell out of the truck. A vehicle that was passing nearby found the Troxler gauge and returned it to the licensee about 10 minutes after the employee notified the Radiation Safety Officer. The gauge was visually inspected and no physical damage was found. The gauge was also surveyed to confirm the presence of the source. No elevated readings were found. The licensee has locked the gauge in the yellow shipping container and removed it from service. A follow-up site visit is scheduled and a 30 day written report is to follow."

Nebraska Event: NE-17-0001

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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Part 21 Event Number: 52537
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: FISHER CONTROLS INTERNATIONAL LLC
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KIM SAGAR
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/08/2017
Notification Time: 11:17 [ET]
Event Date: 01/02/2017
Event Time: [CST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
50.55(e) - CONSTRUCT DEFICIENCY
Person (Organization):
SHANE SANDAL (R2DO)
MICHAEL KUNOWSKI (R3DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - VALVE ASSEMBLY NONCONFORMANCE

"Subject: 3" Style HPNS Valve Body/Cage/Plug Retainer Binding

"Equipment Affected by this Fisher Information Notice: Items subject to this Fisher Information Notice (FIN) are confined to the equipment and orders
referred to in Appendix A attached. Specifically, affected equipment refers to the 3" style HPNS valve body for next-generation nuclear plants and its associated cage and plug retainer.

"Purpose: The purpose of this FIN is to alert affected customers that, as of 2 January 2017, Fisher Controls International LLC (Fisher) became aware of a situation which may affect the performance of the aforementioned equipment, including its safety-related function. Fisher is informing affected customers of this circumstance in accordance with Section 21.21(b) of 10 CFR 21.

"Applicability: This FIN applies only to the equipment identified in Appendix A, which lists serial numbers and order numbers that were delivered to customers. Specifically, it applies to the Fisher 3 style HPNS valve body assembly, sold to AP1000 next generation plant sites, Commodity Package PV14, Datasheet 111.

"Discussion: During plant hot functional testing, certain valve assemblies did not achieve full travel. Upon disassembly, site inspection found wear between the cage and plug retainer in some valves. Vertical scratches in the cage internal diameter and plug retainer outside diameter was confirmation of galling which prohibited full travel. In one valve, the cage could not be removed from the body as it was friction-welded due to galling.

"The valve body-to-cage interference is attributed to body-to-bonnet gasket compression which caused the valve body gasket groove to distort/yield, particularly the cage guide internal diameter bore. Regarding the cage-to-plug retainer binding, thermal expansion calculations
between cage internal diameter and plug retainer outside diameter indicate an undersized diametrical clearance at temperature.

"Extent of Condition: In addition to the equipment listed in Appendix A, all other style HPNS designs (NPS 1/2, 1, 2, 3, 4, 6, and 8) were examined for extent of condition. Results indicate that DS111 was a lone outlier and this issue is not expected to occur for the other sizes, material combinations and datasheets sold into their respective applications and temperatures. Arrangements have been made with the customers to replace or maintenance the trim for the equipment listed in Appendix A. In addition, a Corrective Action Request (CAR 1817) has been initiated by Fisher to prevent reoccurrence of this issue.

"10 CFR 21 Implications: Fisher requests that the recipient of this FIN review it and take appropriate action in accordance with 10 CFR 21. If there are any technical questions or concerns, please contact: Ben Ahrens, Quality Manager, Emerson Automation Solutions, Fisher Controls International LLC, 301 South First Avenue, Marshalltown, IA 50158, Phone: (641) 754-2249, F (641) 754-2830."

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Power Reactor Event Number: 52539
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN TUITE
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/08/2017
Notification Time: 13:04 [ET]
Event Date: 12/15/2016
Event Time: 13:32 [EST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
SHANE SANDAL (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

60 DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID CONTAINMENT VENTILATION ISOLATION ACTUATION

"This 60 day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an Invalid Containment Ventilation Isolation (CVI) actuation at Watts Bar Nuclear Plant (WBN) Unit 2.

"On December 15, 2016 at 1332 Eastern Standard Time (EST), Unit 2 maintenance personnel were preparing to perform a breaker swap for the normal feed to the 2B1B C and A vent board. When the power was removed from Radiation Monitor 2-RM-90-131, the B Train master isolation signal status panel was unexpectedly lit for CVI. The only automatic action observed from the containment isolation status panel was that 2-FCV-30-037, Lower Compartment Purge Control valve, went closed. The loss of power to 2-RM-90-131 de-energized the relay associated with the high radiation setpoint, resulting in an invalid Train B CVI actuation.

"During this event, the train B CVI actuation was complete and equipment functioned as designed. Upon identification of the Train B CVI, maintenance activities were halted and a prompt investigation was initiated. WBN found that the work order to perform the breaker swap was planned to lift leads to disable actuation of CVI. The work order lifted the lead for the K622 relay, which was insufficient to prevent the actuation. Two other leads on relays should have been lifted to prevent the actuation in Mode 1. A contributor to this error was that this work had been rescheduled several times prior to actual performance. From the time it was planned to the actual performance, mode changes had been performed on the Unit and no further reviews were performed.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 52542
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: ADAM SCHUERMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/08/2017
Notification Time: 17:06 [ET]
Event Date: 02/08/2017
Event Time: 08:51 [CST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

TECHNICAL SUPPORT CENTER EMERGENCY VENTILATION SYSTEM INOPERABLE

"At 0851 CST on Wednesday, February 8th, 2017, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) Emergency Ventilation System was emergently declared inoperable due to a failure of the outside air damper to reposition. This resulted in the inability for the TSC ventilation to maintain the required air flow to support habitability during emergency conditions. Actions are being taken to repair damper to restore functionality of the TSC ventilation system. In the interim, station procedures provide guidance to relocate the TSC to an alternate facility. This event is being reported under 10 CFR 72(b)(3)(xiii), Any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52543
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JASON WIGGINS
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/08/2017
Notification Time: 17:31 [ET]
Event Date: 02/08/2017
Event Time: 11:51 [EST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SHANE SANDAL (R2DO)

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 INOPERABLE DUE TO DEGRADED DC TO AC INVERTER

"During a control room panel walk down by an on-shift Reactor Operator at approximately 1151 [EST] on 2/8/2017, Unit 1 High Pressure Coolant Injection (HPCI) suction and discharge pressure indicators were noted to be downscale. I & C investigated and found the output of 1E41K603, DC to AC inverter, degraded. This inverter also powers the HPCI flow controller. Without the flow controller HPCI would not auto-start to mitigate the consequences of an accident, thus HPCI was declared inoperable. All other emergency core cooling systems and the Reactor Core Isolation Cooling (RCIC) system remain operable.

"HPCI is a single train system with no redundant equipment in the same system, thus this failure is reportable as an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident, 10CFR50.72(b)(3)(v)(D).

"Inverter 1E41K603 was replaced and functionally tested satisfactorily at 1630 on 2/8/2017, restoring HPCI to operable status."

The NRC Resident Inspector was notified.

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Power Reactor Event Number: 52544
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROB EISENMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/08/2017
Notification Time: 22:19 [ET]
Event Date: 02/03/2017
Event Time: 20:24 [EST]
Last Update Date: 02/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
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

UNANALYZED CONDITION DUE TO UNACCOUNTED LOADS IN SAFE SHUTDOWN ANALYSIS

"On February 3rd, 2017, during engineering modification reviews of electrical busses for a station switchyard transformer, electrical loads were identified on 4kV breakers that are not accounted for in the current safe shutdown analysis. Further reviews revealed the unanalyzed loads are associated with 26 cables that are routed through multiple fire zones in the Turbine Building and both Unit 1 and Unit 2 4kV rooms that have the potential to be affected from a fire event. Per NFPA 805 requirements, the cables need to be analyzed for overcurrent trip capability to demonstrate that the breakers will isolate a fault for a fire.

"Hourly Fire Watch tours have been established in the identified fire zones. The public health and safety is not impacted. This notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition.

"The NRC Resident Inspector was notified. This is a late notification for the 8 hour report."

Page Last Reviewed/Updated Thursday, February 09, 2017
Thursday, February 09, 2017