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Event Notification Report for March 24, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2017 - 03/24/2017

** EVENT NUMBERS **


52253 52480 52612 52613 52614 52630 52631 52632 52636

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52253
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: HENRY WATERS
HQ OPS Officer: VINCE KLCO
Notification Date: 09/19/2016
Notification Time: 21:40 [ET]
Event Date: 09/19/2016
Event Time: 15:50 [CDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK JEFFERS (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 87 Power Operation 87 Power Operation

Event Text

CONTROL ROOM EMERGENCY VENTILATION CHARCOAL NOT MEETING ACCEPTANCE CRITERIA

"At 1550 [CDT] on September 19, 2016, Dresden received the Methyl Iodide Penetration test results for the Control Room Emergency Ventilation (CREVS) charcoal. The test results did not meet technical specification acceptance criteria. This results in the inoperability of CREVS. CREVS is a single train system and therefore is reportable per 10CFR50.72(b)(3)(v)(D). The Air Filtration Unit (AFU) is required to operate during a design basis accident to maintain Main Control Room habitability. This places unit 2 and unit 3 in a 7 day LCORA [Limiting Condition of Operation Required Action] per Tech Spec 3.7.4 Required Action A.1."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1635 EDT ON 03/23/17 FROM HENRY WATERS TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"The purpose of this notification is to retract ENS notification 52253 made on September 19th, 2016, for Dresden Nuclear Power Station. After further evaluation and testing, it has been determined that the Control Room Emergency Ventilation System (CREVS) charcoal would have fulfilled its safety function given the Methyl Iodide Penetration test results. The initial tests were performed with a 2 inch bed depth due to a difference in batches used in each charcoal filter, but testing at a 4 inch bed depth is the correct testing methodology for Dresden's configuration. At a 4 inch bed depth, the test results met the Technical Specification acceptance criteria with significant margin. Therefore, this event does not meet the criteria of 10 CFR 50.72(b)(3)(v)(D) and the ENS report is being retracted."

The NRC Resident Inspector has been notified.

Notified R3DO (Orlikowski).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52480
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARK HAWES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/10/2017
Notification Time: 22:45 [ET]
Event Date: 11/10/2016
Event Time: 16:04 [EST]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
PART 21/50.55 REACT (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 67 Power Operation 67 Power Operation

Event Text

PART 21 - FAILURE OF POWER SUPPLIES TO MEET VOLTAGE STABILITY SPECIFICATIONS

"This notification is a 10 CFR 21.21(a)(2) interim report for power supply model N-2ARPS-A6. Two instrument power supplies for the 'B' Residual Heat Removal (RHR) system were being bench tested prior to installation when it was discovered that they failed to meet Vendor Technical Manual specifications for voltage stability for varying loads. The deviation was a voltage drop of approximately 300mV. This did not meet the specification of less than 150mV when varying current from 5 amps (full load) to 2.5 amps. A second replacement power supply exhibited a similar 300 mV drop.

"James A. FitzPatrick (JAF) reviewed the work order instructions to determine if there was a deviation from the recommendations in the Foxboro technical manual F180-0309 Spec 200 Multinest Power Supply 2ARPS Series calibration. Since as-found voltage readings were within the required tolerance of the RHR instrument loops, the power supplies appear to have been capable to perform their intended function. However, this evaluation did not troubleshoot why the power supplies failed to meet the calibration requirements.

"The power supplies were sent to a repair vendor. The input from this vendor is expected to allow JAF to complete the evaluation per 10 CFR 21.21(a)(1) by March 21, 2017, and a notification for failure to comply or defect per 10 CFR 21.21(d)(3)(i) is expected by March 24, 2017, if necessary. This notification is being submitted as an interim report per 10 CFR 21.21(a)(2)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTED AT 1705 EDT ON 03/23/17 FROM MARK HAWES TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"The testing vendor Argo Turboserve Corp provided input to this condition in Non Conformance Report NC161. Engineering reviewed NC161 and discussed this condition with the vendor. The power supplies showed an initial drift following a 100 hour burn-in but continued operation was stable. Therefore, even though the initial voltage drift did not meet the power supply's calibration requirement in F180-0309, it would not be expected to drift significantly further. Engineering concluded that this condition will have a negligible impact on system components. Readings were steady and within the tolerance of the RHR instrument specification. Based on all current information, the component will function over its mission time of 100 days.

"Based on these results, a notification for failure to comply or defect per 10 CFR 21.21(d)(3)(i) is not required and the interim report per 10 CFR 21.21(a)(2) may be retracted."

The licensee informed the NRC Resident Inspector. Notified R1DO (Bickett) and Part 21 Group via email.

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Agreement State Event Number: 52612
Rep Org: COLORADO DEPT OF HEALTH
Licensee: FRONT RANGE INSPECTIONS
Region: 4
City: LITTLETON State: CO
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/15/2017
Notification Time: 16:22 [ET]
Event Date: 03/15/2017
Event Time: 09:00 [MDT]
Last Update Date: 03/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

COLORADO AGREEMENT STATE REPORT - MISSING CO-57 ANALYZER SOURCE

The following information was obtained from the state of Colorado via email:

"The general license section of the Radioactive Materials Program [at the Colorado Department of Public Health and Environment (CDPHE)] sent out annual notifications requesting response regarding a Cobalt 57, 0.165 mCi, FA4C Analyzer Source serial #C9285 distributed under Edax Portable Products Division back in July 22, 1996. After 10 years of sending a report requesting information to the [business] address with no response, our [CDPHE] general license section is closing out this record."

Colorado Event Report ID No.: CO17-0007

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: 52613
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: JOHNS HOPKINS UNIVERSITY
Region: 1
City: BALTIMORE State: MD
County:
License #: MD-07-005-05
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/16/2017
Notification Time: 09:44 [ET]
Event Date: 03/15/2017
Event Time: [EDT]
Last Update Date: 03/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR ROD STUCK IN UP POSITION

The following report was received from the Maryland Radioactive Materials Division via email:

"This afternoon [3/15/17], our [Johns Hopkins University (JHU)] JL Shepherd Mark I irradiator malfunctioned. This is a manual model. The source is lifted up into position by a knob that lifts a rod attached to the source. When lifting the knob up, the rod became jammed. The rod is stuck in an up position, slightly past halfway. It will not move up or down.

"JL Shepherd was called for help. One suggestion was to move the knob slightly from side to side while lifting or lowering. This had no effect. Because this is a manual model not much can be done besides a repair by manufacturer. The technician [at JL Shepherd] said the most likely cause was due to some part (bearing, spring, etc.) falling down into transfer tube causing it to jam.

"The irradiator's power supply is controlled by computer and is off now. The door latch on the irradiator is locked. The alarming area radiation monitor on the irradiator door is on and functioning. The key to both the irradiator controller and the door latch have been removed from the irradiator room. The irradiator room is locked and monitored by corporate security and a Remote Monitoring System. The irradiator room is only accessible to approved individuals. Because this unit is a self-shielded irradiator, radiation levels outside the unit are minimal, <0.2 mR/hr) even with the source being partially exposed inside. There is no sample inside the chamber. There is no way to physically open the irradiator door due to an electric interlock. The interlock will not function without power and will not function without the rod in the fully down position. A sign has been put on the irradiator, 'Do Not Use'.

"JL Shepherd was scheduled to visit [the JHU] site to calibrate another irradiator in March. On Thursday we [JHU] will find out when we [JHU] can have a technician here to fix the problem.

"Source Make: J.L. Shepherd and Associates
Source Model: 6810-G
Source Serial #: 81Cs-S14
NSTS Source ID Number: 6729
Isotope: Cs-137
Activity: 5329 Ci
Activity Date: 02/25/2017"

MD Event Report ID No.: 52613

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Non-Agreement State Event Number: 52614
Rep Org: SIOUXLAND UROLOGY CENTER
Licensee: SIOUXLAND UROLOGY CENTER
Region: 4
City: DAKOTA DUNES State: SD
County:
License #: 40-34223-01
Agreement: N
Docket:
NRC Notified By: RUSS RUPOLO
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/16/2017
Notification Time: 14:28 [ET]
Event Date: 03/16/2017
Event Time: 08:00 [CDT]
Last Update Date: 03/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - PATIENT DOSAGE HIGHER THAN PRESCRIBED

At approximately 0800 CDT today, a patient was treated with 110 Palladium-103 seeds (1.68 milliCuries each) to the prostrate. The quantity was determined by calculation for a prescribed dose of 125 Gy, however the calculation was incorrect. The mistake was discovered after the patient's treatment. Only 80 seeds should have been implanted. The activity injected is 38 percent higher than prescribed.

The referring physician has been notified. The physician is notifying 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.

* * * UPDATE FROM GREG HAAR TO BETHANY CECERE VIA EMAIL 1241 EDT ON 3/17/17 * * *

"This email is to confirm our notification to the NRC of a possible medical event that occurred during an LDR [Low Dose Rate] brachytherapy prostate seed implant at our clinic on (3/16/2017) at approximately 0800 [CDT]. The associated license number is #40-34223-01.

"The procedure was a Palladium-103 implant, with a prescribed dose of 125 Gy. The implant was using Pd-103 seeds with an average activity of 1.68 milliCuries per seed. During this implant, 110 seeds were implanted into the patient instead of 80 seeds. This resulted in a total implanted activity of 184.8 milliCuries, which we estimate to exceed the prescribed dose to the patient by 20 percent.

"The patient and the referring physician have been notified."

Notified R4DO (O'Keefe) and NMSS Events Notification (email).

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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Power Reactor Event Number: 52630
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAMON FEGLEY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/23/2017
Notification Time: 02:48 [ET]
Event Date: 03/23/2017
Event Time: 00:14 [EDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 16 Power Operation 3 Startup

Event Text

AUTOMATIC START OF AUXILIARY FEED WATER

"On March 23, 2017, at 0014 EDT, Watts Bar Nuclear Plant Unit 2 (WBN2) experienced an unplanned trip of both Turbine Driven Main Feed Pumps (TDMFP) following a loss of Main Condenser Vacuum. The trip of both TDMFPs caused an automatic start of both Motor Driven Auxiliary Feed Water Pumps and the Turbine Driven Auxiliary Feed Water Pump. [The] cause of the loss of Main Condenser Vacuum is currently under investigation."

The plant was performing a normal startup, and had just synced the main generator to the grid. Subsequent to the event, the plant was transitioned to Mode 3. All rods are fully inserted. Decay heat is being removed via the atmospheric relief valves.

Unit 1 remains in Mode 5 for a refueling outage.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52631
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TIM GATES
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/23/2017
Notification Time: 07:24 [ET]
Event Date: 03/23/2017
Event Time: 02:56 [CDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES DRAKE (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

Event Text

HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE

"River Bend Station personnel declared the High Pressure Core Spray (HPCS) system inoperable at 0256 on 3/23/2017.

"During performance of the HPCS Pump and Valve Operability Test, the operators observed an unusual system response after E22-MOVF023 (HPCS Test Return to the Suppression Pool) was stroked closed. A field check showed that the key that connects the E22-MOVF023 valve stem to the anti-rotation device had become dislodged.

"E22-MOVF023 is a Primary Containment Isolation Valve (PCIV) and is designed to close automatically on an ECCS [Emergency Core Cooling System] initiation signal to ensure that injection flow is directed to the reactor vessel. Technical Specification (TS) 3.6.1.3 requires that containment penetrations associated with an inoperable PCIV be isolated. E22-MOVF023 was declared inoperable at 0028. Operators were unable to close or demonstrate that E22-MOVF023 was fully closed as required by TS 3.6.1.3 and proceeded to isolate the associated containment penetration by closing other system valves. This action was completed at 0320.

"The net effect of the actions taken to isolate the containment penetration is that HPCS is inoperable as of 0256. This results in 14 day LCO."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM DAN JAMES TO KARL DIEDERICH ON 3/23/17 AT 10:01 EDT * * *

The Event Time was 0028 CDT rather than 0256 CDT. "The scheduled surveillance test of the high pressure core spray system was initiated at 2355 CDT on March 22, and the pump was secured at 0028 CDT on March 23. The inspection of the HPCS test return valve to the suppression pool occurred at 0050 CDT, and it was at that point that an apparent malfunction of the valve had occurred to the extent that it did not appear to be able to perform its safety function to close upon receipt of a design basis system initiation signal. Thus, the event time for this condition would be more accurately defined as 0028 CDT."

Notified R4DO (James Drake) via e-mail.

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Power Reactor Event Number: 52632
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DONALD TOWNSEND
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2017
Notification Time: 13:55 [ET]
Event Date: 03/23/2017
Event Time: 06:00 [PDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JAMES DRAKE (R4DO)
FFD GROUP (EMAI)

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

FITNESS-FOR-DUTY REPORT INVOLVING DISCOVERY OF KOMBUCHA TEA INSIDE THE PROTECTED AREA

An employee reported finding a container of herbal tea (Kombucha) in the Administrative Building refrigerator which is inside the Protected Area. Kombucha tea is a fermented tea containing trace amounts of alcohol. A similar incident occurred on 6/16/2016. The licensee issued a communication to all employees at that time identifying that Kombucha tea is not permitted on-site.

The licensee will re-issue their communication to all employees and continue their investigation to identify who may have brought the tea on-site.

The licensee informed the NRC Resident Inspector and R4 (Haire).

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Power Reactor Event Number: 52636
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RYAN RODE
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2017
Notification Time: 21:06 [ET]
Event Date: 03/23/2017
Event Time: 03:25 [CDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
FFD GROUP (EMAI)

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 N 0 Cold Shutdown 0 Cold Shutdown

Event Text

SIGNIFICANT FFD POLICY VIOLATIONS OR PROGRAMMATIC FAILURES

"On 3/23/17, at 0325 hours CDT, it was discovered that a prohibited item was present in the protected area from 0508-1718 hours on 3/22/17, which resulted in a reportable condition pursuant to 10 CFR 26.719(b)(1).

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Friday, March 24, 2017
Friday, March 24, 2017