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Event Notification Report for May 24, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/23/2017 - 05/24/2017

** EVENT NUMBERS **


52646 52754 52755 52759 52760 52767 52768 52769

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52646
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RAUL MARTINEZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/29/2017
Notification Time: 03:28 [ET]
Event Date: 03/28/2017
Event Time: 19:57 [CDT]
Last Update Date: 05/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS HIPSCHMAN (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

UNANALYZED CONDITION FOR A POSTULATED MODERATE ENERGY LINE BREAK

"On March 28, 2017 at approximately 1957 CDT, a condition was discovered whereby a postulated moderate-energy line break (MELB) involving three fire protection (FP) pipe segments in the Safeguards Building did not contain MELB shielding. It was subsequently determined a postulated crack in one of the affected FP piping sections could adversely affect circuitry associated with the cooling support system for the train A RHR [Residual Heat Removal] pump room, potentially causing the ventilation system to be unavailable to support operation of the train A RHR pump. This condition is not consistent with the CPNPP licensing basis for the protection of essential safe shutdown RHR equipment.

"At approximately 1957 CDT train A RHR was declared inoperable but available and the unit entered a seventy-two hour LCO [Limiting Condition for Operation] Action Statement per Technical Specification 3.5.2 B pending completion of mitigative actions.

"Since Unit 1 train B RHR system components and related supporting equipment have been periodically declared inoperable at various times in the last three years for surveillance testing or maintenance, given the MELB condition, both trains of RHR and or support equipment could have been inoperable and this represents an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B). At the time of discovery, train B RHR and support equipment were operable. Therefore, the identified condition is not reportable as a loss of safety function per 10 CFR 50.72(b)(3)(v).

"The Senior NRC Resident Inspector has been notified."

Compensatory actions will include installing a spray shield on the affected cable trays.

* * * RETRACTION FROM JOHN ALEXANDER TO VINCE KLCO ON 5/23/17 AT 1720 EDT * * *

"On 03/29/2017 Comanche Peak reported an ENS Report (no. 52646) related to the identification of potential moderate-energy line break (MELB) considerations in the Safeguards Building and the potential for adverse interaction with specified Unit 1 electrical equipment. The specific interactions of concern were related to ventilation equipment which would support operation of the Unit 1 A RHR train and several segments of fire protection piping.

"Subsequent investigations by Engineering have determined: (1) all but one of the suspected potential interactions were determined to not be credible, i.e., the potential MELB would not result in an adverse interaction with the 'target' equipment, and (2) for the remaining potential interaction, an assessment of piping stresses determined there was not a credible MELB source in the affected piping segment and therefore there was not a potential for adverse interaction with the ventilation support equipment.

"Based on the above, the condition described in ENS report no. 52646 is not considered to be an un-analyzed condition as described in 10 CFR 50.72(b)(3)(ii)(B)."

The licensee informed the NRC Resident Inspector.

Notified the R4DO (Groom).

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Agreement State Event Number: 52754
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: GREENVILLE HEALTH SYSTEM CANCER INSTITUTE
Region: 1
City: GREENVILLE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ANDREW M. ROXBURGH
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/15/2017
Notification Time: 11:58 [ET]
Event Date: 05/12/2017
Event Time: [EDT]
Last Update Date: 05/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE - DELIVERED DOSE TO PATIENT DIFFERED BY MORE THAN 20 PERCENT

The following report was received from the South Carolina Department of Health and Environmental Control (SCDEH) via email:

"The licensee notified the Department [SCDEH] on May 15, 2017 that it had a medical event on May 12, 2017 involving a delivered dose that differed by more than 20 percent and dose that would have resulted from the prescribed dosage by more than 0.5 Sv (50 rem) to an organ or tissue. The patient was prescribed 145 Gray from I-125 prostate seed implants. The dose delivered was 103.53 Gray which is 28.6 percent below the prescribed dose."

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: 52755
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TEAM INDUSTRIAL SERVICES, INC
Region: 4
City: GONZALES State: LA
County:
License #: LA-9098-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/15/2017
Notification Time: 17:24 [ET]
Event Date: 05/15/2017
Event Time: 11:50 [CDT]
Last Update Date: 05/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE - SOURCE UNABLE TO BE RETRIEVED INTO SHIELDED DEVICE

The following report was received from the Louisiana Department of Environmental Quality via email:

"[On] 05/15/2017, [at] 11:50 [CDT], the Radiation Safety Officer of Team Industrial Services, Inc. called the Radiation Section of LDEQ [Louisiana Department of Environmental Quality] to report a source retrieval that occurred on 05/14/2017 [at approximately] 18:00 [CDT] at the INDORAMA VENTURES OLEFINS Refinery is Sulphur, LA at 4300 Hwy 108, Westlake, LA 70669. The camera was being used on a gridded walkway to radiograph some construction material situated on a tripod. The tripod became unstable causing the material to fall and crimp the guide tube. The source was in the collimator and was unable to be retrieved into the shielded exposure device. A retrieval crew was assembled and they were able to retrieve the source and return it to the shielded position. Two radiographers and a site RSO [Radiation Safety Officer] conducted the retrieval activities. The retrieval process was safely completed at [approximately] 20:30 [CDT] on 05/14/2017.

"A radiography exposure device was a QSA Global Model 880D, S/N D12919 and the source was an AEA Technology Model A424-9. The exposure device was loaded with 85.7 Ci of Ir-192. The guide tube was a 7 ft. tube that utilized a collimator. The exposure device and source were returned to the office for storage until being evaluated. The crimped guide tube was tested for leakage and then sent for disposal. The area was restricted to the public and controlled for the employees of Indorama. The exposures to the retrievers were minimal."

LA Event Report ID No.: LA170008

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Agreement State Event Number: 52759
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ACUREN INSPECTION, INC.
Region: 3
City: WISCONSIN RAPIDS State: WI
County:
License #: 133-2008-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/16/2017
Notification Time: 14:02 [ET]
Event Date: 05/15/2017
Event Time: [CDT]
Last Update Date: 05/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PATRICIA MILLIGAN (EMAI)
GRETCHEN RIVERA-CAPE (NMSS)

Event Text

AGREEMENT STATE REPORT - POTENTIAL EXCESSIVE EXPOSURE OF RADIOGRAPHER

The following information was received from the Wisconsin Radiation Protection Section via email:

"On May 15, 2017, radiographers with Acuren Inspection, Inc. were performing radiography on a boiler at Verso Paper in Wisconsin Rapids, WI. They were utilizing an approximately 90 Ci Se-75 source, with a 17.5 HVL [Half Value Layer] collimator to perform shots through the boiler wall. The assistant radiographer would position a panel on the inside of the boiler wall and then move to the far side of the boiler. The main radiographer would then position the collimator for multiple shots from the outside of the boiler. They were in contact via radio. At approximately 7:45 p.m., following a shot, the main radiographer approached the collimator with his survey meter. As he approached, he realized the source had not yet been cranked in, and began walking back to crank it in. At that time, he was contacted via radio by the asst. radiographer. Setting down his survey meter, he had a 30-40 second conversation. Following the conversation, he forgot what he had been in the process of doing, and approached the collimator without his survey meter, and positioned it for the next shot. Turning to walk back, he spotted his survey meter on the ground halfway to the crank, remembered he had yet to crank it in, and realized he had been exposed. He was wearing a functioning alarming rate meter that did not alarm.

"Acuren notified the state approximately three hours after the event on the evening of the 15th of the possible overexposure. The radiographer initially estimated he had held the source 10 seconds, and Acuren calculated this would result in approximately a 680 Rad dose to the hands. The radiographer was wearing a direct reading dosimeter on his chest which read 100 mR. Other whole body dosimetry is being processed. Following the event, the licensee had the radiographer do a mock performance 3 times. These indicated he held the collimated source approximately 3-5 second in each hand. QSA global is currently performing an independent dose calculation and the radiographer has been removed from duty. The radiographer is not currently experiencing any symptoms of acute radiation exposure. The department has dispatched inspectors to perform a site inspection."

Wisconsin Event Report ID No.: WI-170007

* * * UPDATE ON 5/18/17 AT 1012 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *

The following update was received from the Wisconsin Radiation Protection Section via email:

"Wisconsin DHS [Department of Health Services] performed a site investigation on May 17, 2017. On the night of the event, there were approximately eight individuals supporting radiography at the temporary jobsite. Two individuals were performing radiography and the rest of the individuals were securing the boundaries. One radiographer was overexposed; no one else on the crew received an elevated dose due to the event. There was no exposure to members of the public. Inspectors confirmed that all radiography equipment (survey meters, alarming rate meters, etc.) was available and operational.

"The licensee determined that the radiographer held the collimator in his hands in a way that exposed his fingers to the uncollimated beam for several seconds on two separate occasions (once for each hand). The licensee contracted with a third-party to perform a dose assessment. The assessment shows a hand exposure of 176 rem per hand. DHS is evaluating these results.

"The radiographer's whole body badge was read by the dosimetry provider and showed a 152 millirem dose. This is consistent with the previously reported 100 mR direct-reading dosimeter exposure for May 15. Both the whole body badge and direct-reading dosimeter were located in the radiographer's left front shirt pocket.

"Wisconsin DHS is continuing to monitor the licensee's response, including medical follow-up of the affected individual."

Notified R3DO (Cameron), NMSS Events, NMSS (Rivera-Capella), and NSIR (Milligan) by email.

* * * UPDATE FROM MEGAN SHOBER TO VINCE KLCO ON 5/23/17 AT 1741 EDT * * *

The following information was received from the State of Wisconsin via facsimile:

" The source activity on the date of the incident was 96 curies."

Notified R3DO (Kunowski), NMSS Events, NMSS (Rivera-Capella), and NSIR (Milligan) by email.

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Agreement State Event Number: 52760
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: DESERT NDT, LLC
Region: 4
City: ELK CITY State: OK
County:
License #: OK-32104-01
Agreement: Y
Docket:
NRC Notified By: MICHAEL BRODERICK
HQ OPS Officer: VINCE KLCO
Notification Date: 05/16/2017
Notification Time: 23:40 [ET]
Event Date: 05/16/2017
Event Time: [CDT]
Last Update Date: 05/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - LICENSEE STRUCTURE DAMAGE DUE TO TORNADO

The Midwest Inspection Services building has been severely damaged by a tornado storm. All radiography cameras have been accounted for and are stored in a safe location. The vault is intact.

Tornados are forecasted to continue throughout the evening.

* * * UPDATE AT 1205 EDT ON 05/17/17 FROM MICHAEL BRODERICK TO JEFF HERRERA * * *

The following update was received from the Oklahoma Department of Environmental Quality via email:

"Shortly after 22:30 [CDT] on the evening of May 16th, Oklahoma DEQ [Department of Environmental Quality] verbally notified the HOO [NRC Headquarters Operations Officer] of an event affecting an Oklahoma radiography company. This is a follow-up report to confirm the verbal report and provide more details.

"Facility Name: Desert NDT, LLC dba Shawcor (note) the facility was historically known as Midwest Inspections, and was accidentally referred to by that name in the initial report.

"Facility license number: OK-32104-01

"Because of concern generated by news reports, DEQ [Oklahoma Department of Environmental Quality] contacted the facility at about 22:00 [CDT] and over the following few minutes, we were able to reach the facility manager. [The facility manager] reported that their licensed facility at Elk City had been largely destroyed by the tornado reported in the media. He indicated that the vault was mostly intact, but had damage to the ceiling. All power at the facility was out. [The facility manager] indicated they [Desert NDT] had fifteen cameras in the vault, and others were out in trucks on jobs around the region. [The facility manager] reported that they [Desert NDT] had done an inventory on the fifteen cameras in the vault, and confirmed that they were accounted for. [The facility manager] had no reports of problems with any sources dispatched on jobs. [The facility manager] explained that they [Desert NDT] did not regard the damaged vault as suitable for secure storage, but they [Desert NDT] had one radiography truck that was largely intact, and they [Desert NDT] were storing the fifteen cameras in one truck, and keeping the truck under constant surveillance by an employee who was authorized unescorted access. Media reports indicated that another storm, weaker than the first, but still having potential tornadoes was headed for the area. In a second call, the facility manager reported that because of concerns about further storms, they had moved the cameras into a storm shelter in [a secure location]. [The facility manager] indicated that the storm shelter was under surveillance, and was lockable, and would remain locked unless being directly accessed. In view of the remarkable circumstances, [Oklahoma] DEQ approved this arrangement as an interim measure. About 8:20 [CDT] on the morning of the 17th, [Oklahoma] DEQ contacted the manager again. [The facility manager] indicated that the fifteen cameras were still secured in the storm shelter. [The facility manager] reported that there was no known further damage during the night, and that the company would be conducting a confirmatory inventory of the fifteen cameras, and conducting an inventory to ensure that cameras out on jobs were safe and under control. [The facility manager] will report the results of this to [Oklahoma] DEQ when available. [The facility manager] explained that they were doing an assessment of undamaged trucks that were suitable for secure storage under Part 37, and that they planned to retain some sources at the Elk City facility using the trucks that were suitable. [The facility manager] indicated that excess sources would be moved to a licensed company facility out of state. [The facility manager] will follow up with [Oklahoma] DEQ later today.

"[Oklahoma] DEQ has used GIS [Geographic Information System] to identify seven other licensed facilities that are near the storm track, and are not considered as having as much concern. We [Oklahoma DEQ] contacted all of them by phone this morning and confirmed that all is well."

Notified the R4DO (Miller) and NMSS via email.

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Power Reactor Event Number: 52767
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: MICHAEL HOFFMASTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/23/2017
Notification Time: 11:34 [ET]
Event Date: 03/24/2017
Event Time: 14:25 [EDT]
Last Update Date: 05/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
CHRISTOPHER CAHILL (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

INVALID SYSTEM ACTUATION DURING TESTING

"On March 24, 2017, at 1425 EDT, while performing Engineered Safeguards Actuation System (ESAS) quarterly High Pressure Injection/Low Pressure Injection Logic and Component testing, an unintended test signal was generated when a test switch was moved to the OFF position but went slightly past this position and engaged contacts for the Test no. 1 position. When examined, the test switch was found to be degraded which allowed the switch to move past the center position and engage the test no. 1 contacts. This resulted In a partial actuation of 'B'- train ESAS components. It also resulted in an injection to the reactor coolant system (RCS). The test signal was immediately removed by operators and the inadvertently started equipment secured.

"The plant was operating at 100% power when the event occurred. There were no valid signals or plant conditions present to warrant the safety system actuation. The 'B' Emergency Diesel Generator rolled on air start but did not get up to full speed. Decay Heat Removal Pump 'B' started and the Decay Heat Removal Injection valve 4B opened, Make-Up Pump 'C' started, Make-Up Pump suction valve 14B opened, Make-Up pump discharge valves 16C and 16D opened, Spent Fuel Pump 1B tripped off, Air Handling Fan 18 tripped off and Air Handling Fan 1C trip tripped off. These components properly functioned from the inadvertent test signal and were secured prior to any adverse impact to plant operation. There was a small injection of borated water into the RCS. The plant remained stable at 100% power operation.

"Pursuant to 10 CFR 50.73(a)(1) the following information is provided as a sixty (60) day telephone notification to the NRC. This notification, reported under 50.73(a)(2)(iv)(A), is being provided in lieu of the submittal of a written LER to report a condition that resulted in an invalid partial actuation of the 'B' train of the Engineered Safeguards Actuation System (ESAS) as it was not part of a pre-planned sequence.

"The Licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 52768
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: RANDY KOUBA
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/23/2017
Notification Time: 15:57 [ET]
Event Date: 05/23/2017
Event Time: 08:30 [CDT]
Last Update Date: 05/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JEREMY GROOM (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

LOSS OF METEOROLOGICAL TOWER PRIMARY AND BACKUP COMMUNICATION EQUIPMENT

"This notification is being made due to a loss of emergency assessment capability in accordance with 10 CFR50.72(b)(3)(xiii). On [May, 23, 2017] at 0830 (CDT), the meteorological tower primary and backup communication equipment failed, which resulted in a loss of meteorological data to the plant. Information technology and communications personnel investigated and restored the primary system to service. Meteorological data to the plant was restored at 0925 on [May 23, 2017].

"The NRC Senior Resident Inspector has been informed."

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Power Reactor Event Number: 52769
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT CAMENISCH
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/24/2017
Notification Time: 04:10 [ET]
Event Date: 05/23/2017
Event Time: 23:30 [EDT]
Last Update Date: 05/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMIE HEISSERER (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
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

ALL FOUR EDGs AUTOSTARTED DURING TRANSFER OF SHUTDOWN BOARD TO NORMAL POWER SOURCE FOR UNIT 2 TESTING

"On May 23, 2017 at 2330, while transferring 2A-A 6.9 kV Shutdown Board from its alternate power source to its normal power source in support of outage testing, a failure occurred which resulted in the loss of the Shutdown Board, emergency start of all 4 Emergency Diesel Generators (EDGs), and required the manual emergency stop of 2A-A EDG.

"During transfer of the 2A-A 6.9kV Shutdown Board, the hand switch for the normal feeder breaker on the shutdown board was being maintained in the 'CLOSE' position while the alternate feeder breaker hand switch was placed in 'TRIP.' As expected, the alternate feeder breaker opened and the normal feeder breaker closed. However, the upstream supply breaker to the normal feeder breaker immediately tripped due to an overcurrent relay actuation on a single phase. As a result, the 2A-A 6.9 kV Shutdown Board deenergized, initiating a blackout signal which started all 4 of the station's EDGs. During board stripping (opening of all feeder and load breakers, to prepare the board for automatic reenergization from the EDG), the normal feeder breaker to the Shutdown Board failed to trip. This failure to trip prevented the emergency feeder breaker in the output of 2A-A EDG from closing, in accordance with interlock logic. As a result, 2A-A 6.9 kV Shutdown Board remained deenergized which prevented the cooling water supply valve for the EDG from opening due to loss of motive power. This lack of cooling caused operators to emergency stop the 2A-A EDG.

"Power was restored to the Shutdown Board on May 24, 2017 at 0037.

"Unit 1 is currently stable in Mode 1, at 100% power and Unit 2 is stable in Mode 5 with RCS at 164 F and 340 psig.

"The cause of the breaker trip on overcurrent and the failure of the normal feeder to trip on load shedding are under investigation.

"This event had no impact on the health and/or safety of the public. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, May 24, 2017
Wednesday, May 24, 2017