Event Notification Report for October 19, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/18/2017 - 10/19/2017

** EVENT NUMBERS **


53007 53008 53009 53022 53023

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Agreement State Event Number: 53007
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: U.S. STEEL CORPORATION - EDGAR THOMPSON PLANT
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/10/2017
Notification Time: 10:35 [ET]
Event Date: 10/06/2017
Event Time: [EDT]
Last Update Date: 10/10/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTERS ON TWO FIXED NUCLEAR GAUGES

The following information was received from the Commonwealth of Pennsylvania via email/fax:

"Event Description: The licensee reported that on October 6, 2017, while performing a lockout procedure for a major outage, the workers noted that two shutters were stuck in the open position. The shutters were both on Berthold Model LB7410 gauges and contained 300 milliCuries of americium-241 each. Both gauges are located in a pit area within major piping lines and a locked gate. This is an inaccessible area, thus no overexposures have occurred. Both units have been taken out of service and a service provider was contacted and has developed a plan to repair or replace the units if necessary.

"Cause of the Event: Equipment failure.

"ACTIONS: The Department [PA Bureau of Radiation Protection] will perform a reactive inspection. More information will be provided upon receipt.

"Event Report ID No: PA170015"

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Agreement State Event Number: 53008
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS DEPT OF STATE HEALTH SERVICES
Region: 4
City: AUSTIN State: TX
County: TRAVIS
License #: 05865
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DAN LIVERMORE
Notification Date: 10/11/2017
Notification Time: 11:16 [ET]
Event Date: 10/10/2017
Event Time: 11:35 [CDT]
Last Update Date: 10/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

ALARM SYSTEM BREACH

The following report was received from the Texas Department of State Health Service via email:

"On October 10, 2017, the Agency had an alarm system breach at 1135 CDT. Security called our program stating the alarm to the source room was alarming. I went down to the room to check it out. I checked the door and it was locked, turned off the alarm system by entering the code, and called the security company and provided information to stop law enforcement from responding to the location. The postal service technician was next door and I asked her who opened the door, she said the contractors asked her to open the door and she stated she went to building operations office and got the key and opened the door for the contractors. And she said when the alarm went off, the door was closed and security guard was informed. That is when our program received the call to go down there. An investigator from our program stayed with the contractors and set the alarm when they were finished. A complete investigation will be completed. Investigation ongoing. Update will be provided in accordance with SA300."

Texas Incident#: I-9516

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Agreement State Event Number: 53009
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/11/2017
Notification Time: 13:58 [ET]
Event Date: 08/11/2017
Event Time: [CDT]
Last Update Date: 10/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017.

"DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event."

Wisconsin Event Report: WI170016

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: 53022
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ARIC HARRIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/18/2017
Notification Time: 05:27 [ET]
Event Date: 10/18/2017
Event Time: 02:09 [CDT]
Last Update Date: 10/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL VASQUEZ (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

HPCI DECLARED INOPERABLE

"Eight hour report due to HPCl [High Pressure Coolant Injection] inoperability.

"HPCl valve operability testing was performed on October 18, 2017. Following satisfactory completion of opening stroke timing, the control switch for HPCI-MOV-MO19, HPCI Injection Valve, was taken to close. The valve indicates that it moved to an intermediate position, but it has not indicated that it has fully closed. This resulted in the valve being declared inoperable. This valve is normally closed and automatically opens on a HPCI initiation signal.

"HPCl was previously declared inoperable at time 0136 [CDT] on October 18 for surveillance testing. Entry was made into Tech Spec LCO 3.5.1 Condition C - HPCI System Inoperable at that time. Required Actions for Condition C are to verify by administrative means RCIC System is operable within 1 hour and restore HPCI System to operable status within 14 days. RClC was verified operable by administrative means concurrent with declaration of HPCI inoperable.

"Troubleshooting activities for HPCI are being planned.

"HPCI is a single train safety system. This report is submitted as a condition that at time of discovery could prevent the fulfillment of the safety function of an SSC [structures, systems, and components] needed to mitigate the consequences of an accident.

"This condition has been entered into the CNS Corrective Action Program."

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 53023
Rep Org: PALO VERDE NUCLEAR GENERATIING
Licensee: WESTINGHOUSE
Region: 4
City: WINTERSBURG State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JORGE RODRIGUEZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/18/2017
Notification Time: 11:55 [ET]
Event Date: 10/11/2017
Event Time: [MST]
Last Update Date: 10/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - HPSI MOTOR LEAD INSULATION GOUGED

"On October 11, 2017, Arizona Public Service Company (APS) completed an evaluation of a deviation and concluded the condition represented a defect under 10 CFR 21.

"On August 25, 2017, a 1000 horsepower, High Pressure Safety Injection critical spare pump motor was discovered to have a gouge in the insulation in one of the three primary leads providing three-phase power to the motor. This deviation was identified by Palo Verde Electrical Maintenance staff during a pre-storage inspection. The gouge was inside the main terminal box, close to the (T2) terminal landing and was deep enough to expose the internal conductive wire. This motor was received on April 5, 2017, following refurbishment at the Westinghouse, Waltz Mill, Pennsylvania, facility.

"APS concluded this condition could result in the motor failing to perform its safety function and thus could create a substantial safety hazard. The motor was shipped back to the Westinghouse, Waltz Mill facility on October 6, 2017 for repair.

"The NRC resident inspector has been informed.

"Vendor: WESTINGHOUSE
INTERSTATE 70
MADISON EXIT 54, MADISON, PA 15663

"Device: WESTINGHOUSE MOTOR, 1000 HP;
3557 RPM FULL LOAD 3600 SYNC.,
4000 VAC, 3 PHASE, 60 HZ -
S/N 76F60563 (No model number)"

Page Last Reviewed/Updated Thursday, March 25, 2021