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Event Notification Report for February 16, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/15/2018 - 02/16/2018

** EVENT NUMBERS **


53183 53199 53200 53212 53213 53214 53215 53216

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53183
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: NORMA WELLS
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/25/2018
Notification Time: 18:20 [ET]
Event Date: 01/25/2018
Event Time: 12:00 [MST]
Last Update Date: 02/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
EUGENE GUTHRIE (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

POTENTIAL DEFICIENCY ASSOCIATED WITH AN ITEM RELIED UPON FOR SAFETY

"During a self initiated review, ISA [Integrated Safety Analysis] Staff performed a preliminary review of the ISA to determine whether or not there was a chemical safety issue concerning the proximity of combustible fuel to the yard tractors/shuttle lifts that UUSA's [Urenco USA] Logistics organization uses to move UF6 [Uranium Hexa Fluoride] cylinders around outside on site.

"ISA staff determined that the ISA lacked sufficient information regarding the proximity of combustible fuel to the IROFS36c [Item Relied Upon for Safety] controlled yard tractors/shuttle lifts. ISA determined that revisions to one, or more, of the applicable IROFS Boundary Definition Documents was necessary to establish operator actions to ensure that the volumetric fuel limit is not compromised due to the proximity of other fuel sources, therefore UUSA is conservatively making this report.

"UUSA remains in a safe and stable condition. UUSA Logistics has issued a stop work that prohibits applicable cylinders from traveling where proximity to combustible fuel could occur.

"10 CFR 70.50(c)(iii)
(A) There was not a material release, no radiological or chemical hazards were present.
(B) No exposure occurred
(C) A deficiency exists in the ISA in which the limiting of external fuel sources near IROFS36c controlled yard tractors/shuttle lifts was not discussed
(D) IROFS36c remains operable and available to perform its safety function. The identified deficiency only affects applicable UF6 cylinders that could be moved in proximity to other fuel sources. UUSA has issued a stop work to adequately address the deficiency.
(iv) No external conditions affect this event
(v) A stop work was issued to prevent the movement of applicable UF6 cylinders where proximity to other fuel sources could occur
(vi) An event did not occur at UUSA. UUSA remains in a safe and stable condition
(vii) No emergencies have been, nor will any be declared
(viii) No state or other federal agencies will be notified
(ix) No press releases are planned."

The licensee will be contacting the NRC Region 2 office (Ortiz).

* * * RETRACTION AT 1048 EST ON 02/15/2018 FROM NORMA WELLS TO JEFF HERRERA * * *

"UUSA has completed the ISA process for the event in question and has concluded that that while the accident is credible it is highly unlikely, therefore 10 CFR 70.61 performance requirements are being met and IROFS are not required for prevention or mitigation. The reportability criteria in 10 CFR Part 70 Appendix A (b) (1) for a 24 hour report is an event that results in the facility being in a state that was improperly analyzed AND results in a failure to meet the performance requirements of 10 CFR 70.61, because UUSA has shown through the ISA process that the facility meet the 10 CFR 70.61 performance requirements the event does not meet both reportability criteria and therefore does not require a 24 hour report."

The Licensee will be notifying the Region II Office (Lopez).

Notified the R2DO (Lopez) and NMSS (via email).

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Agreement State Event Number: 53199
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CARDINAL HEALTH 414, LLC
Region: 4
City: LAKEWOOD State: CO
County:
License #: CO 1219-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: DAVID AIRD
Notification Date: 02/07/2018
Notification Time: 17:02 [ET]
Event Date: 02/07/2018
Event Time: 14:24 [MST]
Last Update Date: 02/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PACKAGE ARRIVED WITH SURFACE CONTAMINATION

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

"Red Rocks Radiation Oncology received a package of Ra-223 Xofigo that had removable contamination levels of approximately 23,000 cpm on the outside of the package. The Ra-223 package was delivered by a Cardinal courier from the Cardinal Health facility in Denver, CO which distributes all radiopharmaceuticals (license CO 392-03 is the Cardinal Health license for general radiopharmaceuticals, they share the same building as CO 1219-01). The inner packaging of the Ra-223 shipment did not evidence removable contamination, nor did the car used to transport the Ra-223 package. Cardinal Health has received the wipes and decontamination waste from Red Rocks Radiation Oncology to attempt to determine the isotope causing the removable contamination. The investigation is currently ongoing."

Event Report ID No.: CO180003

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Non-Agreement State Event Number: 53200
Rep Org: CENTRO DE RADIOTERAPIA
Licensee: CENTRO DE RADIOTERAPIA
Region: 1
City: HATO REY State: PR
County:
License #: 52-30937-01
Agreement: N
Docket:
NRC Notified By: LUIS RIVERA
HQ OPS Officer: ANDREW WAUGH
Notification Date: 02/08/2018
Notification Time: 14:47 [ET]
Event Date: 02/06/2018
Event Time: [EST]
Last Update Date: 02/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
RAY POWELL (R1DO)
DOUGLAS BOLLOCK (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

SKIN REACTION RESULTING FROM RADIATION THERAPY

The following event was received from Auxilio Mutuo Radiation Therapy Center via phone:

A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.

The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.

This event is under further investigation.

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: 53212
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM PEREZ
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/15/2018
Notification Time: 05:04 [ET]
Event Date: 02/15/2018
Event Time: 03:06 [CST]
Last Update Date: 02/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG WERNER (R4DO)

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

MAIN STEAM LINE RADIATION MONITOR DETERMINED TO BE NON FUNCTIONAL

"At time 0306 [CST], Main Steamline Radiation Monitor 2-RE-2326 (Main Steamline 2-02) reading spiked and declared non-functional.

"With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 2-02 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10CFR50.72(b)(3)(xiii).

"Comanche Peak Nuclear Power Plant [CPNPP] has assurance of steam generator integrity and fuel cladding integrity and there is a negligible safety significance to the current condition from a public health and safety perspective.

"Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator or fuel cladding. The N16 radiation monitor serves as a backup with alarm function and Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-02.

"Corrective actions are being pursued to restore 2-RE-2326 to functional status.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 53213
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: TERRY MARTIN
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/15/2018
Notification Time: 13:39 [ET]
Event Date: 02/15/2018
Event Time: 11:00 [CST]
Last Update Date: 02/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

NOTIFICATION OF UNANALYZED CONDITION AFFECTING ACCIDENT MITIGATION FOR TORNADO GENERATED MISSILES

"On February 15, 2018, during evaluation of protection for Technical Specifications (TS) equipment from the damaging effects of tornado generated missiles, LaSalle Station identified a non-conforming condition in the plant design such that specific TS equipment is considered to not be adequately protected from tornado generated missiles. Tornado generated missiles could strike the components supporting the operation of Control Room (VC) and Auxiliary Electric Room (VE) ventilation. This could result in inoperable VC/VE systems, which provide a protected environment for occupants to control the unit following an uncontrolled release of radioactivity, hazardous chemicals, or smoke if a tornado were to occur.

"This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B) as a condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety and 10 CFR 50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"This condition is being addressed in accordance with NRC enforcement guidance provided in Enforcement Guidance Memorandum (EGM) 15-002, Revision 1, 'Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance,' and DSS-ISG-2016-01, Revision 1, 'Clarification of Licensee Actions in Receipt of Enforcement Discretion' per Enforcement Guidance Memorandum EGM 15-002, 'Enforcement Discretion for Tornado Generated Missile Protection Noncompliance.' Compensatory measures have been implemented in accordance with these documents.

"The NRC Resident Inspector has been informed of this notification."

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Power Reactor Event Number: 53214
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: DANIEL MORRIS
HQ OPS Officer: DAVID AIRD
Notification Date: 02/15/2018
Notification Time: 17:36 [ET]
Event Date: 02/15/2018
Event Time: 14:00 [EST]
Last Update Date: 02/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
AARON McCRAW (R3DO)
FFD GROUP (EMAI)

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

FITNESS FOR DUTY - CONTRABAND DISCOVERED IN THE PROTECTED AREA

A can of alcohol (8.4 ounces) was discovered unopened in a refrigerator inside the protected area. Site security took possession of the can of alcohol. The owner of the can of alcohol is unknown. This report is being made under 10 CFR 26.719(b)(1) as a 24 hour telephone notification.

The can had an expiration date of April 2017.

The licensee notified the NRC Resident Inspector and the Regional Inspector.

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Power Reactor Event Number: 53215
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE LESTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2018
Notification Time: 02:50 [ET]
Event Date: 02/15/2018
Event Time: 21:53 [MST]
Last Update Date: 02/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GREG WERNER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOW DEPARTURE FROM NUCLEATE BOILING SIGNAL

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On February 15, 2018, at approximately 2153 Mountain Standard Time (MST), the Palo Verde Generating Station (PVGS) Unit 1 Control Room received Reactor Protection System alarms for Low Departure from Nucleate Boiling Ratio and an automatic reactor trip occurred. Prior to the reactor trip, Unit 1 was operating normally at 100 percent power. Plant operators entered the emergency operations procedures and diagnosed an uncomplicated reactor trip but noted that Reactor Coolant Pumps 1B and 2B were not running due to a loss of power. All CEAs [Control Element Assemblies] fully inserted into the core. Following the reactor trip, all nuclear instruments responded normally. No emergency classification was required per the PVGS Emergency Plan.

"The PVGS Unit 1 safety related electrical busses remained energized from normal offsite power during the event. The Unit 1 'B' Diesel Generator is currently removed from service for maintenance. Due to ongoing planned maintenance on NAN-X02, Startup Transformer 2, fast bus transfer for NAN-S02 (from NAN-S04) was blocked. This resulted in a loss of offsite power to NAN-S02 and NBN-S02. The offsite power grid is stable. Unit 1 is currently stable in Mode 3 with the reactor coolant system at normal operating temperature and pressure.

"The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The NRC Resident Inspector has been informed of the Unit 1 reactor trip."

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Power Reactor Event Number: 53216
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2018
Notification Time: 04:43 [ET]
Event Date: 02/16/2018
Event Time: 02:01 [EST]
Last Update Date: 02/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
FRED BOWER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC TRIP DUE TO LOSS OF EXCITATION ON MAIN GENERATOR

"On February 16, 2018 at 02:01 EST Indian Point Unit 3 automatically tripped on a turbine trip due to a loss of main generator excitation. All control rods fully inserted and all plant equipment responded normally to the unit trip. This is reportable under 10 CFR 50.72(b)(2)(iv)(B).

"The auxiliary feedwater system actuated following the automatic trip as expected. This is reportable under 10 CFR 50.72(b)(3)(iv)(A). During the event offsite power remained available and stable. No primary or secondary reliefs lifted. The plant is stable, in Mode 3, at no load operating temperature and pressure. Decay heat removal is via the steam generators to the main condenser via the condenser steam dumps. No radiation was released.

"Indian Point Unit 2 was unaffected by this event and remains at 100 percent power.

"A post trip investigation is in progress.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Friday, February 16, 2018
Friday, February 16, 2018