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Event Notification Report for November 12, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/9/2018 - 11/12/2018

** EVENT NUMBERS **


53685 53709 53710 53713 53714 53732 53733 53734 53736

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53685
Facility: DAVIS BESSE
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: NICK DOWNING
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/22/2018
Notification Time: 14:42 [ET]
Event Date: 10/22/2018
Event Time: 00:00 [EDT]
Last Update Date: 11/09/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

Event Text

CONTROL ROOM ENVELOPE DECLARED INOPERABLE DUE TO DOOR LATCH FAILURE

"At 0856 EDT on October 22, 2018, it was discovered that the Control Room Envelope, a single-train system, was inoperable due to failure of a boundary door to latch; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D) as a loss of safety function. The door latch was repaired, and the Control Room Envelope declared operable at 0910 EDT.

"There was no impact on the health and safety of the public or plant personnel, as the door was capable of being closed at all times and the door was manned the entire time it could not latch.

"The NRC Resident Inspector has been notified."

* * * RETRACTION AT 1510 EST ON 11/09/18 FROM NICK DOWNING TO OSSY FONT * * *

"Retraction of Event #53685, Control Room Envelope Declared Inoperable due to Door Latch Failure

"Based on subsequent field measurements taken for the boundary door, the force needed to open the unlatched door is sufficient to maintain the Control Room Envelope positive pressure. Therefore, the Control Room Envelope remained Operable with the boundary door unlatched, and this issue did not prevent the system from fulfilling its safety function to mitigate the consequences of an accident.

"The NRC Resident Inspector has been notified."

Notified the R3DO (Hanna).

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Agreement State Event Number: 53709
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: WORLD TESTING
Region: 1
City: NASHVILLE   State: TN
County:
License #: R-95009
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 11/01/2018
Notification Time: 10:26 [ET]
Event Date: 10/31/2018
Event Time: 00:00 [CDT]
Last Update Date: 11/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following information was obtained from the State of Tennessee via email:

"On 10/31/18, while performing radiography work in Nashville, TN, a radiographer working for World Testing noticed that his survey meter still had elevated readings and that the source had not successfully returned back to the camera. He attempted again to return the source but was unsuccessful. The [Radiation Safety Officer] RSO was notified. After responding and investigating, the RSO was able to retract the source back into the camera. The device information includes the following:

"Manufacturer: USA Global
Model #: A424-9
Serial #: 9269
Source Serial #: 65744G
Isotope: Ir-192 (20.1 Ci)

"A follow-up report will be submitted within 30 days."

Tennessee State Event Report ID No.: TN-18-197

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Agreement State Event Number: 53710
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EAGLE US 2, LLC
Region: 4
City: LAKE CHARLES   State: LA
County:
License #: LA-2257-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/01/2018
Notification Time: 15:33 [ET]
Event Date: 10/31/2018
Event Time: 00:00 [CDT]
Last Update Date: 11/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEVEL GAUGE SHUTTER MALFUNCTION

The following was reported by the Louisiana Department of Environmental Quality via email:

"On 10/31/2018, Eagle US 2 was performing their semiannual inventory and operational checks of their RAM [radioactive material] licensed devices. During their routine semiannual maintenance checks, the shutter malfunction was discovered. The gauge shutter would not close due to a shutter pin sheer.

"Eagle US 2 called a service contractor, BBP Sales, [to] perform the semiannual checks. BBP Sales is evaluating the situation to determine the best course of action to correct the problem. [The contractor] was unable to close the shutter and will determine the course of corrective action. It appears the corrective action will be to replace the device. The cause appears to be the conditions of a corrosive environment where the gauge is installed and used.

"The sources and device with a broken shutter pin and shutter stuck open will remain installed and utilized on the process until the repairs are made. This is not a radiation exposure hazard and does not pose a health and safety situation for the Eagle US 2 employees or the general public.

"The Gauge is a RONAN SA1-C-10 device/source holder, S/N 5977-GK, loaded with a 5 mCi Cs-137 source."

Event Report ID No.: LA-180018

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Non-Agreement State Event Number: 53713
Rep Org: TILDEN MINING CO
Licensee: TILDEN MINING CO
Region: 3
City: ISHPEMING   State: MI
County:
License #: 21-26748-01
Agreement: N
Docket:
NRC Notified By: LAWRENCE M GRAY
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/02/2018
Notification Time: 13:20 [ET]
Event Date: 03/19/2015
Event Time: 00:00 [EDT]
Last Update Date: 11/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PROCESS GAUGE SHUTTER STUCK OPEN

"In the process of performing the inventory/shutter check it was reported on March 19, 2015 that our Kay Ray Model Number: 7050, Serial Number: 1405, 200 mCi, Cs-137 gauge located on 4B DTU (Deslime Thickener U/Flow) in the deslime basement had a broken handle on the shutter mechanism, rendering the shutter non-operable. Work order (1545064) was entered into Ellipse. It was determined that the area in which the gauge is located does not create an exposure hazard.

"The plant process requires the shutter to remain in the open position during normal operation and does not create a hazard to individuals, the course of action will be to remove and replace the gauge at the first opportunity. Once the gauge is removed, it will be placed and locked in the cage located in the warehouse. The gauge will be placed on top of the required amount of lead to remove any potential exposure hazard; surveys will be performed to confirm personnel safety."

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Agreement State Event Number: 53714
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: GEOENGINEERS, INCORPORATED
Region: 4
City: REDMOND   State: WA
County:
License #: WN-I0204-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/04/2018
Notification Time: 21:35 [ET]
Event Date: 11/03/2018
Event Time: 00:00 [PST]
Last Update Date: 12/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED DENSITY GAUGE

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

"On 11/3/2018, a gauge user was working at a jobsite located in Kirkland, Washington. He sat the gauge down and moved approximately 30 feet away to speak to a contractor. While the gauge was out of his direct control, it was hit by a piece of heavy equipment and damaged. The contractor took the gauge back to the Redmond office, secured it in the gauge storage room, and notified the office ARSO [Assistant Radiation Safety Officer] and corporate RSO [Radiation Safety Officer]. The ARSO, notified DOH [Washington State Department of Health] that evening. [The Washington State Department of Health Laboratory Program Manager] spoke with [the ARSO] to get an overview of the incident.

"[The DOH Laboratory Program Manager] met with the ARSO and the corporate RSO, at the Redmond office at 0930 PST on 11/4/2018 to examine the gauge (CPN MC1DRP S/N MD00805859) to determine whether the Cs-137 and Am-241 sources had been compromised. After performing swab tests of the interior and exterior of the gauge and measuring the exposure rates around the gauge, [The DOH Laboratory Program Manager] made the assumption that the sealed sources were not compromised (the licensee couldn't do this because they don't have a survey instrument). [The DOH Laboratory Program Manager] also surveyed the vehicle used to transport the damaged gauge to verify that there was no detectable contamination in the vehicle.

"DOH will conduct an investigation into the incident, and the licensee is submitting an incident report. More information to follow."

Event Report ID: WA-18-027

* * * UPDATE AT 1229 EST ON 12/5/2018 FROM ANDREW HALLORAN TO MARK ABRAMOVITZ * * *

The following update was received via e-mail:

"DOH [Washington State Department of Health] conducted an investigation and a review of the licensee's internal incident report and root cause analysis. The gauge user did not maintain direct control of the gauge, resulting in the gauge being left unattended when it was damaged by an excavator. Additionally, the licensee failed to follow both the emergency procedures and radiation safety program guidance included in their radioactive materials license application renewal, further compounding the health and safety issues. Instead of securing the area and remaining onsite and alerting DOH as required by procedure, the gauge user and project manager decided to remove the damaged gauge and return it to the Redmond storage location. Both the failure to maintain control of the gauge and the failure to follow the emergency procedures were cited as violations in a compliance letter sent to GeoEngineers. In addition to the corrective actions required by the compliance letter, DOH will also perform a follow-up inspection of the Redmond office and field site."

This event was closed on 12/5/2018.

Notified the R4DO (Gaddy) and NMSS (via e-mail).

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Power Reactor Event Number: 53732
Facility: RIVER BEND
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: T. W. GATES
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/10/2018
Notification Time: 04:35 [ET]
Event Date: 11/10/2018
Event Time: 00:00 [CST]
Last Update Date: 11/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK HAIRE (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 Shutdown

Event Text

AUTOMATIC REACTOR SCRAM ON HIGH REACTOR PRESSURE

"At 0046 CST, River Bend Station experienced an automatic reactor scram on high reactor pressure. Initial indications are that the cause of the scram was an uncommanded closure of the #3 turbine control valve.

"The plant is stable with reactor water level in the normal level band of 10-51 inches being maintained with feedwater and condensate. Reactor pressure is in the prescribed band of 500-1090 psig, being maintained with turbine bypass valves and steam line drains.

"No injection systems were actuated either manually or automatically as a result of the event.

"The reactor scrammed on a Reactor Pressure High scram signal. A Reactor Level 3 signal resulted from the normal post-scram water level response. All systems responded as designed.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an automatic RPS actuation with the reactor critical."

All control rods fully inserted. The Unit is in a normal shutdown electrical alignment. All control rods inserted properly and all systems functioned as designed. The licensee is investigating the cause of the event.

The licensee notified the NRC resident inspector.

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Power Reactor Event Number: 53733
Facility: PALISADES
Region: 3     State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: PAUL E ADAMS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/10/2018
Notification Time: 17:48 [ET]
Event Date: 11/10/2018
Event Time: 00:00 [EST]
Last Update Date: 11/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN HANNA (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

BORIC ACID IDENTIFIED ON REACTOR VESSEL HEAD PENETRATION

"On November 10, 2018, during a planned bare metal visual inspection of the reactor head, boric acid was discovered at a CRDM [Control Rod Drive Mechanism] nozzle to reactor head penetration. Investigation of the source of the boric acid is ongoing. The plant was in cold shutdown at 0% power and Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. All other reactor vessel head penetrations have had a bare metal visual inspection completed with no other indications identified.

"This condition has no impact to the health and safety of the public.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier.

"The licensee notified the NRC Senior Resident Inspector."

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Power Reactor Event Number: 53734
Facility: PALISADES
Region: 3     State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: MIKE BAILEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/11/2018
Notification Time: 21:59 [ET]
Event Date: 11/11/2018
Event Time: 00:00 [EST]
Last Update Date: 11/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN HANNA (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

DEGRADED CONDITION DUE TO INDICATION DURING ULTRASONIC INSPECTION OF REACTOR HEAD NOZZLE PENETRATION

"On November 11, 2018, during ultrasonic data analysis from reactor vessel closure head in-service inspections, signals that display characteristics consistent with primary water stress corrosion cracking in head penetration 33 were identified. No indications of boric acid leakage and no surface indications were detected at this location during bare metal visual inspection.

"The plant was in cold shutdown at 0% power and in Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage.

"This condition has no impact to the health and safety of the public.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier.

"The licensee notified the NRC Senior Resident Inspector. "

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Power Reactor Event Number: 53736
Facility: SURRY
Region: 2     State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BEN EVANS
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/12/2018
Notification Time: 20:52 [ET]
Event Date: 11/12/2018
Event Time: 00:00 [EST]
Last Update Date: 11/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
REBECCA NEASE (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 Defueled 0 Defueled

Event Text

SPECIFIED SYSTEM ACTUATION

"On November 12, 2018, at 1636 EST, with Surry Unit 1 at 100 percent power and Surry Unit 2 defueled, the 'C' Reserve Station Service Transformer (RSST) pilot wire lockout actuated during restoration of the 'C' RSST following transformer replacement. This resulted in electrical isolation of the 'C' RSST, the 'F' Transfer Bus, the Unit 1 'H' Emergency Bus, and the Unit 2 'J' Emergency Bus. The #1 and #3 Emergency Diesel Generators automatically started and loaded onto the 1H and 2J emergency buses, respectively, as designed. Operations entered the appropriate abnormal procedures and stabilized both units. This equipment operated as expected during the event.

"The Surry electrical distribution system was in an off-normal alignment to support 'C' RSST replacement with the dependable alternate power supply from Unit 2 station service backfeed supplying the 1H and 2J emergency buses. The 'C' RSST pilot wire lockout tripped and locked out the station service supply tie breaker to the 'F' Transfer Bus.

"The organization is reviewing the 'C' RSST pilot wire lockout and the required actions for recovery. Surry Unit 1 entered a 6-hour action statement to place the unit in Hot Shutdown due to this partial loss of offsite power. This clock was exited upon reset of the pilot wire lockout, restoring backfeed as a dependable offsite power source. Unit 1 remained at 100 percent power throughout the event.

"No radiological consequences resulted from this event. This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to actuation of the #1 and #3 Emergency Diesel Generators.

"The NRC Resident was notified."


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