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Event Notification Report for December 28, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/27/2018 - 12/28/2018

** EVENT NUMBERS **


53712 53750 53794 53795 53797 53799 53800

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53712
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: JEFFREY MYERS
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/01/2018
Notification Time: 20:10 [ET]
Event Date: 11/01/2018
Event Time: 13:00 [EDT]
Last Update Date: 12/28/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
KARLA STOEDTER (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

Event Text

UNANALYZED CONDITION DUE TO MODIFICATION NOT ADDED TO PROCEDURE

"On November 1, 2018, at approximately 1300 EDT, Fermi 2 identified that a Station Blackout (SBO) procedure was deficient as a result of a modification installed during a recent refueling outage. A review identified that the performance of the SBO procedure could have resulted in a challenge to having an alternate AC source available within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2. The alternate AC source was always available to be manually aligned in accordance with other standard operating procedures. The modification did not affect the function for Appendix R alternative shutdown.

"Immediate actions are underway to revise the impacted procedure. The health and safety of the public was not affected as offsite power has remained available since the modification was installed. Investigation into the cause and corrective actions is ongoing.

"Fermi 2 is reporting this event as an unanalyzed condition pursuant to the requirements of 10 CFR 50.72(b)(3)(ii)(B)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 12/28/18 AT 1228 EST FROM JEFFREY MYERS TO JEFFREY WHITED * * *

"The purpose of this notification is to retract a previous report made on November 1, 2018 (EN 53712) under 10 CFR 50.72(b)(3)(ii)(B). Subsequent to the initial notification, the event, site procedures, and the NRC guidance in NUREG-1022 pertaining to 10 CFR 50.72(b)(3)(ii)(B) were reviewed further. The evaluation determined that at the time of the event, there were multiple methods defined in existing station procedures to establish an available alternate AC source within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2.

"Under these circumstances, the event does not represent an unanalyzed condition under 10 CFR 50.72(b)(3)(ii)(B). Therefore, EN 53712 can be retracted and no Licensee Event Report (LER) under 10 CFR 50.73(a)(2)(ii)(B) is required to be submitted.

"The licensee has notified the NRC Resident Inspector."

Notified R3DO (Riemer).

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53750
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: ANGEL YARBROUGH
HQ OPS Officer: DAN LIVERMORE
Notification Date: 11/22/2018
Notification Time: 03:56 [ET]
Event Date: 11/21/2018
Event Time: 21:25 [CST]
Last Update Date: 12/28/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ROSE (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 13 Power Operation 13 Power Operation

Event Text

HPCI UNEXPECTEDLY TRANSFERRED TO ALTERNATE SUCTION SOURCE DURING TESTING

"At 2125 [CST] on 11/21/2018, it was discovered that U1 High Pressure Coolant Injection System (HPCI) was inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), as an event or 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.

"During performance of a routine surveillance, HPCI automatically transferred from its normal suction source to the alternate suction source. The control room operator then manually tripped the HPCI turbine. HPCI was already inoperable in accordance with Technical Specifications (TS) Limiting Condition for Operability (LCO) 3.5.1, ECCS Operating, Condition C during performance of the surveillance. However, this condition was not expected nor induced by the testing.

"There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified.

"CR 1469109 documents this condition in the Corrective Action Program."

* * * RETRACTION ON 12/28/18 AT 1300 EST FROM MARK MOEBES TO JEFFREY WHITED * * *

"ENS Event Number 53750, made on November 22, 2018, is being retracted.

"NRC notification 53750 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72(b)(3)(v)(D) were met when the licensee discovered an event or 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.

"During performance of a routine surveillance, the High Pressure Coolant Injection (HPCI) System automatically transferred from its normal suction source to the alternate suction source. As a result, Unit 1 HPCI was declared inoperable.

"On December 20, 2018, a Past Operability Evaluation was completed which determined that the HPCI System remained operable. The evaluation determined that the HPCI System could have performed its specified safety function of vessel injection throughout the time that the suction path was aligned to the torus. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"TVA's evaluation of this event is documented in the Corrective Action Program in Condition Report 1469109.

"The licensee has notified the NRC Resident Inspector."

Notified R2DO (Desai).

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Agreement State Event Number: 53794
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: ENGLEWOOD   State: CO
County:
License #: CO 251-02
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 12/19/2018
Notification Time: 11:10 [ET]
Event Date: 12/15/2018
Event Time: 00:00 [MST]
Last Update Date: 12/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"[Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018.

"Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected.

"The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee."

Colorado Event Report ID No.: CO180032

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: 53795
Rep Org: COLORADO DEPT OF HEALTH
Licensee: THERMO MF PHYSICS, LLC
Region: 4
City: COLORADO SPRINGS   State: CO
County:
License #: CO 803-02
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: KAREN COTTON
Notification Date: 12/19/2018
Notification Time: 17:28 [ET]
Event Date: 12/19/2018
Event Time: 00:00 [MST]
Last Update Date: 12/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT- CONTAMINATED PACKAGE

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

"Event description: Thermo MF Physics, LLC received 2 packages of radioactive materials, both containing approximately 700 Ci of H-3. When performing contamination surveys as part of the package receipt, wipe tests indicated approximately 600 dpm/cm2 of removable H-3. A third package that was received at the same time, which did not contain any radioactive materials, also exhibited removable contamination. Thermo MF Physics, LLC has contacted the final delivery carrier and made them aware of the situation. Thermo MF Physics, LLC is continuing to count removable contamination samples to determine the extent of the contamination event."

Colorado Event Report ID No.: CO180033

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Agreement State Event Number: 53797
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: PASADENA REFINING SYSTEM
Region: 4
City: PASADENA   State: TX
County:
License #: L01344
Agreement: Y
Docket:
NRC Notified By: Irene Casares
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 12/20/2018
Notification Time: 10:24 [ET]
Event Date: 12/19/2018
Event Time: 10:49 [CST]
Last Update Date: 01/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER

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

"On December 19, 2018 at 10:49 am, the licensee's radiation safety officer reported a stuck shutter on a fixed gauge, found during routine maintenance. Gauge is in the open operating position; no employee or public exposures are anticipated. Gauge is attached to a vessel located several feet off the ground. Device information: source SN 8423CN, model SH-F1B, Cs-137, 100 mCi. A service company has been called to repair the gauge. Update will be sent in accordance with SA300 guidelines."

Texas Incident #: I-9646

* * * UPDATE ON 01/30/2019 AT 1135 EST FROM MATTHEW KENNINGTON TO JEFFREY WHITED * * *

The following update was received from the State of Texas via email:

"On January 29, 2019, the licensee's Radiation Safety Officer (RSO) reported to the [Texas Department of State Health Services] that after further investigation two additional gauges were found on December 19, 2018, with shutters stuck in the open position. Open is the normal operating position. The gauges are Ohmart Vega model SH-F1B serial number 8431CN and 8443CN, both containing 100 mCi of cesium (Cs)-137. The RSO stated he discovered the additional shutter failures after reviewing reports received on January 21, 2019. The gauges are located on towers, not easily accessible, and are unlikely to cause unintended exposure. The RSO has contacted a service company and is anticipating the repairs completed to all three gauges in the next week. The RSO intends to apply grease to O-rings to prevent moisture from entering and fouling the shutter mechanism."

Notified R4DO (Werner) and NMSS Events Notification via email.

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Non-Agreement State Event Number: 53799
Rep Org: FROEHLING AND ROBERTSON
Licensee: FROEHLING AND ROBERTSON
Region: 1
City: FORT BRAGG   State: NC
County:
License #: 45-08890-02
Agreement: Y
Docket:
NRC Notified By: BRETT CLARKE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/20/2018
Notification Time: 14:12 [ET]
Event Date: 02/27/2017
Event Time: 00:00 [EST]
Last Update Date: 12/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

A technician did not secure the Troxler Moisture Density Gauge in his truck before moving from one job site to the next. The tailgate was open and the gauge fell from the truck onto the dirt road. Someone subsequently found the gauge and returned it to the technician approximately 20 minutes after losing the gauge. The sources remained in the stored position. Subsequent surveys and wipe tests determined that no damage had occurred to the sources however the case itself was cracked. The gauge was sent back to the manufacturer and the case was replaced.

Troxler model 3430 (S/N 23714)
Sources: Cs-137 at 8 mCi and Am-241 at 40 mCi

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Agreement State Event Number: 53800
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MINISHIELLO BROTHER SCRAP IT
Region: 1
City: EVERETT   State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWARD SALOMON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 12/20/2018
Notification Time: 16:32 [ET]
Event Date: 12/18/2018
Event Time: 00:00 [EST]
Last Update Date: 12/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - REPORT OF LOST METAL DISC CONTAINING RA-226 FOUND WITHIN SCRAP LOAD

The following was received from the State of Massachusetts via e-mail:

"On December 18, 2018, the Massachusetts Radiation Control Program (MARCP) was informed by Schnitzer Steel Metal Recycling Facility that a scrap metal load shipment from Minichiello Brothers Scrap It (431 Second Street, Everett, MA 02149) set off the radiation monitor alarms. The vehicle returned back to Minichiello Brothers Scrap It for radiation consultant follow-up survey via MARCP Department of Transportation Special Scrap Permit MA-MA-18-4. On December 20, 2018, this material was identified, removed and segregated from this scrap load by the radiation consultant. The radioactive material found is an abandoned metal disc (three inch in diameter) containing Radium-226. The radiation consultant's direct radiation dose rate reading was 1.2 mR/hour at 30 cm from the metal disc. The Radium-226 activity was estimated to be approximately 5.55 MBq (150 uCi) based on the dose rate taken. This material is being held in a secured location at the Minichiello Brothers Scrap It Facility awaiting appropriate disposal.

"This activity meets the immediate event report requirements where report of lost or abandoned RAM [Radioactive Material] is found to be greater than 1,000 times the quantities specified in 10 CFR 20 Appendix C or MA equivalent 105 CMR 120.297 Appendix C. (The 1000 times reportable quantity for Radium-226 is 100 uCi.)

"The MARCP considers this event to be open until proper disposal of this metal disc is confirmed."

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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Friday, May 03, 2019