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Event Notification Report for March 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/22/2019 - 3/25/2019

** EVENT NUMBERS **


53853 53932 53934 53935 53936 53938 53939 53940 53953 53954

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53853
Facility: PRAIRIE ISLAND
Region: 3     State: MN
Unit: [] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DOUG LARSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/31/2019
Notification Time: 10:48 [ET]
Event Date: 01/31/2019
Event Time: 07:43 [CST]
Last Update Date: 03/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMNES CAMERON (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



EN Revision Imported Date : 3/25/2019

EN Revision Text: BOTH EMERGENCY DIESEL GENERATORS INOPERABLE DUE TO LOW AIR TEMPERATURE

"At 0743 [CST] on 1/31/2019, both trains of Unit 2 Diesel Generators were declared INOPERABLE due to outside air temperature exceeding the low temperature design limit for the diesel engines; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v) for an event or condition that could have prevented the fulfillment of a safety function. The Unit 2 Diesel Generators are still able to start if necessary to provide power. Additionally, multiple layers of defense in depth measures are in place to ensure safety. Prairie Island has five sources of offsite power; all of which are currently available. The Unit 1 Diesel Generators are OPERABLE and capable of being cross-connected to Unit 2. Additional equipment capable of responding to beyond design basis events is available on site providing another layer of defense in depth.

"Both Unit 2 Diesel Generators were returned to an OPERABLE status at 0810 on 1/31/2019 based on outside air temperature rising above the low temperature design limit with forecasted temperatures to remain above the low temperature design limit.

"There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The air temperature limit was -30 degrees Fahrenheit.

Unit 1 was not affected. The EDGs were supplied by a different manufacturer with different air temperature limits.

* * * RETRACTION AT 1340 EDT ON 03/22/2019 FROM BRIAN JOHNSON TO JEFFREY WHITED * * *

"Engineering analysis performed subsequent to the event notification has determined that both Unit 2 Diesel Generators would have been able to fulfill their safety function during the period of time when the outside air temperature had exceeded the low temperature design limit. Therefore, EN# 53853 is being retracted.

"The NRC Resident Inspector has been notified of the event notification retraction."

Notified R3DO (McCraw).

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Agreement State Event Number: 53932
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN   State: TX
County:
License #: L05108
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/14/2019
Notification Time: 16:05 [ET]
Event Date: 03/07/2019
Event Time: 00:00 [CDT]
Last Update Date: 03/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF DOSE TO PATIENT

The following was received via e-mail:

"On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9665

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: 53934
Facility: COOPER
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: IAN KERR
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/15/2019
Notification Time: 07:08 [ET]
Event Date: 03/15/2019
Event Time: 05:46 [CDT]
Last Update Date: 03/24/2019
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JEREMY GROOM (R4DO)
WILLIAM GOTT (IRD)
MARK SHAFFER (R4DRA)
HO NIEH (NRRD)
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



EN Revision Imported Date : 3/25/2019

EN Revision Text: UNUSUAL EVENT DECLARED DUE TO HIGH RIVER LEVEL

At 0546 CDT, Cooper Nuclear Station declared an Unusual Event due to the Missouri River level reaching 899.05 feet above mean sea level (MSL), which is above the Emergency Action Level (EAL) HU 1.5 elevation of 899 feet above MSL. The river is expected to crest above 901 feet above MSL within the next day, and remain above 899 feet above MSL for the next several days.

Declaration of an Unusual Event is a 1 hour report, and is reportable under 10 CFR 50.72.a.1.1. Actions are in progress in accordance with site flooding procedure, including strategic placement of barriers at building entrances and important facilities. There is no major plant equipment out of service at this time. Personnel access to the site is not presently impeded and emergency evacuation routes remain available.

A press release is planned for this event, which is a four hour report, reportable under 10 CFR 50.72.b.2.11.

If the Missouri River were to reach 901.5 feet above MSL, Cooper would initiate a unit shutdown in accordance with their procedures. If the Missouri River were to rise greater than 902 feet above MSL, Cooper will declare an Alert.

The licensee notified the NRC Resident Inspector.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE AT 1742 EDT ON 3/24/2019 FROM KLINTON BEHRENDS AND CURTIS MARTIN TO JEFFREY WHITED * * *

The licensee terminated the Unusual Event at 1601 CDT due to lowering Missouri River water levels. River water level is currently at 896.0 feet MSL and lowering.

"A press release will be issued to inform the public of Cooper Nuclear Station's exit from the Notification of Unusual Event regarding high Missouri River level. The initial entry into the Notification of Unusual Event occurred on 03/15/2019 and was exited on 03/24/2019 at 1601 CDT. The press release is reportable per 10 CFR 50.72(b)(2)(xi)."

The licensee notified the NRC Resident Inspector.

Notified R4DO (O'Keefe), NRR EO (Miller), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

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Agreement State Event Number: 53935
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CERTAIN TEED CORPORATION
Region: 1
City: OXFORD   State: NC
County:
License #: 0411-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/15/2019
Notification Time: 10:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE SHUTTER STUCK IN CLOSED POSITION

The following report was received via e-mail:

"On 3/14/2019, NC Radioactive Materials Branch (RMB) was notified that a fixed nuclear gauge was stuck in the closed position (found that day). The reporting licensee had the vendor arrive on site, the same day, and repaired the gauge."

Source Sr-90, 100 milliCuries

North Carolina State Tracking ID: 190009

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Agreement State Event Number: 53936
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KOURY ENGINEERING
Region: 4
City: CHINO   State: CA
County:
License #: 6449
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/15/2019
Notification Time: 11:03 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED BY BACKHOE

The following report was received from the California Department of Public Health via email:

"A moisture density gauge was being used at a construction site when it was struck by a backhoe. The gauge operator had visual contact with the gauge, and had been assured by the backhoe operator that the gauge would not be impacted by the backhoe operation. However, that was not the case. The backhoe bucket struck the gauge source rod extension, bending it, and damaging the gauge casing. Due to the damage, the source rod could not be fully shielded and locked in the storage position."

CA 5010 Number: 031419

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Agreement State Event Number: 53938
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CONSTRUCTION ENGINEERING CONSULTANTS
Region: 1
City: WHITE TOWNSHIP   State: PA
County:
License #: PA-1034
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/15/2019
Notification Time: 14:05 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - STUCK OPEN GAUGE SHUTTER

The following was received via e-mail:

"On March 14, 2019, the licensee informed the Department [Pennsylvania Department of Environmental Protection (DEP)] of a moisture/density nuclear gauge with a stuck open shutter. It is reportable per 10 CFR 30.50(b)(2).

"While at a temporary job site, a DEP inspector found a Troxler gauge with a stuck open shutter. The technician did not know how long the shutter had been open and was only able to get the Tungsten sliding block closed by tapping on the gauge. After it was closed the technician was unable to get the sliding block open again. The DEP will update this event as soon as more information is provided.

"The Department will perform a reactive inspection. More information will be provided upon receipt."

Pennsylvania Event Report ID No: PA190008

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Agreement State Event Number: 53939
Rep Org: LA DEPT OF ENVIRONMENTAL QUALITY
Licensee: TURNER INDUSTRIES GROUP, LLC
Region: 4
City: PORT ALLEN   State: LA
County:
License #: LA-5820-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/15/2019
Notification Time: 14:37 [ET]
Event Date: 03/15/2019
Event Time: 10:30 [CDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - THREATENED OVER-EXPOSURE

The following was received via e-mail:

"On March 14, 2019 around 1430 CDT, Turner Industries Group, LLC was performing work in a permanent shooting cell. Two industrial radiographers got into a verbal altercation, which lead to one industrial radiographer cranking out a source onto the other industrial radiographer. Dose reconstruction indicated less than 2 millirem/hr whole body to the one radiographer. The first radiographer was twelve feet from the four Half-Value Layer (HVL) collimator and ran to a shielded condition within seconds after realizing the source had been cranked out. The second radiographer was behind a shooting cell wall performing the crankout.

"The radiographer performing the crankout has been terminated and led off the property. All access that he had has been revoked and access codes changed."

Louisiana Event Report ID No.: LA20190004

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Agreement State Event Number: 53940
Rep Org: CA DEPARTMENT OF PUBLIC HEALTH
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES   State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/15/2019
Notification Time: 17:37 [ET]
Event Date: 03/14/2019
Event Time: 00:00 [PDT]
Last Update Date: 03/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - UNDER-DOSAGE TO PATIENT

The following was received via e-mail:

"On March 15, 2019, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a medical event involving Y-90 TheraSphere had occurred on March 14, 2019. A patient was prescribed 120 Gy to the left lobe of their liver with Y-90 TheraSpheres. However, the authorized user (physician) was only able to deliver 80.9 Gy (67.4 percent of the prescribed dose) due to suspected complications with the delivery system. UCLA's Office of Environment, Health and Safety (EH&S) team will continue to investigate and notify the BTG Radiation Safety Officer (RSO) group to examine the delivery system.

"The patient was notified of the under-dosage and potential continuation of their treatment. The patient was discharged in a stable condition."

CA 5010 No.: 031419

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: 53953
Facility: HATCH
Region: 2     State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RUSSELL LEWIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/24/2019
Notification Time: 05:23 [ET]
Event Date: 03/24/2019
Event Time: 01:59 [EDT]
Last Update Date: 03/24/2019
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):
JONATHAN MONTGOMERY (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 25 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO DEGRADING CONDENSER VACUUM

"At 0159 [EDT], with Unit 2 in Mode 1 at 25 percent power, the reactor was manually tripped due to degrading condenser vacuum. After the turbine was tripped, the station service electrical buses did not transfer to alternate supply resulting in loss of the condensate feedwater system and level being controlled by the RCIC system.

"Operators responded and stabilized the plant. Reactor water level is being maintained via the RCIC system.

"Pressure is being controlled and decay heat is being removed by the HPCI system in pressure control mode. Unit 1 is not affected.

"Additionally, an actuation of the primary containment isolation system occurred during the reactor scram. The reason for the actuation was a group II isolation signal was received on reactor water level and a group I isolation was received on decreasing vacuum.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non- emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the primary containment isolation system.

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

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Power Reactor Event Number: 53954
Facility: INDIAN POINT
Region: 1     State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: OSSY FONT
Notification Date: 03/24/2019
Notification Time: 17:40 [ET]
Event Date: 03/24/2019
Event Time: 14:45 [EDT]
Last Update Date: 03/24/2019
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):
CHRISTOPHER CAHILL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 96 Power Operation 0 Hot Standby

Event Text

REACTOR AUTOMATIC TRIP ON TURBINE TRIP

"On March 24, 2019, at 1445 EDT, Indian Point Unit 2 automatically tripped on a turbine trip due to a loss of excitation. All control rods fully inserted and plant equipment responded normally to the unit trip. This RPS [reactor protection system] actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B).

"The auxiliary feedwater system actuated following the automatic trip as expected. This specified system actuation 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. Unit 2 is in Mode 3 at normal operating temperature and pressure. Decay heat removal is via the steam generators to the atmospheric steam dumps. No radiation was released.

"Indian Point Unit 3 was unaffected by this event and remains defueled in a scheduled refueling outage.

"A post trip investigation is in progress.

"The licensee has notified the NRC Resident Inspector"

The New York State Public Service Commission, Consolidated Edison System Operator, and New York State Independent System Operator were also notified.


Page Last Reviewed/Updated Monday, March 25, 2019
Monday, March 25, 2019