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Event Notification Report for April 23, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/22/2019 - 4/23/2019

** EVENT NUMBERS **


53942 53994 53995 53996 54016 54017 54018 54020 54021

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53942
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/17/2019
Notification Time: 14:10 [ET]
Event Date: 03/17/2019
Event Time: 07:35 [CDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SCOTT SHAEFFER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 47 Power Operation 47 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"At 0735 CDT on March 17, 2019, the High Pressure Coolant Injection (HPCI) system was isolated due to a water-side leak from the HPCI Gland Seal Condenser. Unit 3 declared the HPCI system Inoperable and entered Technical Specification LCO 3.5.1 Condition C with required actions to verify the Reactor Core Isolation Cooling system is Operable, and to restore the HPCI system to Operable status within 14 days. All other Unit 3 Emergency Core Cooling Systems (ECCS) remain Operable.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(V)(D), 'Any 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.' This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(V)(D).

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

* * * RETRACTION FROM WESLEY CONKLE TO HOWIE CROUCH ON 4/23/19 AT 1549 EDT * * *

"ENS Event Number 53942, made on March 17, 2019, is being retracted.

"NRC Notification 53942 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, 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.

"At 0735 CDT, on March 17, 2019, during the performance of a routine surveillance, a momentary pressure transient of 844 psig from the Feedwater system was introduced into the High Pressure Coolant Injection (HPCI) system discharge and suction piping that ruptured the seal on the gland seal condenser and flooded the U3 HPCI Room. Unit 3 HPCI was declared inoperable due to isolation of the waterside of the HPCl system.

"On April 11, 2019, a Past Operability Evaluation was completed which determined that the HPCI System remained operable. The evaluation of the potential pressure transient and room flooding concluded that the HPCI System could have performed its specified safety function of vessel injection throughout the time that the gland seal was ruptured. 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 149973.

"The licensee has notified the NRC Resident Inspector."

Notified R2DO (Ehrhardt).

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Agreement State Event Number: 53994
Rep Org: ALABAMA RADIATION CONTROL
Licensee: VITAL INSPECTION PROGESSIONALS, INC.
Region: 1
City: ALABASTER   State: AL
County:
License #: 1118
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/12/2019
Notification Time: 09:37 [ET]
Event Date: 04/11/2019
Event Time: 12:23 [CDT]
Last Update Date: 04/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POTENTIAL PERSONNEL OVEREXPOSURE

The following was received via e-mail:

"On April 11, 2019, at 1223 (CDT), the Radiation Safety Officer (RSO) for Vital Inspection Professionals, Inc. advised the [Alabama Department of Public Health] Office of Radiation Control (ORC) of an incident that occurred on that day in the permanent shooting room at their facility in Alabaster, AL. Vital Inspection Professionals, Inc. has an Alabama Radioactive Material License No. 1118 for conducting industrial radiography. Preliminary information indicates that the radiographer, working alone, cranked out a 67 Curie Ir-192 source for an exposure and failed to crank the source back in before setting up for the next exposure. The radiographer's personal dosimeter badge has been sent in for emergency processing. Results are pending.

"Personnel from ORC are currently at the licensee's facility performing an incident investigation to include interviewing personnel and conducting re-enactments of the event."

Alabama Incident: 19-08

* * * UPDATE AT 1118 EDT ON 4/15/19 FROM DAVID TURBERVILLE TO JOANNA BRIDGE * * *

The following was received via fax:

"This is an update to Alabama incident 19-08 that was reported the morning of April 12, 2019. As background, the Radiation Safety Officer (RSO) for Vital Inspection Professionals, Inc. (Alabama License No. 1118) advised the Office of Radiation Control (ORC) of an incident that occurred on April 11, 2019 in the permanent shooting room at their facility in Alabaster, AL. The radiographer, working alone, cranked out a 67 Curie Ir-192 source for an exposure and failed to crank the source back in before setting up for the next exposure.

"The radiographer's personal dosimeter badge was been sent for emergency processing and the results determined the badge received an exposure of 8.149 Rem. The licensee's preliminary investigation calculated extremity exposure to the left hand of 39.684 Rem and exposure to the right hand of 9.338 Rem. The radiographer is being monitored by a medical physician. Personnel from ORC performed an initial investigation of the incident on the morning of April 12, 2019. The primary cause of the incident appears to be human error. Specifically, the radiographer failed to crank in the source at the conclusion of the exposure; failed to observe the radiation actuated visible alarm; bypassed the audible alarm feature of the shooting room; and failed to observe his survey meter upon entry into the shooting room. The investigation concluded that all safety features were operating properly at the time of the incident. Additional contributing factors are being evaluated at this time. The licensee's written report is pending.

"The information in this report is current as of 1000 CDT, April 15, 2019."

Notified R1DO (Bicket), NMSS (Rivera-Capella), INES Coordinator (Milligan), and NMSS_Events_Notification email group.

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Non-Agreement State Event Number: 53995
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 GRAY
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/12/2019
Notification Time: 11:24 [ET]
Event Date: 04/12/2019
Event Time: 08:00 [EDT]
Last Update Date: 04/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PROCESS GAUGE STUCK SHUTTER

The following is a synopsis of an event received via email:

On April 11, 2019, a trained technician was in the process of performing the biannual inventory/shutter check when the individual reported that Kay Ray Model #7050, Serial #1399, 250 mCi, Cs-137 gauge located on 5B DTU (Deslime Thickener U/Flow) in the Deslime basement had a frozen shutter mechanism and cannot be closed, rendering the shutter non-operable.

The gauge won't be replaced until the first time the slurry pipeline goes down for repair. If the line goes down prior to that, the gauge will be replaced at that time.

Similar events in the past have never had an exposure to any individuals. In the event of an emergency, the gauge will be removed and placed on a piece of lead and brought to storage.

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Agreement State Event Number: 53996
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: CATY NOLAN
Notification Date: 04/12/2019
Notification Time: 13:21 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION OF Y-90 THERASPHERES

The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:

On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.

There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).

The licensee will follow-up with a formal report.

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: 54016
Facility: BRUNSWICK
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALAN SCHULTZ
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/22/2019
Notification Time: 01:51 [ET]
Event Date: 04/21/2019
Event Time: 23:07 [EDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
FRANK EHRHARDT (R2DO)
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 TRIP AND SPECIFIED SYSTEM ACTUATION

"At 2307 EDT on April 21, 2019, in Mode 1 at approximately 100 percent reactor power, Unit 1 automatically tripped due to a Main Turbine Trip. The Main Turbine Trip was a result of two out of three level instruments sensing a false high reactor water level. All control rods inserted as expected during the scram. Safety Relief Valves G and K lifted per design. The same level instruments that failed also tripped both Reactor Feed Pumps. As a result, reactor water level dropped below the Low Level 1 and 2 actuation setpoints. Per design, the Low Level 1 signal resulted in Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves) and Group 8 (i.e., shutdown cooling isolation valves) isolations. The Low Level 2 signals resulted in Group 3 (i.e. Reactor Water Cleanup) isolation, a secondary containment isolation signal, and an auto start of Standby Gas Treatment and Control Room Emergency Ventilation. Also, the Low Level 2 resulted in [high pressure coolant injection] HPCI and [reactor core isolation cooling system] RCIC automatically starting and injecting into the vessel.

"All systems responded as designed.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B) for RPS actuation and 10 CFR 50.72(b)(3)(iv)(A) as an event that results in valid actuations 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."

Decay heat is currently being removed via the turbine bypass valves. Condensate and feed water are maintaining water level. The reactor is still at saturation temperature and 475 psi, lowering slowly. The reactor is still in a normal electrical lineup.

There was no impact to Unit 2 as a result of this event.

* * * UPDATE ON 04/22/19 AT 0220 EDT FROM ALAN SCHULTZ TO JEFFREY WHITED * * *

The licensee updated the event report to include a 4-Hr Non-Emergency Notification in accordance with 10 CFR 50.72(b)(2)(iv)(A) for Emergency Core Cooling System, HPCI, Discharge to the Reactor Coolant System.

Notified R2DO (Dickson), NRR EO (Miller) and IR MOC (Gott).

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Power Reactor Event Number: 54017
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: LINDSEY GRISSOM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/22/2019
Notification Time: 16:16 [ET]
Event Date: 04/22/2019
Event Time: 11:30 [EDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
FRANK EHRHARDT (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

CONTRACT SUPERVISOR TEST POSITIVE FOR DRUGS ON A FOLLOW-UP TEST

A contract supervisor tested positive for drugs on a follow-up fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a random test administered the next day (see EN #54018).

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 54018
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: LINDSEY GRISSOM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/22/2019
Notification Time: 16:16 [ET]
Event Date: 04/22/2019
Event Time: 11:30 [EDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
FRANK EHRHARDT (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

CONTRACT SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST

A contract supervisor tested positive for drugs on a random fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a follow-up test administered the previous day (see EN #54017).

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 54020
Facility: BYRON
Region: 3     State: IL
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN LEWIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/22/2019
Notification Time: 20:41 [ET]
Event Date: 04/22/2019
Event Time: 13:24 [CDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DARIUSZ SZWARC (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

MANUAL INITIATION OF THE AUXILIARY FEEDWATER SYSTEM IN RESPONSE TO A LOSS OF FEEDWATER

"At 1324 CDT, on 4/22/2019, with unit 2 in Mode 3 at 0 percent power, an intentional manual initiation of the Auxiliary Feedwater System occurred in response to a loss of feedwater condition. The loss of feedwater condition occurred after the non-safety related Startup Feedwater Pump was secured due to high bearing temperatures. The A Train Auxiliary Feedwater Pump was started per procedure. The Auxiliary Feedwater System started and operated as designed following intentional manual initiation.

"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 Auxiliary Feedwater 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: 54021
Facility: WATTS BAR
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JUSTIN GALLAGHER
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/23/2019
Notification Time: 09:44 [ET]
Event Date: 04/23/2019
Event Time: 02:32 [EDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
FRANK EHRHARDT (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

TEMPORARY LOSS OF CONTROL ROOM ENVELOPE BOUNDARY

"At 0232 EDT on April 23, 2019, a Main Control Room (MCR) alarm was received for low control room positive pressure.

"At 0233 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains. Watts Bar Unit 1 entered Condition B. Watts Bar Unit 2 was not performing movement of irradiated fuel assemblies and did not meet the APPLICABILITY for CREVS per LCO 3.7.10.

"At 0233 EDT on April 23, 2019, the alarm cleared, CREVS was declared operable and LCO 3.7.10 Condition B was exited.

"The safety function of the CRE boundary is to ensure the in-leakage of unfiltered air into the CRE will not exceed the in-leakage assumed in the licensing basis analysis of Design Basis Accident (DBA) consequences to CRE occupants. From 0232 EDT to 0233 EDT, [Watts Bar Nuclear] WBN was unable to validate that CREVS could fulfill its required Safety Function.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019