Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 52332 | 29 October 2016 15:31:00 | This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility. A deficiency with the TSC and EOF ventilation system was discovered on October 29, 2016 at 1032 (EDT). The deficiency involved a fire alarm unable to be reset impeding the ability to place the TSC and EOF in recirculation mode in the event of a radiological release. The fire alarm was reset at 1204 (EDT) on October 29, 2016, restoring capability to perform full emergency assessment to the TSC and EOF. If an emergency had been declared while the fire alarm was unable to be reset requiring TSC or EOF activation during this period, the TSC and EOF would be staffed and activated using existing emergency planning procedures unless the TSC or EOF became uninhabitable due to ambient temperature. radiological, or other conditions. If relocation of the TSC or EOF became necessary, the Emergency Response Manager would relocate the TSC and/or EOF staff to an alternate location in accordance with applicable site procedures. This condition had no impact on the health and safety of the public. The NRC Resident Inspector has been notified. A malfunctioning smoke detector was removed from the system. Compensatory measures are being employed. |
| ENS 52291 | 8 October 2016 14:23:00 | Loss of all offsite power capability, Table S-5, to 6.9kV emergency buses 1A-SA and 1B-SB for greater than or equal to 15 minutes. At 1328 EDT, while shutdown in Mode 4 (Hot Shutdown), Harris declared an Unusual Event due to a loss of offsite power. Following the loss of offsite power (LOOP), the Emergency Diesel Generators started and loaded onto their respective emergency buses. The reactor remains stable and shutdown in Mode 4. The licensee is currently investigating the cause of the LOOP and the emergency buses will continue to be powered by the EDGs until the licensee has determined the cause for the LOOP. Offsite power is currently available into the switchyard. The licensee notified the state government, the local government, and the NRC Resident Inspector. Notified DHS SWO, FEMA OPS Center, FEMA National Watch (email only), DHS NICC, Nuclear SSA (email only).
The cause (of the LOOP) is not known. Duke Energy Control Center has evaluated the grid and is comfortable with Harris connecting emergency buses back to the grid. Harris Plant is evaluating restoration. Faults were validated on the 115kV Cape Fear North and South supply lines into the Harris switchyard. This notification also addresses various valid actuations of safety systems, including the Emergency Diesel Generators, as well as, potential loss of Emergency Assessment Capabilities due to the LOOP impacting Emergency Planning equipment. The licensee notified the NRC Resident Inspector. Notified R2DO (Bonser), IRD (Grant), and NRR EO (King).
The cause of the LOOP has been determined to be a momentary electricity loss on the 115kV Cape Fear North and South supply lines into the Harris switchyard. This event notification also addresses the loss of safety function of the offsite power system which occurred as a result of grid perturbations. The licensee notified the NRC Resident Inspector. Notified R2DO (Bonser), IRD (Grant), and NRR EO (King).
Based on the grid being stable and the 115kV Cape Fear North and South lines being available, the licensee terminated the Unusual Event at 2049 EDT on 10/8/16. The licensee notified the NRC Resident Inspector. Notified R2DO (Bonser), IRD (Grant), and NRR EO (King). Notified DHS SWO, FEMA OPS Center, FEMA National Watch (email only), DHS NICC, Nuclear SSA (email only).
10 CFR 50.72(b)(2)(XI) - OFFSITE NOTIFICATION At approximately 1305 EDT on October 9, 2016, Duke Energy personnel notified the North Carolina Department of Environment and Natural Resources of a spill of untreated sanitary wastewater. During a significant rainfall event associated with Hurricane Matthew, wastewater was released from the overflow of a lift station that did not function as a result of a power outage. The untreated sanitary wastewater entered the plant's storm drain system. The release has been stopped and the lift station power is restored. An investigation is in progress to further determine the cause and additional corrective actions. There is no impact to public health and safety or the environment due to this incident. This event is reportable per 10 CFR 50.72(b)(2)(xi), an event related to protection of the environment for which a notification to other government agencies has been made. The NRC Resident Inspector has been notified. Notified R2DO (Bonser). |
| ENS 52290 | 8 October 2016 13:44:00 | UE SU1.1 declared due to momentary loss of power from the qualified off-site source. Both Emergency Diesel Generators started and loaded to supply power to both of the Emergency Buses. 'A' Service Water Pump did not start on Blackout sequencer. Sufficient Service Water flow is available from the other three operating pumps. All other systems operated as designed." At 1304 EDT Robinson Unit 2 experienced a momentary grid voltage drop that lowered the 4kV bus voltage and initiated an automatic reactor trip. All rods inserted and decay heat is being removed by steam generator PORVs. In response to the reduced bus voltage, the Emergency Diesel Generators (EDGs) automatically started and loaded onto the emergency busses. At 1317 EDT, the licensee declared an Unusual Event (EAL SU1.1) due to the loss of offsite power. The licensee is currently investigating the cause of the grid voltage instability. The emergency busses will continue to be powered by the EDGs until the licensee has determined the cause for the voltage drop. All offsite power sources and all equipment is available. The licensee has notified the state government and Darlington County. The NRC Resident Inspector has been notified. Notified DHS SWO, FEMA OPS Center, FEMA National Watch (email only), DHS NICC, Nuclear SSA (email only).
At 1303 EDT on 10/08/2016, a reactor trip occurred. The cause was under voltage to the plant 4kV buses due to an offsite grid disturbance. The cause of the disturbance is under investigation. Following the reactor trip, the Auxiliary Feedwater System actuated as expected on low steam generator level. At the time of the trip, the plant was in Mode 1. Currently, the Plant is in Mode 3. The current RCS Temperature is 550 degrees F (Average), and the Steam Generator Levels are in the range of 42 to 53% (normal range) with levels controlled by the Auxiliary Feedwater System. Decay heat removal is being controlled by the steam generator PORVs. 'A' Service Water Pump did not start on Blackout sequencer. Sufficient Service Water flow is available from the other three operating service water pumps 'B', 'C', and 'D'. All other systems operated as designed. Due to the Automatic Actuation of the Reactor Protection System, this event is being reported as a 4-hour Non-Emergency per 10 CFR 50.72(b)(2)(iv)(B). Due to the valid actuation of Auxiliary Feedwater System, this event is also being reported as an 8-hour Non-Emergency per 10 CFR 50.72(b)(3)(iv)(A)(B)(6). At no time during this occurrence was the public or plant staff at risk as a result of this event. The Resident Inspector has been notified.
At 2323 (EDT) Emergency Bus E-2 powered from off-site power." The NRC Resident Inspector will be notified. Notified R2DO (Bonser), IRD (Grant), NRR EO (Miller).
At 0011 (EDT) Robinson Nuclear Plant has terminated the Unusual Event. Basis for the Unusual Event termination was restoration of power to Emergency Bus E-2 from off-site power. The licensee has notified the NRC Resident Inspector. Notified R2DO (Bonser), NRR EO (Miller), IRD (Grant), DHS SWO, FEMA OPS Center, FEMA National Watch (email only), DHS NICC, Nuclear SSA (email only).
At approximately 2323 EDT on 10/08/2016, an auto-start of the Auxiliary Feedwater (AFW) Motor-Driven pumps occurred during the transfer of Emergency Bus power from the 'B' Emergency Diesel Generator (EDG) to offsite power. AFW system auto-start logic associated with Main Feed Pump (MFP) breakers being open is defeated when the EDG output breaker is closed. As such, when the EDG output breaker was opened during the power transfer while the MFP breakers were open, the auto-start logic was thereby met causing the AFW auto-start. Due to the valid actuation of the AFW System, this event is being reported as an 8-hour Non-Emergency per 10 CFR 50.72(b)(3)(iv)(A). At no time did this occurrence pose undue risk to the health and safety of the public. The NRC Senior Resident Inspector has been notified of this event. H.B. Robinson Unit 2 was in Mode 3 during this event. Notified R2DO (Bonser). |
| ENS 52247 | 16 September 2016 23:35:00 | At 1657 Eastern Daylight Time (EDT) the plant entered Mode 4 (from Mode 5), and subsequently, at 1710 EDT, it was discovered that 480V AC essential busses E1 and F1 were being supplied from the shutdown operations transformers. The essential busses E1 and F1 are required to be aligned to the power operations transformers in Mode 4 for operability in accordance with TS 3.8.9. With both E1 and F1 essential busses aligned to the shutdown operations transformers with the plant in Mode 4, both trains of the essential electrical power distribution system were inoperable, resulting in a loss of safety function. At 1733 EDT both E1 and F1 essential busses were aligned to the power operations transformers as required by TS 3.8.9. This issue is being reported as a loss of safety function of the essential electrical busses. The NRC Resident Inspector has been notified of the event.
Engineering reviewed the actual conditions during the approximate 36 minutes the 480V AC essential busses were being supplied from the shutdown operations transformers. Grid voltages were higher than assumed minimum voltages, and electrical loading during Mode 4 conditions were reduced from expected full power operation loading. As a result, Engineering determined that all equipment remained capable of performing its required functions while connected to the shutdown operations transformers. Because the equipment remained capable of satisfying the requirements for Operability, no condition existed that could have prevented the fulfillment of a safety function. Therefore, no loss of safety function existed for the 480V AC essential buses, and the notification made per 10 CFR 50.72(b)(3)(v)(A-D) by the Davis-Besse Nuclear Power Station on 9/16/2016 (EN# 52247) is being retracted. The NRC Resident Inspector has been briefed on the evaluation results and informed of this retraction. Notified the R3DO (Jeffers). |
| ENS 52245 | 16 September 2016 12:17:00 | At 0858 (EDT) on September 16th, 2016, approximately 3 ounces of hydraulic fluid (fish oil) was spilled in front of the Unit Two Circulating Water System (CWS) Intake trash racks at the Salem Generating Station. The spill of hydraulic fluid (fish oil) was caused by a leak from the crane used to rake debris from the Unit Two trash racks. The crane was stopped and the leak terminated at the time of discovery. Nuclear Environmental Affairs Department determined a 4 hr report to the NRC, under RAL 11.8.2.a, was warranted due to the 15 minute notification to the New Jersey Department of Environmental Protection at 0913 (EDT). Nuclear Environmental Affairs Department intends to retract the report to the New Jersey Department of Environmental Protection based on the fluid remained within the Circulating Water System (CWS) Intake Structure. The licensee has notified the New Jersey Department of Environmental Protection, the NRC Resident Inspector, and will notify the Lower Alloways Creek Township. |
| ENS 52226 | 8 September 2016 04:27:00 | On September 7th, 2016 at approximately 2131 Mountain Standard Time (MST), Palo Verde Unit 1 was manually tripped due to a stuck open main spray valve. Unit 1 was operating at 100 percent power at normal operating temperature and pressure prior to the event. A 120 VAC non-class instrument distribution panel was being transferred to its alternate power supply to establish maintenance conditions. The distribution panel failed to transfer. The panel remained energized from its normal power supply; however, multiple components powered from the distribution panel began to exhibit uncharacteristic behavior. At this time, it was noted that a reactor coolant system main spray valve was open. The alarm response procedure was followed; however, the actions taken were unsuccessful at closing the main spray valve. The plant was then manually tripped due to pressurizer pressure continuing to lower. The reactor coolant pumps were turned off to terminate main pressurizer spray flow to control pressurizer pressure due to the inability to close the main spray valve. No ESF (Engineered Safety Features) actuations occurred and none were required. No emergency classification was required per the emergency plan. Safety related buses remained energized during and following the reactor trip. The emergency diesel generators did not start and were not required. The offsite power grid is stable. Limiting condition for operation 3.4.1 was entered due to low pressurizer pressure. No major equipment was inoperable prior to the event that contributed to the event. Unit 1 is stable at normal operating temperature and pressure in Mode 3. Reactor coolant pumps are secured and natural circulation has been verified. Primary pressure is being maintained at its normal operating pressure manually with pressurizer heaters and auxiliary spray, from the charging system. 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 minimum RCS pressure was approximately 2070 psia (normal 2250). The event did not adversely affect the safe operation of the plant or the health and safety of the public. All rods inserted and the trip was uncomplicated. Units 2 and 3 were not affected and continue to run at full power. The NRC Resident Inspector has been notified. |
| ENS 52221 | 3 September 2016 08:44:00 | At 0710 CDT, Cooper Nuclear Station declared a Notification of Unusual Event under EAL HU1.1 due to the station seismic event alarm registering a response to an earthquake (epicenter near Pawnee, OK). The reactor was not affected by the earthquake and remains at 93 percent power. The licensee is performing walkdowns of structures and equipment to verify that the site is unaffected. Notified the DHS SWO, FEMA Ops Center, DHS NICC, FEMA National Watch Center (E-mail) and Nuclear SSA (E-mail).
At 1547 CDT, Cooper Nuclear Station terminated the Notice of Unusual Event. All inspections and walkdowns of the plant have been completed. No damage or injuries were reported. The seismic event caused no impact to the plant. The Licensee has notified the NRC Resident Inspector. Notified R1DO (Warnick), NRR EO (Miller), IRDMOC (Stapleton), DHS SWO, FEMA Ops Center, DHS NICC, FEMA National Watch Center (E-mail) and Nuclear SSA (E-mail). |
| ENS 52324 | 27 October 2016 16:43:00 | The following was received via email: Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International LLC ('Fisher') is providing required written interim notification of a potential failure to comply concerning Type 546NS Electro-Pneumatic Transducer Qualification Reports. On August 30, 2016, Fisher became aware of a potential issue with the past qualification of the Type 546NS Transducers. Fisher's published seismic literature and certifications, based on testing by a 3rd party laboratory, exhibit inconsistencies when compared to more recent testing completed by Fisher. Regardless of these discrepancies, the Type 546NS Transducer remains qualified to perform before and after seismic loading. The scope of this investigation pertains only to operability during seismic events. An extent-of-condition investigation is underway and 546NS testing data is being evaluated to determine if further testing is required. Fisher will complete the investigation by November 27, 2016 and, if necessary, will complete additional testing by February 10, 2017. Should there be any further questions concerning this matter, please contact Benjamin Ahrens, Manager, Quality by email at Benjamin.Ahrens@Emerson.com or via phone at 641-754-2249.
The following was received via email: Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International LLC ("Fisher") is providing an update to a previous written interim notification of a potential failure to comply concerning Type 546NS Electro-Pneumatic Transducer Qualification Reports. On August 30, 2016, Fisher became aware of inconsistencies exhibited by prior qualification reports of the 546NS. A review of all previous Type 546 qualifications has been completed to reaffirm the qualification of the device for operation during seismic events. Based on this review, the 546NS remains qualified to perform before and after seismic loading. Additional testing is required to confirm if the device is capable of operating during an event. This additional testing is scheduled to be completed by February 10, 2017. Once this additional testing has been completed and operability status determined, an appropriate announcement will be made pursuant to 10CFR21 reporting requirements. Should there be any further questions concerning this matter, please contact Benjamin Ahrens, Manager, Quality by email at Benjamin.Ahrens@Emerson.com or via phone at 641-754-2249. Notified the R1DO (Dwyer), R2DO (Heisserer), R3DO (McCraw), R4DO (Taylor), Part 21/50.55 Reactors (via email) and Part 21 Materials (via email).
The following is a summary of information that was received via email: Pursuant to 10CFR21.21(a)(2), Fisher Controls International LLC ('Fisher') is providing required written interim notification of a potential failure to comply concerning Type 546NS Electro-Pneumatic Transducer Qualification Reports. This notification serves as a follow-up to a similarly titled report dated October 27, 2016. Fisher initiated in-house seismic testing to analyze the performance of the device and associated mounting hardware when exposed to high-level seismic activity. These tests concluded on February 10, 2017. Test data analysis is still underway. However, at the time of this publication, preliminary observations and conclusions can be made. The device itself, when rigidly mounted, does not exhibit natural frequencies in the tested frequency range consistent with previous qualification literature. When mounted to the standard 546 mounting bracket, the tested assemblies do not exhibit natural frequencies below 60 Hz. During the course of testing, additional questions were raised regarding the configuration of the mounting bracket. These questions are currently being investigated. Questions regarding 546NS mounting will be addressed on a case-by-case basis with individual customers. Further analysis and verification of the test data is needed before Fisher can make specific claims regarding the operability of the 546NS during high-level seismic loading. Fisher will complete the investigation by April 13th, 2017. Should there be any further questions concerning this matter, please contact Benjamin Ahrens, Manager, Quality by email at Benjamin.Ahrens@Emerson.com or via phone at 641-754-2249. Notified the R1DO (Powell), R2DO (Bartley), R3DO (Jeffers), R4DO (Pick), Part 21/50.55 Reactors (via email) and Part 21 Materials (via email). |
| ENS 52201 | 25 August 2016 21:11:00 | On August 25, 2016, Engineering staff were reviewing a proposed modification to install additional internal flooding protection for the Intake Building staircase down to the Raw Water Pump vault. Fort Calhoun Station determined that the existing Intake Building internal flooding and tornado-borne missile analyses did not sufficiently account for the potential of tornado-borne missiles striking Fire Protection piping in the Intake Building. A tornado-borne missile strike could potentially cause a double-ended rupture of Fire Protection piping in the vicinity of the stairwell down to the Raw Water Pump vault, which could cause flooding and subsequent failure of all four Raw Water Pump motors more quickly than bounded by the Engineering Analysis. The Engineering Analysis uses a postulated crack from a Moderate Energy Line Break per USNRC Branch Technical Position MEB 3-1, vice postulating a double ended pipe rupture. The resulting flow rate from this postulated crack is less than that possible from a tornado-borne missile strike. This condition creates a potential loss of safety function from the Fort Calhoun Station Raw Water System (ultimate heat sink). All four Raw Water Pump motors could potentially become inoperable from flooding caused by a tornado-borne missile impacting the Fire Protection System Piping near the Raw Water vault stairwell prior to operator action to secure both Fire Pumps. This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and per 10 CFR 50.72(b)(3)(v)(D) for 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. Interim compensatory measures are to isolate the Fire Protection piping in the vicinity of the Raw Water Pump vault stairwell when severe weather is forecast. The NRC Resident Inspector has been notified. |
| ENS 52192 | 22 August 2016 06:49:00 | At 2251 EDT on 8/21/2016, the 'A' Train of Control Room ventilation was inoperable for scheduled testing and the 'B' Train of Control Room ventilation was declared inoperable due to a thermal overload of a cooling fan. This resulted in not meeting the limiting condition for operation in accordance with Technical Specification 3.7.6. No action statement exists for having two trains of Control Room Ventilation inoperable and Technical Specification 3.0.3 was applied. At 2255 on 8/21/2016 the 'A' Train of Control Room Ventilation was declared operable and Technical Specification 3.0.3 was exited. The licensee notified the NRC Resident Inspector.
Event notification 52192 is being retracted. Upon further evaluation, Harris determined that the 'A' train of Control Room Emergency Filtration was Operable at the time 'B' train became Inoperable. Therefore, there was no loss of safety function. The NRC Resident Inspector has been informed of this retraction. Notified R2DO (Rose). |
| ENS 52169 | 11 August 2016 11:09:00 | Reactor operators manually tripped the reactor due to the loss of two out of four circulating water pumps which caused a drop in condenser vacuum. The trip was uncomplicated. The reactor is shutdown and stable with decay heat removal via steam dumps to the condenser. The cause of the circulating water pump trips is currently unknown, but initial indications are that the pumps tripped due to a lightning strike that caused an electrical perturbation. The reactor will remain shutdown while the licensee investigates the cause. Unit 3 was not affected. The licensee notified the NRC Resident Inspector and the State and Local governments. |
| ENS 52165 | 10 August 2016 11:28:00 | The following was received from the Commonwealth of Pennsylvania via email: On August 10, 2016, the Department (Pennsylvania Bureau of Radiation Protection) was notified by Testing Services, Inc. that a moisture/density gauge had been damaged while on location at a temporary job site. It is reportable per 10 CFR 30.50(b)(2). While at a temporary job site, a Humboldt Model 5001 gauge was damaged and became unusable after being run over by a compactor. A survey of the gauge indicated that the source was still in its shielded position. A leak test sample has been taken and sent for analysis and the gauge has been removed from service and secured. No over exposures have occurred. A service provider has been contacted to see if repairs are possible or if the gauge will be returned to the manufacturer. Radionuclides: Cs-137 and Am-241:Be Manufacturer: Humboldt Model: 5001 Serial Number: 2394 Activity: 11 mCi Cs-137, 44 mCi Am-241:Be The gauge has been securely stored and placed out of service until repairs/return can be accomplished. The Department has scheduled a reactive inspection. More information will be provided when available. PA report # PA160022 |
| ENS 52149 | 2 August 2016 20:33:00 | At 1612 EDT on 08/02/16, Fermi 2 discovered a sanitary sewer system leak from underground lines beneath the parking lot near Warehouse B. Some of the sewage has entered the storm drain system. The sewage leak was stopped at approximately 1730 EDT. The duration and quantity of the spill is unknown. A local sanitary contractor is currently responding to the site to clean the affected areas. Reports to the Michigan Department of Environmental Quality (MDEQ), the local health department (Monroe County), and the local news media are in progress. Since these reports are in the process of being made, this is considered a News Release or Notification to Other Government Agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified. |
| ENS 52148 | 2 August 2016 17:55:00 | On August 2, 2016 at 0934 CDT, Byron Operators entered and exited 1BOL 8.1 Conditions B and F for the 1A and 1B Diesel Generators due to 0DSSD192 (1B DOST Watertight Door) being discovered open and unattended. 0DSSD192 was closed within 5 minutes of discovery. 0DSSD192 protects the DOST (diesel oil storage tank) transfer pumps from the effects of a postulated failure of a Circulating Water expansion joint at the condenser waterboxes in the Turbine Building. An open watertight door associated with one DOST has the potential of making both Diesel Generators inoperable. This event is reportable per 10 CFR 50.72(b)(3)(v)(D) for any event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident. The licensee has notified the NRC Resident Inspector.
The purpose of this report is to retract a previous report made on August 2, 2016 at 1755 EDT (EN 52148). Notification of the event to the NRC was initially made for a condition where the station determined that an open watertight door associated with one DOST (Diesel Oil Storage Tank) had the potential to make both Diesel Generators inoperable, and the condition was reported under 10 CFR 50.72(b)(3)(v)(D) for any event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident. Upon further investigation, Byron Station has concluded that the 1A Diesel Generator was never inoperable, and therefore, no loss of safety function occurred. Based on this, the prior ENS notification is being retracted. The NRC Senior Resident Inspector has been notified. Notified R3DO (Dickson). |
| ENS 52146 | 2 August 2016 14:42:00 | On August 2, 2016 at 1015 EDT, while restoring the east train of Reactor Building HVAC (RBHVAC) after a surveillance test on Division 2 Standby Gas Treatment System (SGTS), the Technical Specification (TS) for the secondary containment pressure boundary was not met for a duration time of approximately 1 second. The maximum secondary containment pressure observed during that time was approximately 0.120 inches of vacuum water gauge. Secondary containment pressure was returned to within the TS operability limit by RBHVAC and SGTS already in operation. There were no radiological releases associated with this event. The cause of the event is under investigation. The TS requirement is to maintain secondary containment vacuum greater than or equal to 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) for secondary containment operability. Declaring secondary containment inoperable is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material. The licensee has notified the NRC Resident lnspector. |
| ENS 52145 | 2 August 2016 14:22:00 | This is a non-emergency eight-hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility. A condition impacting functionality due to a loss of cooling of the TSC (Technical Support Center) Ventilation system was discovered on 8/2/16 at 0630 EDT. Repairs are complete at 1030 EDT on 08/02/16. If an emergency would have been declared requiring TSC activation during this period, the TSC would have been staffed and activated using existing emergency planning procedures unless the TSC had become uninhabitable. If relocation of the TSC had been necessary, the Emergency Coordinator would have relocated the TSC staff to an alternate location in accordance with applicable emergency plan implementing procedures. The Emergency Response Organization team was notified of the condition and the possible need to relocate during an emergency. This condition does not affect the health and safety of the public or station employees. The NRC Resident Inspector has been notified. |
| ENS 52142 | 1 August 2016 17:53:00 | At 1118 (CDT) during planned maintenance activities there was an unintentional release of approximately 146.5 pounds of Halon gas into an enclosed room in the Unit-2 Electrical Auxiliary Building. There was no impact to plant operations or plant personnel. The room was verified by station Safety Personnel to be safe for normal access. At 1518, Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of an event which met the requirements of 'Emission Event' for the TCEQ of a HALON release that exceeded the reportable quantity threshold of 100 pounds in a 24 hour period. No further actions are required by the TCEQ at this time and no press release is planned. The halon discharge was contained within the site protected area. Therefore, this event is not significant with respect to the health and safety of the public. The licensee has notified the NRC Resident Inspector. |
| ENS 52144 | 2 August 2016 12:50:00 | Per 10 CFR 20.1906(d), Veterans Health Administration (VHA) National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received Friday, July 29, 2016, at around 0700 EDT by the North Florida / South Georgia Veterans Health System in Gainesville, Florida. This facility holds permit number 09-12467-02 under the VHA master materials license. The package was checked-in and surveyed upon receipt around 0700 EDT. Wipe tests performed on the external surface of the package indicated a removable contamination level of around 347 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. The package contained one unit dosage of about 57 millicuries of fluorine-18 (as fluorodeoxyglucose) at the time of receipt. The dosage was shipped from PETNET Solutions, Inc., out of Jacksonville, Florida, who was also the delivery carrier. The facility nuclear medicine technologist immediately notified the delivery carrier by phone about the contaminated package around 0710 EDT. The patient dosage inside the package was not impacted and was able to be used. As corrective actions, the packaging materials were set aside in a restricted area at the facility. VHA National Health Physics Program, who manages the master materials license, was notified of the incident around 1030 EDT on August 2, 2016. In addition, we notified our NRC Region III Project Manager of the event. This event was reported to the State of Florida by the shipper, PETNET Solutions, Inc., and entered by the NRC as an Agreement State report (EN 52141). |
| ENS 52141 | 1 August 2016 16:13:00 | The following was received via email: The Gainesville VA Medical Center (VAMC) received a unit dose of the F-18 FDG radiopharmaceutical used for PET/CT scans on Friday, July 29, 2016 at 0657 (EDT). The swipe test performed upon receipt of the package found that the container was contaminated externally with F-18. The radiopharmaceutical was shipped and transported to the VAMC from the company, PETNET Solutions, Inc., 3728 Phillips Highway, Suite 220, Jacksonville, Florida, 32207. The State of Florida RAM license number for the PETNET Solutions laboratory is #3887-3. |
| ENS 52127 | 26 July 2016 18:12:00 | On July 26, 2016 at 1252 hours (CDT), the Control Room Emergency Ventilation (CREV) system was declared inoperable due to a toxic gas analyzer spurious alarm which resulted in the 'B' Air Filtration Unit (AFU) being inadvertently isolated. In this condition, Control Room Emergency Ventilation (CREV) system cannot be guaranteed to achieve required design flow rate. Tech Spec 3.7.4, Condition A was entered which requires the CREV system to be restored to an operable status in seven (7) days. The CREV system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions as well as protection of the operators from a high dose environment assumed during a design basis accident. This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), 'Event or Condition That Could Have Prevented Fulfillment of a Safety Function,' because the CREV system is a single train system required to mitigate the consequences of an accident. The NRC Resident Inspector has been notified. |
| ENS 52120 | 22 July 2016 17:09:00 | The following was received via email: Qualspec, LLC. Radiation Safety Officer, reported the following source disconnect incident on July 21, 2016, at (1843 PDT) via email. The incident took place at the Valero refinery, located at 3400 East Second St., Benicia, CA, at approximately 1430. During their 4th and last exposure, they were not able to return the radiography source (Ir-192, 63 Ci) to the INC 100, S/N 4848 radiography camera's shielded position. The RSO and ARSO, were notified right away and responded immediately to the location. After their assessment, they determined the source pigtail had become detached from the drive cable due to the drive cable ball connector breaking off. There was no other sign of physical damage to the camera, the crank assembly or related equipment. After phone consultation with the manufacturer, a retrieval method was determined and the source was safely secured back into the exposure device. TLD dosimeters have been sent to Radiation Detection Company for emergency processing. Individuals involved (received) based on their pocket dosimeter (readings) - Radiographer Trainer 20 mR, Radiographer 10 mR, Radiographer Assistant 10 mR (as measured by) 200 mR scale Arrow pocket dosimeter; Radiation Safety Officer 400 mR, Assistant RSO 300 mR (as measured by) 5R scale Arrow pocket dosimeter. California 5010 # 072116 |
| ENS 52119 | 22 July 2016 14:38:00 | The following was received via email: The licensee (QSA Global, Inc.) made telephone notification at 1026 (EDT) on July 22, 2016 followed by written report to the Agency (Massachusetts Radiation Control Program), that the licensee was notified by carrier that one piece of a four piece shipment incoming from Australia and destined for QSA Global, Inc., Burlington, Massachusetts is unaccounted for. The licensee initially identified that it did not know which of the four pieces is the one missing. The licensee provided update by telephone at 1335 on July 22, 2016 that it had determined that the piece missing is a Model 650L source changer, Type B(U) package, UN2916, containing two special form iridium-192 sources, 0.44 TBq (12 curies) total of iridium-192. The missing package is believed by the licensee to possibly be in Memphis, Tennessee at the carrier's hub. The licensee reports that it initiated a trace yesterday with the carrier and has also requested a ramp search of the Boston (Logan Airport) facility in case it was separated there. The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. The Agency made notification to FBI. The Agency considers this event to be open. At 1616 (EDT), on July 22, 2016, the licensee (QSA Global, Inc. of Burlington, MA) notified us (Massachusetts Radiation Control Program) by telephone that the missing package has been located by the carrier at its Memphis, Tennessee hub and that the package is expected to be delivered to the licensee on Monday. The licensee reports that a label had apparently fallen off of the package. THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 52116 | 21 July 2016 18:28:00 | Southern Nuclear Operating Company had a non-licensed supervisory contractor employee confirmed positive result for alcohol during a follow-up fitness-for-duty test. The contractor employee's unescorted access to the plant has been revoked. The NRC Senior Resident Inspector has been informed. |
| ENS 52121 | 22 July 2016 17:20:00 | During a sealed source leak test of two (2) cesium-137 needles, prior to implant into an animal, leakage greater than 0.005 microcuries was measured. The leakage was contained in the source holder. The Cs-137 needles have been stored in shielding pending disposal. There was no contamination or over- exposure. The needles contain 10 mCi of Cs-137 total (for both). The licensee has notified NRC Region 3 and expects to submit a 30 day follow up report.
Follow-up leak tests have been performed on all remaining Cs-137 needles used for equine brachytherapy. One additional leaking needle was identified. The activity for the additional leaking needle, as of 7/18/2016, was 7.1 mCi. The additional leaking needle was manufactured in 1982. The additional leaking needle has been taken out of service, put into secondary containment, and is awaiting waste disposal. The licensee notified NRC Region 3. Notified R3DO (Peterson) and via E-mail NMSS Events Notification. 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 |
| ENS 52114 | 21 July 2016 13:20:00 | The following was received via email: On July 21, 2016 at approximately 1200 (EDT), (Georgia Radioactive Materials Program) received a call from WestRock Southeast, notifying (Georgia Radioactive Materials Program) that a fixed gauge malfunction had occurred and that the shutter was not closing. The shutter malfunction was initially noticed on Thursday July 14, 2016. Thermofisher was contacted about repairing the gauge, but (the licensee) was informed that the fixed gauge cannot be repaired. WestRock Southeast has decided to dispose of the fixed gauge and has contacted Ram Services to handle disposal. No disposal date has been determined. Until such time, the fixed gauge has been tagged with danger signs and instructions not to enter (the area). The fixed gauge is still in use. Isotope: Cs-137; Activity: 10 millicuries; Manufacturer: Kay-Ray; Model: 7062B; Source Serial #: 24784A; Leak Test Results: Pass (last tested August 2014) Georgia Event # 80359. |
| ENS 52033 | 22 June 2016 13:02:00 | At 0841 (CDT) an automatic turbine trip occurred, resulting in an automatic reactor protective system (RPS) actuation due to loss of turbine load. The source of the turbine trip was from the distributed control system (DCS) and is being investigated via a root cause analysis. This was an uncomplicated trip, all systems responded as expected post trip, and the reactor trip recovery procedure was entered at 0852 (CDT). The plant is stable in Mode 3 with a normal electrical line up and decay heat removal via steam dumps to the condenser. The NRC Resident Inspector has been notified. |
| ENS 52034 | 22 June 2016 13:28:00 | The following was received from Colorado via email: The facility manager completed the documentation for the 2016 Annual General License reports. During his inspection, only 2 of the 4 Tritium exit signs were reported. It is unknown as to what may have occurred with the other two signs as staff has changed since the signs were designated to be used at the facility. Pictures were submitted showing the labels on the existing two signs located within the modern fold doors at the school. No serial number was provided on the label from the manufacture Shield Source. The distributor, Isolite, did report serial numbers on the quarterly report to the state. Colorado Report # CO16-I16-09 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 |
| ENS 52030 | 21 June 2016 18:12:00 | Today at 1646 EDT a reportable spill of approximately 1 liter of Sodium Hypochlorite 15 percent solution reached the soils of New Jersey. The leak was able to be isolated and the area is being cleaned up. This event is reportable within 4 hours per 10 CFR 50.72(b )(2)(xi) any event or situation related to protection of the environment for which a notification to other government agencies has been made. The licensee notified the New Jersey Department of Environmental Protection and has notified the NRC Resident Inspector. |
| ENS 52028 | 21 June 2016 14:28:00 | The following was received from California via email: The RSO of Nova Engineering and Environmental notified RHB (Radiologic Health Branch) in Brea that a Troxler yellow transport case containing a Troxler model 3411B # 18840 moisture density gauge containing 8 mCi of Cs-137 and 40 mCi of Am-241/Be was stolen from a technician's pickup truck today. The technician stated that he had loaded and secured the Type A case into his pick-up truck from a storage facility in Irvine, CA then stopped at a coffee shop before traveling to his work location. He went to unlock the gauge case and found that it had been stolen. He returned to the coffee shop, but was unable to find his gauge. He is contacting the Irvine Police Dept. to make a theft report. The RSO indicated that they lock and chain each side of the case to the truck independently and once again around the top of the case to prevent it from opening. Nova E&E does have contact information on the gauge and the case and they use a small padlock on the Cs-137 source rod handle to prevent accidental deployment. CA 5010 # 062116
The following was received from California via email: A moisture density gauge that had been reported stolen on 6/21/16 (see NMED Item # 160262) was recovered this morning, after it was dropped off at a construction site where it was not being used. The gauge was not in its transportation container, and the source rod was not locked, although it was in the shielded position. Survey measurements confirmed that both sources (Cs-137 and Am-241) are present. The gauge is presently in the California radiation control program's possession pending return to its licensed owner (Nova Environmental Engineering, license # CA 7732-37). Notified R4DO (Gepford), NMSS Events Notification, and Mexico via email. 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 |
| ENS 52026 | 20 June 2016 17:19:00 | On June 20, 2016 at 1540 EDT, Watts Bar Nuclear Plant Unit 2 reactor tripped due to (reaching the) automatic Lo-Lo steam generator trip (setpoint) on (the) #4 steam generator. Concurrent with the reactor trip the Auxiliary Feedwater system actuated as designed. All control and shutdown rods fully inserted. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and main steam dump systems. The station is in a normal shutdown electrical alignment. The cause is currently under investigation. This is being reported under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72 (b)(2)(iv)(B). The NRC Senior Resident has been notified. There was no effect on Unit 1. |
| ENS 52027 | 21 June 2016 11:37:00 | The following was received from Minnesota via email: On June 20, 2016 at 0930 (CDT) Midwest Industrial X-Ray, Inc. (License number 1086-89) had a source disconnect event. Their Radiation Safety Officer notified the Minnesota Department of Health (MDH) of the event at 0925 (CDT) on June 21, 2016. Initial details: - The event happened on a jobsite in Lakeville, MN. - The Camera was a QSA 880 Delta. - Source was 47.5 curies of I-192. - The cause has been initially determined to be a worn drive cable. The licensee stated that the drive cable passed the go-no-go test prior to hooking up. - They were able to retrieve the source and get it back in the shielded position. - All equipment was inspected after the retrieval. - The faulty drive cables were brought back to the licensee's corporate office in Fargo, ND for repair. - Pocket dosimeter readings following the retrieval were: 41 mrem, 20 mrem, 11 mrem, and 10 mrem. The licensee is in the process of preparing a written report that will be submitted within 30 days as required. MDH will continue to investigate this event. MDH Inspectors will be on-site at the licensee's office in Albertville MN on June 23, 2016 to perform a follow-up inspection. |
| ENS 52025 | 20 June 2016 15:27:00 | This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) because the Tennessee Valley Authority (TVA) is in the process of informing the Alabama Radiological Protection Department, Alabama Department of Environmental Management, Limestone County Emergency Management Department, and Nuclear Energy Institute (NEI) of recent groundwater monitoring results at the Browns Ferry Nuclear Plant in accordance with NEI 07-07, Industry Ground Water Protection Initiative. There are no indications of any impacts to any off-site drinking water source as indicated by Browns Ferry's off-site groundwater monitoring well samples. TVA has taken immediate action to address the apparent leak following the detection of elevated tritium levels from on-site groundwater monitoring wells and will be monitoring affected wells on an increased frequency. No elevated tritium levels have been detected from off-site monitoring locations, and the public is not at risk. The licensee has notified the NRC Resident Inspector. |
| ENS 52035 | 22 June 2016 17:46:00 | The following was received from Wisconsin via email: On Friday, June 17, 2016, a licensee discovered contamination on a package that was used to ship I-125 prostate brachytherapy seeds. The post procedure survey of the packaging revealed elevated levels of radiation. After wipes were taken, the licensee determined that there was I-125 contamination on the inside of the packaging. There was no other contamination in the operating room. The licensee had the patient return to the facility to perform a urine bioassay. The bioassay revealed elevated levels of I-125 in the patient's urine. However further analysis will be required to determine activity concentrations. The licensee has also administered Lugols solution to the patient to block the thyroid. The department and the licensee are still collecting data to determine if this is a medical event. Site visits and updates will be performed as needed. Wisconsin Report ID # WI160004 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. |
| ENS 52004 | 13 June 2016 22:13:00 | At 1845 CDT on June 13, 2016, TVA Corporate Emergency Preparedness notified the Shift Manager at Browns Ferry Nuclear Plant that eight of the BFN (Browns Ferry Nuclear) Alert & Notification Sirens (19, 39, 55, 59, 60, 61, 69, 95) failed to rotate. The sirens were activated at 0915 CDT. Post sounding siren feedback indicated thirteen sirens that failed to rotate. BFN EP (Emergency Preparedness) Senior Instrument Mechanics were dispatched to inspect the thirteen sirens and determined, through field inspections that only eight sirens would not rotate. The field inspection was completed and communicated to Corporate Emergency Preparedness at 1733 CDT. Per NPG-SPP-03.5.1, the affected sirens which were lost affect 25.1 percent of the Emergency Planning Zone (EPZ) population and the sirens are not expected to be returned to service within 24 hours. Per NPG-SPP-03.5.1, a Loss of Alert and Notification System Capability exists when there is an unplanned or planned loss of primary Alert and Notification System (ANS) equipment for greater than one hour resulting in a loss of capability to alert 25 percent or more of the total Emergency Planning Zone (EPZ) population and either the Federal Emergency Management Agency (FEMA) approved backup alerting method cannot be implemented for the area affected by the lost primary ANS equipment OR the primary ANS equipment is not expected to be returned to service within 24 hours. TVA Corporate Emergency Preparedness is redirecting a team from Watts Bar Nuclear Plant to commence repairs on Wednesday 6/15/2016. This 8 hour notification is being made per the reporting requirements specified by 10 CFR 50.72(b)(3)xiii. The NRC Resident Inspector has been notified. This event has been entered in the Corrective Action Program.
The licensee is retracting this event notification. Upon further evaluation using siren modeling software, back-up route alerting was deemed unnecessary since the overlap from neighboring sirens provided the required minimum siren coverage over all populated areas within the EPZ. The TVA siren system provides significant acoustic overlap that is not completely accounted for in the population factors used to initially determine the impacted population for the purposes of reportability. During the event, BFN remained capable of providing adequate siren coverage, and the loss of ANS equipment impacted less than 25 percent of the population within the EPZ. Therefore, this was not a reportable event. The NRC Resident Inspector has been notified. Notified the RII RDO (Seymour). |
| ENS 51999 | 10 June 2016 16:38:00 | A Troxler Model 4640B gauge was run over by a steam roller and damaged at a jobsite at the Kona, HI airport. The licensee established a perimeter around the damaged gauge and the RSO approached using a radiation survey meter. The RSO placed the damaged gauge in its case and will transfer it to a secure location until it can be returned to the manufacturer. The gauge contains 0.8 mCi of Cesium-137. |
| ENS 52115 | 21 July 2016 13:37:00 | The following was received via email: Lost/Abandoned Tritium Exit Signs, Manufacturer - Best Lighting Products Inc. (Forever Lite), Model #SXLTU1GB10, Serial # 206112 to 206140 (29 signs), 7.09 Ci of H-3 (tritium) per sign. Date shipped 9-3-2008. The property (at 1818 Spring Water Point, Colorado Springs, CO) was received through reorganization and has now been assigned to a trustee. Twenty nine exit signs were directed for use by Best Lighting Products at the location listed. Annual general license notifications were sent to SRKO Family LTD Partnership from 2009 thru 2014 with no response. County records provided contact information regarding receivership and further review provided New Crossings Inc. as a contact. The property was inspected by the trustee and no exit signs were located. There were approximately 60 subcontractors on the site at the time the exit signs may have arrived. It is unknown what occurred with them. In September of 2008 Best Lighting Products Inc. (Forever Lite) shipped 29 exit signs to be installed at 1818 Spring Water Point, Colorado Springs, CO. The site was going to be a commercial building and construction had started. According to the trustee, approximately 60 subcontractors/creditors were involved with the owner when they walked away from the project. It is unknown what occurred with the exit signs. No information has been discovered through years of trying to contact the SRKO Family Partnership LLC. The trustee has provided a statement explaining tritium exit signs will never be used in any project they work on. Should they discover any inadvertently they will immediately contact (The Colorado Department of Public Health) for further guidance. Event Report ID No.: CO160010 / CO16-I16-17 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 |
| ENS 51996 | 8 June 2016 17:51:00 | At 0800 CDT on 6/8/2016, 3-SR-3.5.1.7, 'HPCI (High Pressure Coolant Injection) Main and Booster Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure' periodic surveillance was being performed. As part of the surveillance procedure, HPCI was declared inoperable per Technical Specification (TS) Limiting Condition for Operation (LCO) 3.5.1 Emergency Core Cooling Systems (ECCS) - Operating, Condition C at 0925. At 1037, the HPCI turbine was started and a turbine trip alarm was received as well as large swings observed on the suction pressure indicator and slow turbine response. The control room operator then manually tripped the HPCI turbine due to the abnormal indications received. HPCl is a single train safety system and this notification is being made in accordance with 10 CFR 50.72 (b)(3)(v)(D). The NRC Resident Inspector has been notified. |
| ENS 51997 | 9 June 2016 15:56:00 | The following was received from Iowa via email: The licensee (Quad City Testing Lab) reported a source disconnect on a QSA Global 880 Delta radiography camera containing 66.3 curies of lr-192. The RSO was able to retrieve the source and return it to the shielded position. The time from disconnect to retrieval was less than two hours. During the RSO investigation, it was determined that the radiographer trainee did not properly connect the source pigtail to the drive cable and this action was not noticed by the radiographer trainer. Total doses during the event as indicated by pocket dosimeters were: RSO 130 mRem, radiographer trainer 55 mRem, and radiographer trainee 30 mRem. No member of the public received any dose from this event. Incident Number IA160001 |
| ENS 51897 | 1 May 2016 22:14:00 | At 2021 (CDT) on 05/01/2016 Unit 1 automatically tripped due to a generator lockout. Relay 86/G1 actuated. The generator lockout resulted in a Unit 1 turbine trip and a reactor trip. Auxiliary Feedwater and Feedwater Isolation actuated as designed. All Control Rods fully inserted. No primary or secondary relief valves opened. There were no electrical problems. Normal operating temperature and pressure is (being maintained). There were no significant TS LCO's entered. This event was not significant to the health and safety of the public based on all safety systems performed as designed. Unit 2 was not affected. Unit 1 is stable in Mode 3, with decay heat being removed via dump valves to the condenser. The cause of the generator lockout is under investigation. The licensee notified the NRC Resident Inspector. |
| ENS 51896 | 1 May 2016 12:25:00 | On May 1, 2016, at 0847 (EDT), an individual experienced a personal medical emergency during a break. The onsite fire brigade and emergency medical technicians administered first aid, but the individual was unresponsive. The individual was transported to the local hospital. The station was notified at 1008 that the hospital has declared the individual deceased. The individual was outside of the radiological controlled area and not contaminated. Nine Mile Point Unit 2 is shut down for the scheduled refueling outage. The individual was a contractor employee. The licensee has notified the NRC Resident Inspector. The State of New York will be notified. |
| ENS 51895 | 30 April 2016 19:14:00 | Today at 1804 EDT, a manual scram was processed during startup due to rising unidentified leak rate. The rise in unidentified leak rate was identified to be coming from the D Reactor Recirc Pump seal cavity. All rods inserted into the core and all systems functioned as expected during the scram. The event is reportable within 4 hours per 10 CFR 50.72(b)(2)(iv)(B) - any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. The reactor is stable in hot shutdown. The licensee notified the NRC Resident Inspector. |
| ENS 51891 | 29 April 2016 10:48:00 | The licensee notified the Arkansas Department of Emergency Management, National Response Center, and Local Emergency Planning Committee regarding an onsite spill of 12 (percent) Sodium Hypochlorite (bleach solution). Approximately 2000 gallons of Sodium Hypochlorite solution leaked from a bulk tank within the protected area, outside the tank containment berm. Approximately 100 gallons were estimated to have entered the nearby storm drain. The estimate was based on preliminary chemistry samples. The quantity released exceeded the Reportable Quantity (RQ) for Sodium Hypochlorite (RQ of 100 pounds) and was therefore reported. There is no impact to the operation of the ANO units or personnel onsite or offsite. No harm to the environment is expected. No offsite emergency response is required. This event is reportable under 10 CFR 50.72(b)(2)(xi) as an event or situation related to the protection of the environment for which a notification to other government agencies have been made. The NRC Resident Inspector has been notified. |
| ENS 51894 | 30 April 2016 14:31:00 | The following was received from Arizona via email: On April 29th, the licensee (Tucson Medical Center) discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event." Arizona Incident # 16-008 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. |
| ENS 52029 | 21 June 2016 14:50:00 | The following is excerpted from an email provided by the supplier: Items subject to this Fisher Information Notice (FIN) are confined to the equipment and orders referred to in Table 1 (see original submission). Specifically, 'Equipment' refers to the eight inch sized hardfaced HPNS cages supplied per the order numbers listed in Table 1. The purpose of this FIN is to alert affected customers that, as of 29 April 2016, Fisher Controls International LLC ( Fisher) became aware of a situation which may affect the performance of the aforementioned Equipment, including its safety-related function. Fisher is informing affected customers of this circumstance in accordance with Section 21.21(b) of 10 CFR 21. The Equipment in question is subject to CoCr-A hardface overlay requirements. The CoCr-A overlay deposit thickness must be 0.060 inch minimum after machining. However, the cages supplied in fulfilment of the orders listed in Table 1 may have insufficient hardfacing depth on the inside bore diameter at the top of the cages (approximately 1.50 inches from top). This issue first came to Fisher's attention when a material grade inspection revealed insufficient cobalt. Subsequent PMI testing confirmed the upper section at the top of the cage fell short of expected CoCr-A. Two in-stock cages were sent to a third party accredited laboratory for macroetch examination and hardness survey. The results of this survey confirmed the top of the cages did not meet the minimum hardness requirement of 34 HRC and further confirmed the insufficiency is limited to the uppermost 1.50 inches of the inside bore diameter of the cages. The absence of hardfacing at the mating surface between cage and plug creates the potential for galling, which could prevent the valve from performing its intended safety function. Testing has been conducted to analyze the risk of galling. Typically, galling is observed in cycle tests well exceeding the 600 cycle recommended lifetime for the equipment. However, testing has proven galling to be an unpredictable phenomenon and could occur prior to the recommended lifetime of the equipment. There are no known field issues with the affected equipment. The problem of post-hardfacing material shrinkage is associated with the ratio of bore diameter to cage wall thickness. Large bore diameter thin-walled cages are at greater risk for material shrinkage. A third party accredited laboratory performed additional macroetch supplemental tests and evaluations on similar cages of varying bore sizes. It was determined that this issue is unique to the 8 inch sized HPNS cages. Fisher will provide the affected customers with a properly coated cages at Fisher's cost. In addition, a Corrective Action Request (CAR 1804) has been initiated by Fisher to prevent reoccurrence of this issue. The US reactor sites affected by this issue include VC Summer and Vogtle. The foreign reactor sites include Sanmen and Haiyang. FIN 2016-06 dated 20 June, 2016. Point of Contact: Ben Ahrens Quality Manager Emerson Process Management Fisher Controls International LLC 30 1 South First Avenue Marshalltown, IA 50 1 58 Phone: (64 1 ) 754-2249 Benjamin.ahrens@emerson.com |
| ENS 51893 | 30 April 2016 13:53:00 | The following was received from Arizona via email: On April 27th, the licensee (Mayo Clinic Arizona) discovered that one (1) I-125 seed was missing with an approximate activity of 0.3 millicuries. The breast tissue from a patient was analyzed by the licensees' surgical staff on April 26th and one seed was removed and then brought down to the nuclear medicine department on the morning of the 27th. The nuclear medicine staff quickly realized that there should have been two seeds, since two seeds were initially implanted. The licensee's radiation safety staff surveyed both the hospital surgical path area as well as the pathology/histology area and no source was discovered. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event. Arizona Incident # 16-007 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. |
| ENS 51853 | 7 April 2016 08:00:00 | An employee was reported to the Fitness for Duty Coordinator due to improper prescription medicine handling. The employee's site access has been suspended pending outcome of a drug test and investigation. The licensee has notified the NRC Resident Inspector. * * * UPDATE FROM CHRIS TERRY TO STEVE VITTO ON 05/11/2016 AT 0726 EDT * * * The licensee has completed the investigation. The licensee has notified the NRC Resident Inspector. Notified Heisserer (R2DO), Erlanger (FCSE), FFD Group (email), NMSS Events Notification Group (email). |
| ENS 51807 | 18 March 2016 18:43:00 | During a scheduled surveillance test on 3/18/2016 at 1128 (CDT), Fort Calhoun ultrasonic testing technicians discovered a void on the common shutdown cooling heat exchanger discharge piping. This piping is normally isolated during power operation, and the void does not adversely affect the Containment Spray function, Low Pressure Safety Injection function, or High Pressure Safety Injection function. This isolated piping with the void is placed in service only during shutdown cooling operation. The fluid height measured was 10.8 inches, compared to the required height of 11.7 inches for the surveillance test. The void could potentially complicate the initiation of shutdown cooling in the required mode of operation. This piping was last tested satisfactory on 12/31/2015. The source of the void is still under investigation. Fort Calhoun maintenance was successful in venting the void on 3/18/2016 at 1704 CDT. The NRC Resident Inspector has been notified.
Following the 8-hour 10 CFR 50.72 notification made on 3/18/16 (EN 51807), further engineering analysis has determined that the ensuing water hammer transient would not have prevented the shutdown cooling system from performing its required safety functions. Specifically, it was found that the resulting system pressure transient would not cause any relief valves to lift and that piping and supports would not be significantly challenged. Therefore, the common shutdown cooling heat exchanger discharge piping remained operable by the detailed analysis. As such, the safety function was not lost and the event notification is being retracted as it is not reportable pursuant to 10 CFR 50.72(b)(3)(v)(B). Notified the R4DO (G Miller). |
| ENS 51805 | 18 March 2016 14:48:00 | The following was received from Pennsylvania via email: Lost or abandoned licensed material in a quantity greater than or equal to 1000 times the Appendix C quantities in part 20, reportable as per 10 CFR 20.2201(a)(1)(i). A new owner of a facility in Collingdale, Pennsylvania came across a locked room that contained an old lead pig, stamped with a label stating radium-226, 100 mg. The owner contacted Ecology Services, a local radioactive waste management company, who confirmed a dose rate outside the pig. Ecology Services called the Department (PA Bureau of Radiation Protection). The previous occupant of this facility, Universal Technical Equipment Inc., was licensed by the Department (PA-0187) to possess up to 110 mCi of Ra-226 sealed sources and contracted the removal of the radium source. The Certificate of Disposition documentation was submitted to the Department for license termination. The license was ultimately terminated on January 14, 2015. (PA Bureau of Radiation Protection) Southeast regional inspectors visited the facility today, March 18, 2016, and verified there is a source within the locked pig. A smear test revealed no leakage was detected on the outside of the pig. The source remains in a secured and locked location. More information will be provided upon receipt. PA incident # PA160011 |
| ENS 51796 | 17 March 2016 16:19:00 | The following was received from the licensee via email: Medical Event on a Prostate HDR (high dose rate brachytherapy) Fraction #2. The patient was previously treated to Fraction #1 2 weeks earlier without any issue. A patient was under spinal anesthesia for a treatment to the prostate to a prescribed dose of 13.5 Gy. The plan called for 19 interstitial catheters to the 30 cc prostate gland. The V100 of the prostate was expected to be 99.75% (100% dose of 13.5 Gy covered 99.75% of the prostate volume). All coverage and critical organ sparing criteria were met and physician approved the plan. However during treatment and after completion of 9 catheters the treatment console reported an error (and subsequently retracted the source after 2 dwell positions were treated of the 10th catheter). The error code 9 message was source has moved from dwell position and a reset of the treatment console was required. (The medical physicist) went inside the treatment room with the survey meter to ensure the source indeed retracted and transfer tube and applicator appropriately connected. Which they were. Attempts were made to continue with the treatment as the error code direction was cancel the error and try again. However, the afterloader would not resume treatment and the treatment console reported an another error code 117 error during check out-drive in channel (driving out the check cable). Several attempts were made with help of Elekta field service and phone support to troubleshoot the issue as the message on the treatment console with these errors is that if the problem persists, contact your local Elekta service representative. Troubleshooting continued afterwards with the field service engineer coming on site. We were later informed by the engineer that parts had to be ordered to resolve the issue and that they would arrive early the next morning. The procedure was eventually halted due to the service issue and patient was sent to recovery and family informed. (The licensee is) now assessing what dose was delivered. The total treatment time called for 386.6 s. However, only 158.5 s was treated. On the treatment planning system using the catheters and dwell positions and time of 158.5 s the v100 to the prostate is showing as 12.52% (100% of the dose of 13.5 Gy covered 12.52% of the prostate volume) of the partially treated procedure. There was no excessive dose anywhere i.e. to critical structures, just lack thereof to the intended treatment volume of the prostate. The dosimetrist is working with the plan to put on dose points near treated catheters to provide us further details. (The licensee) wanted to take the appropriate direction going forward in regards to documentation, reporting and planning for treatment for the patient on a subsequent date. The machine issue initially occurred at approximately (1430 EDT on 3/16/16). Service on the unit is ongoing so exact details of the repair are not yet available. Remaining prostate patients scheduled for this week been rescheduled for a later date. 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. |
| ENS 51797 | 17 March 2016 16:54:00 | The following report was received from the State of Maryland via email: March 16, 2016 about 1600 (EDT): (The GeoConcepts field representative) notified (the licensee's Radiation Safety Officer) (RSO) of the incident and that the gauge had been damaged. (The field representative) informed (the RSO) that a John Deere Dozer 700 had back up over the gauge. (The field representative), had just completed taking a compaction and moisture test. When the site foreman called to (the field representative) to ask about failing test results, (the field representative) placed the trigger lock back onto the gauge and walked over to the site foreman who was approximately 8-10 feet from where the gauge was located. The John Deere Dozer 700 operator was grading soil and placing it onto an onsite stockpile. The John Deere Dozer 700 operator proceeded to back up, in the vicinity of the gauge. When (the field representative) noticed the operator in close proximity to the gauge, he began to try and get the operators' attention. The operator was not able to see (the field representative's) attempts to gain his attention nor was he able to hear (the field representative) or the site foreman. At that time, the gauge was struck by John Deere 700, which resulted in cracking of the gauge case and breaking of the source rod. March 16, 2016 about 1620: The RSO called the assistant CS (Construction Site) manager and RSO, INC., to inform them of the incident and to immediately get RSO, Inc. to the site and address the issue. (The assistant CS manager) also placed a call to NRC and was informed to call Maryland NRC to notify them of the incident. March 16, 2016 about at 1630: The RSO, left our Ashburn (VA) office for the project in Maryland. (The RSO) arrived onsite at 1730 (EDT) to meet (the representative) of RSO Inc. RSO Inc. proceeded to perform a leak test and take readings of surrounding areas and construction equipment. (The source did not leak and there were no reports of radiation exposures.) March 16, 2016 about 1700: The RSO Inc. representatives were able to retract the source rod into the gauge case shielding. They packaged the gauge back into the carrying case; (The licensee's RSO) took the gauge back to the Ashburn office to secure it. March 17, 2016: The RSO, picked up the gauge and transported it to NETS (North East Technical Services), for the gauge to be disposed. The gauge is a Humboldt model number 5001 EZ, serial number 4704. The licensee is licensed in the Commonwealth of Virginia, VA License #45-25467-01 and MD Material License # MD-13-020-01. Maryland Case Number: 1654 |