Source: https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2014/20140331en.html
Timestamp: 2020-01-25 17:52:51
Document Index: 501837391

Matched Legal Cases: ['art 21', 'ART 21', 'art 21', 'art 21', 'art 21', 'ART 70']

NRC: Event Notification Report for March 31, 2014
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Event Notification Report for March 31, 2014
03/28/2014 - 03/31/2014
49936 49939 49944 49945 49946 49953 49966 49967 49968 49969 49970 49972
Agreement State Event Number: 49936
Licensee: US STEEL CORPORATION
City: CLAIRTON State: PA
License #: PA-1280
HQ OPS Officer: JOHN SHOEMAKER Notification Date: 03/20/2014
Notification Time: 12:35 [ET]
Last Update Date: 03/20/2014
AGREEMENT STATE REPORT - COLLIMATOR BLOCK BROKEN OFF OF THE SHUTTER ASSEMBLY
Notifications: The [Pennsylvania Bureau of Radiation Protection] Department's Central Office was informed of this event on March 19, 2014. This event is reportable within 24-hours per 10 CFR 30.50(b)(2).
"Event Description: During a routine monthly inspection of the gauge, [the licensee] discovered that the collimator block had broken off of the shutter assembly. The collimator block was found lying in the quarter inch steel box that the gauge is housed in to protect it from the operating conditions on the battery. The cause of this event is still being investigated. Radiation surveys performed indicated no employees were exposed as a result of this event.
"Manufacturer: Thermo Measure Tech
Serial Number: B392
Activity: 4 Ci
"ACTIONS: The broken shutter mechanism was removed and replaced by a licensed service provider. The shutter mechanism was tested and confirmed as operating properly. The [State of PA] Department plans a reactive inspection.
"Media attention: None at this time."
PA Event Report ID No: PA140009
Agreement State Event Number: 49939
Licensee: INOVA FAIRFAX HOSPITAL
City: FALLS CHURCH State: VA
License #: 610-116-1
AGREEMENT STATE REPORT - ERROR IN DOSE CALCULATION AND UNDERDOSE ADMINISTRATION
The following was received from the Commonwealth of Virginia via fax:
"Event description: On March 18, 2014, the licensee identified an error in a dose calculation for high dose rate (HDR) treatments administered to a patient on March 11-12. The initial report from the licensee indicates the patient was administered two out of a total of six prescribed fractionated doses. An error was made in planning the correct dwell position for the two fractions. The administered dose differed from the prescribed dose (was less than) by more than 20 percent. The licensee plans to correct for the underdose during the remaining fractions. The licensee is investigating if the dose to tissues other than the treatment site may have met the definition of a medical event."
Virginia Event Report ID No.: VA-14-0002
Agreement State Event Number: 49944
Licensee: APPLUS RTD INC.
City: SHUNK State: PA
License #: PA-1482
HQ OPS Officer: DONALD NORWOOD Notification Date: 03/21/2014
Last Update Date: 03/21/2014
"The Department's [PA Department of Environmental Protection Bureau of Radiation Protection] Central Office was informed of this event on March 20, 2014. This event is reportable within 24 hours per 10 CFR 30.50(b)(2) and within 30 days per 10 CFR 34.101(a)(2).
"Upon completion of a shot, the source was found to be stuck within the collimator and unable to be retracted. The area was roped off and controlled, the Radiation Safety Officer was notified, and a service provider (QSA Global) was called to perform retrieval operations. The source was returned to its fully shielded position at 0002 EDT on March 21, 2014. The radiographer, assistant radiographer, and recovery team received minimal exposure from this source retrieval operation. No one from the general public was exposed to radiation from this operation. Additional information will be provided upon receipt.
"Camera Model: QSA Global 880 Delta; Isotope: Ir-192; Activity: 68 Ci.
"The cause of the event is unknown at this time. The camera and cables are being returned to the manufacturer to be inspected. The Department plans a reactive inspection."
PA Event Report ID No: PA140010
Agreement State Event Number: 49945
Licensee: TEAM INDUSTRIAL
City: ABERDEEN State: OH
License #: 03320990000
NRC Notified By: CHUCK MCCRACKEN
HQ OPS Officer: JOHN SHOEMAKER Notification Date: 03/21/2014
Event Time: 04:30 [EDT]
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA WITH STUCK SOURCE
The following Ohio Bureau of Radiation Protection report was received via facsimile:
"The [Ohio] Bureau of Radiation Protection [BRP] was notified by the licensee's corporate RSO [Radiation Safety Officer] at 1505 [EDT] on 3/21/2014, about an incident involving a stuck radiography source. The incident took place at 0430 on 3/21/2014. Crew members were performing radiography in a boiler penthouse in Aberdeen, Ohio, when a magnetic stand fell over and crimped the source guide tube while the source was still out. Crew members called the RSO at their Woodlawn, Ohio [location], who instructed them to survey and post the area and control access until he arrived. The Woodlawn RSO arrived at the site around 0900, shielded the source and was able to bend the guide tube so the source could be retracted back into the camera. The source was safely [positioned] back into the camera around 0945 on 3/21/14. Because licensee personnel wear Instadose dosimetry badges by Mirion Technologies, the Woodlawn RSO was able to determine that the exposure he received from this source retrieval activity was 159 mRem. The licensee understands they are responsible to provide a written report to the BRP within 30 days."
The radiography device is a QSA 880 Delta camera with a 27 Ci Ir192 source.
Ohio State BRP Incident Report: #2014-006.
Non-Agreement State Event Number: 49946
Rep Org: BOZEMAN DEACONESS HOSPITAL
Licensee: BOZEMAN DEACONESS HOSPITAL
City: BOZEMAN State: MT
License #: 25-10994-04
NRC Notified By: KARI CANN
Notification Time: 17:53 [ET]
THREE MEDICAL MISADMINISTRATION INCIDENTS
During a recent review of historical records, it was determined that three medical misadministration incidents had occurred. Two of these incidents occurred on September 9, 2008 and the third incident occurred on September 30, 2008.
The patients were being treated for prostate cancer and were receiving I-125 brachytherapy. Two patients were each prescribed a source activity of 0.269 mCi but received 0.341 mCi. The third patient was prescribed 0.340 mCi but received 0.439 mCi.
The patients have been followed elsewhere for the last few years. The licensee will assess the patients as soon as they are available. The licensee is in the process of notifying the patients of the misadministrations.
Fuel Cycle Facility Event Number: 49953
NRC Notified By: RON DOCKERY
HQ OPS Officer: JEFF ROTTON Notification Date: 03/24/2014
Event Date: 03/23/2014
Event Time: 20:50 [CDT]
Last Update Date: 03/28/2014
SAFETY EQUIPMENT POTENTIAL FAILURE - HIGH PRESSURE FIRE WATER SPRINKLER SYSTEM
"At 2050 CDT, on 03-23-2014, the Plant Shift Superintendent was notified that the C-333 High Pressure Fire Water (HPFW) Sprinkler System A-16 had been inspected by Fire Services and 11 sprinkler heads had visible corrosion on them, including 4 heads adjacent to each other. The system configuration was evaluated using EN-C-822-99-047, 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads potentially impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to [Technical Safety Review] TSR LCO 2.4.4.5. HPFW system A-16 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage.
"Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the actual affect on operability. This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.
"The NRC Region II (Marvin Sykes) has been notified of this event.
"PGDP Assessment and Tracking Report No. ATR-14-0324; PGDP Event Report No. PAD-2014-03; NRC Worksheet No. 49953
"Responsible Division: Operations"
TSR LCO 2.4.4.5 Action B requires an hourly fire patrol in the affected area.
* * *RETRACTION ON 3/28/14 AT 1959 EDT FROM JOE BARLETTO TO DONG PARK * * *
"Subsequent to the event, the corroded sprinkler heads were replaced with new heads and the removed heads were tested In the laboratory. Based on the test results and the operability criteria defined in EN-C-822-99-047, A-16 was capable of performing its intended safety function. The clustered heads were on a single branch line in a ceiling beam pocket. The middle head failed testing, however overlapping coverage was provided by the adjacent heads on both sides."
Notified R2DO (Sykes).
Power Reactor Event Number: 49966
NRC Notified By: PATRICK ANHALT
HQ OPS Officer: DANIEL MILLS Notification Date: 03/28/2014
FITNESS FOR DUTY VIOLATION
"A contractor supervisor violated the Dominion Nuclear Connecticut FFD policy. The program member's access has been suspended pending assessment and management review.
Part 21 Event Number: 49967
Rep Org: C&D TECHNOLOGIES INC
Licensee: C&D TECHNOLOGIES INC
City: BLUE BELL State: PA
NRC Notified By: CHRISTIAN RHEAULT
INTERIM PART 21 REPORT - MISALIGNED SEPARATORS IN LCR-25 STANDBY BATTERIES
The following is the summary portion of the report submitted by fax:
"Subject Interim Report - Inability to Complete 10CFR Part 21 Evaluation Regarding Misaligned Separators in LCR-25 Standby Batteries
"The purpose of this letter is to provide the NRC a report in general conformity to the requirements of 10CFR Part 21.21 (a)(2). On February 14, 2012 C&D Technologies, Inc. ('C&D') was informed by Entergy Operations that an LCR-25 battery installed at the Palisades Nuclear Power Plant had shown signs of misaligned separators (also known as shifted separators) of between 1/8 to1/4 [inch]. This was identified by the Palisades plant on or about November 4, 2011. On January 16, 2012, three additional cells were identified as experiencing separator misalignment.
"C&D requested that Palisades return the affected batteries for evaluation of this anomaly and issued a Return Material Authorization for that purpose. But since voltage readings were acceptable for all units involved, Palisades determined that an operability issue did not exist and opted to keep the batteries in service until their refuel outage scheduled for Fall, 2013. C&D inadvertently closed the internal corrective action without providing an Interim Report as required by 10CFR, Part 21.
"C&D has not performed a root cause technical evaluation to determine if there is any defect in the component or manufacturing process or whether the reported condition may have been due to user abuse of product, improper maintenance or other negligence or error.
"Thus, C&D is submitting this interim report to the NRC and notifying C&D's customers that use C&D LCR-25 batteries of this interim report, and is initiating an action plan to evaluate the reported potential defect and determine whether it could pose a substantial safety hazard for any U.S. licensee using such batteries.
"If you have any questions or wish to discuss this matter or this report, please contact:
VP Quality and Process Engineering
bmalley@cdtechno.com
(215) 619-7830"
The sites affected are:
Palisades - 65 x LCR-25 NUC Batteries and,
Crystal River - 4 x LCR-25 NUC Batteries
Power Reactor Event Number: 49968
NRC Notified By: KEVIN MOSES
HQ OPS Officer: DONG HWA PARK Notification Date: 03/28/2014
Notification Time: 16:21 [ET]
KEOWEE EMERGENCY POWER SYSTEM 13.8kV CABLE MAY NOT COMPLY WITH LICENSING BASIS
"Event: In an NRC Component Design Basis Inspection (CDBI) debrief held at 1300 EDT on March 28, 2014, it was stated that a potential non-compliance and unanalyzed condition exists with respect to the design and installation of the Keowee emergency power system 13.8kV power cables associated with the underground power path. The NRC stated that Duke does not have sufficient documentation to support the station's position that the cables comply with the station's licensing basis. In particular, there are questions related to the station's compliance with IEEE-279-1971. This issue has been documented in Duke's corrective action program.
"Duke has reviewed the design associated with the subject 13.8kV cables and considers the design to be robust. Pending further analysis and/or testing, Duke has made a decision to report this event in accordance with 10 CFR 50.72(b)(3)(ii) as an 'Unanalyzed Condition.' The Oconee NRC Senior Resident Inspector has been notified of the event.
"Initial Safety Significance: An Immediate Determination of Operability has been performed and concluded the existing system design is adequately robust to address circuit faults. The health and safety of the public and station personnel is not impacted by this event.
"Corrective Action(s): Corrective actions are being implemented in accordance with Duke's Corrective Action Program."
Fuel Cycle Facility Event Number: 49969
NRC Notified By: SCOTT MURRAY
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
ITEMS RELIED ON FOR SAFETY NOT OPERABLE
"It was determined at 1:30PM today (3/28/14) that one of the Items Relied on for Safety (IROFS) associated with the Dry Conversion Process recycle operation was inoperable. Although the second IROFS preventing moderation intrusion to the recycle container continued to operate within its allowable parameters, it alone was not sufficient to meet performance requirements.
"The affected equipment has been shut down and at no time was an unsafe condition present. While this did not result in an unsafe condition, the event is being reported pursuant with the reporting requirements of 10CFR70 Appendix A (b)(2) within 24 hours of discovery.
"Additional corrective actions, extent of condition, and the cause of the failure are being determined."
The licensee will notify NRC Region 2, State of North Carolina Radiation Protection, and New Hanover County Emergency Management.
Power Reactor Event Number: 49970
NRC Notified By: RICK DAVIDSON
Event Time: 13:58 [CDT]
1 N Y 89 Power Operation 89 Power Operation
FAILURE OF SECONDARY CONTAINMENT DOOR INTERLOCK
"At 1358 [CDT] on March 28, 2014, the Control Room was notified that two Secondary Containment doors (DOOR-62 and DOOR-63) were open at the same lime. This occurred while two employees were entering and exiting the Reactor Building at the exact same time. The time that both doors were open was approximately one (1) second. Secondary Containment differential pressure was maintained throughout the event.
"With both doors open, technical specification surveillance requirement SR 3.6.4.1.3 was not met and Secondary Containment was declared inoperable. Secondary Containment was declared operable after independently verifying at least one Secondary Containment access door was closed.
"The health and safety of the public was maintained as the plant was in a normal condition with no initiating event in progress or signs or elevated radiation levels within Secondary Containment. The NRC Resident Inspector has been notified."
Power Reactor Event Number: 49972
NRC Notified By: ROGER BUTLER
HQ OPS Officer: DONG HWA PARK Notification Date: 03/29/2014
Notification Time: 14:09 [ET]
Event Time: 10:08 [CDT]
Last Update Date: 03/29/2014
1 A/R Y 87 Power Operation 0 Hot Shutdown
"Actuation of RPS with reactor critical. Reactor Scram occurred at 1008 [CDT] on 03/29/2014 from 87% CTP [core thermal power]. The cause of the Scram appears to be a Turbine Generator Trip.
"05-S-01-EP-2 RPV Control, 05-1-02-I-1 Reactor Scram ONEP and 05-1-02-l-2 Turbine Generator Trip ONEP were entered to mitigate the transient with all systems responding as designed. No loss of offsite or ESF [engineered safety feature] power occurred. No ECCS [emergency core cooling systems] initiation signals were reached and no ESF or Diesel Generator initiations occurred.
"All control rods are fully inserted. MSIVs [main steam isolation valve] remained open and no SRVs [safety relief valves] lifted. Currently, reactor water level is being maintained by the Condensate and Feedwater system in normal band and reactor pressure is being controlled via Main Turbine Bypass Valves to the main condenser. There are no challenges to Primary or Secondary Containment at this time."
Power Reactor Event Number: 49973
NRC Notified By: RUDY CAPUTO
HQ OPS Officer: CHARLES TEAL Notification Date: 03/29/2014
Notification Time: 23:49 [ET]
Event Time: 16:20 [CDT]
Last Update Date: 03/30/2014
DIVISION 3 CORE STANDBY COOLING SYSTEM VENTILATION FAILED
"This report is being made pursuant to SAF 1.8, 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to Mitigate the Consequences of an Accident. During steady state operations on Unit 1 at 1620 [CDT] hrs. on 3/29/14, the Division 3 Core Standby Cooling System (CSCS) Pump Room, SWGR Room, and Battery Room Ventilation failed in such a manner that heat could not be removed from the rooms. These Division 3 systems supply power and cooling water to the High Pressure Core Spray system (HPCS), which is a single-train system. The HPCS system and its associated power supplies were declared inoperable based on long-term temperature considerations. The system remains available due to manual damper adjustments that than can be made per an approved procedure."