United States Nuclear Regulatory Commission - Protecting People and the Environment

Current Event Notification Report for October 1, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/30/2014 - 10/01/2014

** EVENT NUMBERS **


50428 50457 50479 50481 50484 50485

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Part 21 Event Number: 50428
Rep Org: SCHULZ ELECTRIC
Licensee: SCHULZ ELECTRIC
Region: 1
City: NEW HAVEN State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: BILL ELDREDGE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/05/2014
Notification Time: 11:08 [ET]
Event Date: 09/04/2014
Event Time: [EDT]
Last Update Date: 09/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARC FERDAS (R1DO)
DEBORAH SEYMOUR (R2DO)
CHRISTINE LIPA (R3DO)
WAYNE WALKER (R4DO)
PART 21 REACTORS GRO (EMAI)

Event Text

POTENTIAL PART 21 ISSUE ON MOTOR DEDICATIONS PERFORMED PRIOR TO JUNE 2002

The following information was obtained via fax:

"Pursuant to the 10 CFR Part 21 requirements, this letter is to notify the NRC of a potential Part 21 condition.

"While performing research on questions regarding acceleration presented by First Energy/Davis Besse, Schulz Electric identified that the acceleration calculation used to determine acceleration times for new motors which it dedicated before June 7, 2002 (at which time Schulz developed a shop instruction for calculating acceleration using the proper calculation) was incorrect. The use of this incorrect calculation could potentially cause misleading acceleration times, and therefore motors which may not perform as required by First Energy/Davis Besse and/or other customers.

"Schulz Electric will perform an evaluation to identify:
1. All projects that had acceleration calculations performed as part of a motor dedication prior to June 7, 2002.
2. The methodology used to perform the calculations.
3. Whether the actual acceleration times meet the acceleration/performance requirements of the applicable customers.

"Schulz Electric has the capability and chooses to perform the evaluation to determine if a defect exists. It is the responsibility of Schulz Electric to inform the purchaser(s), and any affected licensees.

"Schulz Electric will complete the specified evaluation of the circumstances within sixty (60) days of discovery of the potential defect. The NRC will be provided a copy of Schulz Electric's evaluation report.

"If you have any questions, please feel free to contact me [Charles 'Bill' Eldredge] by phone 203.562.5811, by fax 203.562.1082, or email me at Eldredge@schulzelectric.com."


* * * UPDATE FROM CHARLES ELDREDGE TO DONALD NORWOOD AT 0922 ON 9/30/2014 * * *

The following is a synopsis of information received via facsimile:

FINAL EVALUATION RE: EVENT # 50428

Customer: First Energy / Davis Besse.

Parts: 3 AC Motors - 1) 400 HP, 1) 450 HP, 1) 600 HP. All located at First Energy / Davis Besse.

Description of Defect/Nonconformance: Schulz Electric identified that the methodology for determining acceleration for the subject motors was incorrect. When the acceleration times were calculated using the correct methodology, it was determined that the three motors will not meet the acceleration requirements for 70% voltage as required by the purchase order.

Corrective Action: The customer has been informed of the nonconformance and Schulz has worked with the customer to generate performance curves at various voltage levels and pump head requirements.

Other Plants Affected: None.

Notified R1DO (Krohn), R2DO (Widmann), R3DO (McCraw), R4DO (Whitten) and Part 21 Reactors Group.

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Power Reactor Event Number: 50457
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/15/2014
Notification Time: 14:54 [ET]
Event Date: 09/15/2014
Event Time: 09:00 [EDT]
Last Update Date: 09/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
74.11(a) - LOST/STOLEN SNM
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

FAILED FUEL ASSEMBLY IDENTIFIED DURING CORE OFF-LOAD

"With North Anna Unit 2 in Mode 6 during a scheduled refueling outage, discharged assembly 4Z9 was identified as a failed fuel assembly by In-Mast Sipping. The fuel assembly was located in core location B11. Initial inspection of the fuel assembly identified two (2) visibly split fuel pins of eight (8) to ten (10) inches long with visible damage to the top of the pins. The internals of the affected pins are visible and the springs from the top of each pellet stack are touching the top nozzle. The fuel assembly has been placed into its designated location in the Spent Fuel Pool. No abnormal increase was noted on any radiation monitor either after or during fuel assembly movement. This fuel assembly had been used during three (3) previous operating cycles and is not scheduled for reuse.

"On September 15, 2014, at 0900 [EDT], subsequent video inspection of the fuel assembly identified that the top springs of the two (2) fuel pins were dislodged. Video inspection of the reactor vessel identified debris that has the potential to be fragments of fuel pellets resting on the core plate. Additional investigations are in progress.

"Due to the fact that the failure exceeded expected conditions, this event is being reported per 10 CFR 50.72(b)(3)(ii)(A), as any event or condition that results in the condition of the nuclear plant, including its principle safety barriers, being seriously degraded."

The licensee has notified the NRC Resident Inspector and will notify local county authorities.

* * * UPDATE FROM PAGE KEMP TO HOWIE CROUCH AT 1227 EDT ON 9/30/14 * * *

"Event Notification #50457 was provided on September 15, 2014, at 1454 hours, pursuant to 10 CFR 50.72(b)(3)(ii)(A), to provide notification that North Anna Unit 2 discharged assembly 4Z9 had two visibly split fuel pins and debris on the core plate that had the potential to be fuel pellet fragments.

"Detailed video inspections estimated that fifteen (15) fuel pellets were dislodged from fuel assembly 4Z9. For reference, the reactor core contains approximately 15 million fuel pellets. Efforts to identify and recover the fuel pellets were performed. Debris fragments, estimated to represent five (5) fuel pellets, were located within the damaged fuel assembly that is currently in the spent fuel pool. In addition, an estimated three (3) pellets worth of material was retrieved by the foreign object search and retrieval (FOSAR) efforts in the reactor vessel. The remaining seven (7) fuel pellets have already or are expected to granulate into fine particles that will remain in low flow areas of the primary plant systems or be removed by normal purification processes. However, since the specific location of the seven (7) fuel pellets is undesignated, a report is being made pursuant to 10 CFR 74.11(a) for the loss of special nuclear material.

"The seven (7) fuel pellets contain licensed material in a quantity greater than 10 times the quantity specified in Appendix C of 10 CFR 20; therefore a report is also being made pursuant to 10 CFR 20.2201(a)(ii).

"The cause of the fuel clad degradation is understood and is being addressed. It has been evaluated that the dispersion of fuel pellet material will pose no threat to the integrity or operation of the reactor fuel and primary system components. Reactor Coolant System activity will remain below Technical Specification limits during power operation. In addition, there are no adverse radiological consequences to the public as a result of this issue."

The licensee will be notifying the state of Virginia, local authorities in Louisa County and has notified the NRC Resident Inspector.

Notified R2DO (Vias) and IRD (Stapleton).

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Agreement State Event Number: 50479
Rep Org: COLORADO DEPT OF HEALTH
Licensee: AVISTA ADVENTIST HOSPITAL
Region: 4
City: LOUISVILLE State: CO
County:
License #: CO 793-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2014
Notification Time: 13:06 [ET]
Event Date: 09/20/2014
Event Time: 12:30 [MDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PATRICIA MILLIGAN (EMAI)
ANGELA MCINTOSH (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"The State of Colorado received a report this morning from a medical licensee of a misadministration. The licensee reported that at 1230 [MDT] on Saturday 9/20/14, the technologist injected a patient with a bulk dose of Tc-99m instead of a [smaller] patient dose. The initial estimate for the amount injected is 140 mCi. The initial potential whole body dose is 6-7 rem with 30 rad as the highest potential organ dose (upper intestine). The investigation is ongoing."

Additional information regarding the intended patient dose will be provided when available. The attending physician and patient will be informed by the licensee.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Agreement State Event Number: 50481
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 4
City: SEATTLE State: WA
County:
License #: WN-NP011-1
Agreement: Y
Docket:
NRC Notified By: CURT DEMARIS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2014
Notification Time: 17:34 [ET]
Event Date: 08/27/2014
Event Time: [PDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL RELEASE EXCEEDING EMISSION LIMIT

The following report was received from the State of Washington via email:

"Event Narrative: Notification [was given] to [Washington] State by the licensee for exceeding the allowable total abated emission limit for this unit [Cardinal Health 414, LLC]. The limit is 7.4 mRem to the MEI [Maximally Exposed Individual] while the licensee acknowledges a release so far in 2014 of a total of 23.7 mRem (21.5 from Fluorine 18 and 2.2 from Carbon 11). The licensee believes the problem is a combination of errors including both human and engineering. Proposed corrective actions include changes in procedures as well as changes in the air discharge system components."

NMED Report Number: WA-14-039.

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Agreement State Event Number: 50484
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: MANUFACTURING SCIENCES CORPORATION (MSC)
Region: 1
City: OAK RIDGE State: TN
County:
License #: S-01046
Agreement: Y
Docket:
NRC Notified By: BILLY FREEMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/23/2014
Notification Time: 16:30 [ET]
Event Date: 09/23/2014
Event Time: [EDT]
Last Update Date: 09/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
LAURA DUDES (FSME)

Event Text

AGREEMENT STATE REPORT - THERMAL EVENT SUFFICIENT TO TRIGGER SPRINKLER SYSTEM

The following report was received from the State of Tennessee via email:

"Event description: Tennessee Division of Radiological Health (DRH) was notified on September 23, 2014, by a representative from [Manufacturing Science Corporation] MSC that there had been a thermal incident in the chip/turnings oxidizer that triggered the sprinkler system. The Oak Ridge [OR] Fire Dept. responded. The sprinkler system released ~200 gallons of water which was contained within the bermed area. The incident was contained sufficiently that the OR fire department left the facility prior to 1000 [EDT]. MSC changed pre-filters upstream of the HEPA filters, the HEPAs did not appear to need changing. MSC felt that this incident is required to be reported per TN State Regulations for Protection Against Radiation (SRPAR) 0400-20-05-.141(2)(c)4, in that the event potentially involved 'an unplanned fire or explosion damaging any licensable material or any device, container or equipment containing licensable material when:
(i) The quantity of material involved exceed five times the lowest annual limit of intake specified for the material in Schedule RHS 8-30 in Rule 0400-20-05-.161, and
(ii) The damage affects the integrity of the licensable material or any device, container or equipment containing licensable material.'

"There was no release to the environment, no personnel contamination, and no injuries.

"Notifications: [State] Oak Ridge Fire Department. Press release has not been issued at this time. TN DRH has not received any media inquiries at this time."

No fire or smoke was observed.

State Event Report ID #: TN-14-181

UPDATE FROM BILLY FREEMAN TO DANIEL MILLS AT 0921 EDT ON 9/24/14:

The following was received via email:

"Tennessee Division of Radiological Health (DRH) was notified on September 23, 2014 by a representative from MSC that there had been a thermal incident in the depleted uranium (DU) chip/turnings oxidizer that triggered the sprinkler system. The Oak Ridge Fire Dept. responded. The sprinkler system released ~200 gallons of water which was contained within the bermed area. The incident was contained sufficiently that the OR fire department left the facility prior to 1000 EDT. MSC changed pre-filters upstream of the HEPA filters the HEPAs did not appear to need changing. MSC felt that this incident is required to be reported per TN State Regulations for Protection Against Radiation (SRPAR) 0400-20-05-.141(2)(c)4. in that the event potentially involved 'an unplanned fire or explosion damaging any licensable material or any device, container or equipment containing licensable material when:
(i) The quantity of material involved exceed five times the lowest annual limit of intake specified for the material in Schedule RHS 8-30 in Rule 0400-20-05-.161, and
(ii) The damage affects the integrity of the licensable material or any device, container or equipment containing licensable material.'

"They are not certain of the quantity of DU involved. There was no release to the environment, no personnel contamination and no injuries.

"Notifications: [State] Oak Ridge Fire Department. Press release has not been issued at this time. TN DRH has not received any media inquiries at this time."

Updated information: The material involved was Depleted Uranium.

Notified R1DO (Gray), FSME MOC (Dudes), FSME Events Resource (email)

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Agreement State Event Number: 50485
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BOSTON UNIVERSITY MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 44-0062
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/23/2014
Notification Time: 17:42 [ET]
Event Date: 09/08/2014
Event Time: [EDT]
Last Update Date: 09/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Category 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL DELIVERED TO WRONG ADDRESS

The following information was obtained from the Commonwealth of Massachusetts via email:

"Boston University Medical Center's (BUMC) Radiation Safety Officer (RSO) reported by telephone to the Massachusetts Radiation Control Program (MA RCP) on 9/23/2014 that a shipment of Iridium-192, in the form of brachytherapy sealed sources containing approximately 10 curies, was delivered by [the shipping company] to the wrong address, a non-BUMC address at [redacted], Boston, MA on 9/8/2014.

"The RSO reported that the package, a yellow III package, was accepted by a mail room employee of the non-BUMC address on 9/8/2014; that BUMC was contacted on 9/8/2014; and that BUMC transferred the package to BUMC less than one hour after the package was delivered to the wrong address.

"The RSO reported that BUMC is conducting an investigation and attempting to contact [the shipping company] and that all radioactive materials that were supposed to have been in the package were accounted for.

"The MA RCP plans to perform inspection upon this event. This event is considered by MA RCP to be open."

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

Page Last Reviewed/Updated Wednesday, October 01, 2014
Wednesday, October 01, 2014