United States Nuclear Regulatory Commission - Protecting People and the Environment

Current Event Notification Report for July 2, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/01/2015 - 07/02/2015

** EVENT NUMBERS **


51132 51161 51162 51172 51175 51176 51177 51195

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Part 21 Event Number: 51132
Rep Org: THERMO FISHER SCIENTIFIC
Licensee: MIRION TECHNOLOGIES
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT BARNES
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 06/05/2015
Notification Time: 18:47 [ET]
Event Date: 03/03/2015
Event Time: 00:00 [PDT]
Last Update Date: 07/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DAVE PASSEHL (R3DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 - POSSIBLE SAFETY DEFECT IN NON-INSTALLED POWER RANGE DETECTOR AT PALISADES

The following is an excerpt of a report that was received via email:

"This letter provides information concerning an evaluation performed by Thermo Gamma-Metrics LLC, a part of Thermo Fisher Scientific, regarding potential noncompliance of our dual uncompensated ion chamber power range detector.

"Based upon the evaluation, Thermo Gamma-Metrics has determined that a Reportable Condition under 10 CFR Part 21 exists for plant listed herein. The information contained in this document informs the NRC of the conclusions and recommendations derived from Thermo Gamma-Metrics' preliminary evaluation of this issue.

"An evaluation [was] performed by Thermo Gamma-Metrics LLC, a part of Thermo Fisher Scientific, regarding potential noncompliance of our dual uncompensated ion chamber power range detector.

"Based upon the evaluation, Thermo Gamma-Metrics has determined that a Reportable Condition under 10 CFR Part 21 exists for [Palisades]. The information contained in this document informs the NRC of the conclusions and recommendations derived from Thermo Gamma-Metrics' preliminary evaluation of this issue.

"The detector in question is in storage at Entergy Palisades and has not yet been installed in their Power Range Systems per discussion with [the System Engineer at Palisades].

"A potential defect has been identified by Mirion IST. Thermo Gamma-Metrics cannot determine by itself if the potential defect would represent a substantial safety hazard to Entergy Palisades if installed in a safety related application.

"We supplied just one potentially defective part from [Mirion] IST to Palisades. [Mirion] IST may have supplied two other potentially defective parts to other vendors per discussions with [Mirion IST.]

"The immediate corrective action is for Thermo Gamma-Metrics to notify Entergy and the NRC of this potential defect. Thermo Gamma-Metrics notified Entergy Palisades on June 2, 2015.

"Thermo Gamma-Metrics will supply a final report on this issue by July 2, 2015 that details the plan for all corrective actions.

"Entergy Palisades should review the letter from Mirion IST. Thermo Gamma-Metrics will help the utility to address and remedy the situation before the power range detector is installed in the power plant."

* * * UPDATE AT 1955 EDT ON 07/01/15 FROM ROB BARNES TO S. SANDIN * * *

The following is an excerpt of a report that was received via email:

"This letter provides information concerning an evaluation performed by Thermo Gamma-Metrics LLC, a part of Thermo Fisher Scientific, regarding noncompliance of our dual uncompensated ion chamber power range detector.

"Based upon the evaluation, Thermo Gamma-Metrics has determined that a Reportable Condition under 10 CFR Part 21 exists for plant listed herein. The information contained in this document informs the NRC of the conclusions and recommendations derived from Thermo Gamma-Metrics' evaluation of this issue.

"Report Notification Information

(i) Name and address of the individual or individuals informing the Commission.

Robert E. Barnes
Technical Service Manager
(858)449-2909 cell

Clark J. Artaud
Global Commercial Director

Jeffery S. Tuetken
Senior Electrical Engineer
Thermo Gamma-Metrics LLC
10010 Mesa Rim Road
San Diego, CA 92121

(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.

"The detector in question is in storage at Entergy Palisades and has not yet been installed in their Power Range Systems per discussion with the System Engineer, Mr. Michael Knapp at Palisades.

(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.

"Mirion IST Horseheads, New York

(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.

"A potential defect has been identified by Mirion IST as described in . . . [a letter] dated March 3, 2015.

"Entergy Palisades has determined that the potential defect would represent a substantial safety hazard if installed in a safety related application and is returning the detector to Thermo Fisher Scientific for repair on Returned Material Authorization #950. Thermo Fisher will return the dual ion chamber to Mirion IST for repair and recertification.

(v) The date on which the information of such defect or failure to comply was obtained.

"March 3, 2015

(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.

"We supplied just one potentially defective part from IST to Palisades. IST may have supplied two other potentially defective parts to other vendors per discussions with Eric Brand at Mirion IST.

(vii) The corrective action, which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.

"The immediate corrective action is for Thermo Gamma-Metrics to notify Entergy and the NRC of this potential defect.

"Thermo Gamma-Metrics notified Entergy Palisades on June 2, 2015 . . .

"Thermo Gamma-Metrics will work with Mirion IST to verify the presence or absence of the potential defect in this dual ion chamber and repair the dual ion chamber before returning it to Entergy Palisades, as soon as repairs can be arranged and expected no later than the end of 2015.

(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"Entergy Palisades has reviewed the letter from Mirion IST and is seeking reparations. Thermo Gamma-Metrics and Mirion IST will help the utility to address and remedy the situation before the power range detector is installed in the power plant.

(ix) In the case of an early site permit, the entities to whom an early site permit was transferred.

"Not applicable - this is not an early site permit concern.

"Should you have any questions regarding this matter, please contact Rob Barnes Technical Service Manager, Thermo Gamma-Metrics LLC, at (858) 882-1356."

Notified R3DO (Kozak) and PART 21/50.55 REACTORS (email).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51161
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WILLIAM McCOLLUM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/17/2015
Notification Time: 04:15 [ET]
Event Date: 06/16/2015
Event Time: 23:43 [EDT]
Last Update Date: 07/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

SERVICE WATER EFFLUENT RADIATION MONITOR OUT OF SERVICE

The B train of the service water effluent radiation monitor failed at 2343 EDT and is being repaired.

The licensee notified the NRC Resident Inspector.



* * * RETRACTION ON 07/01/2015 AT 1411 EDT FROM THOMAS CLEARY TO STEVEN VITTO * * *

"The purpose of this call is to retract a report made on June 17, 2015, NRC Event Number 51161. Event Report number 51161 describes a condition at Millstone Power Station Unit 3 (MPS3) in which a service water radiation monitor failed, was taken out of service for repair and was reported in accordance with 10 CFR 50.72(b)(3)(xiii) as a loss of emergency assessment capability.

"Upon further review, MPS3 has concluded that the subject radiation monitor is not utilized for emergency assessment capability. Therefore, this condition is not reportable and NRC Event Number 51161 is being retracted.

"The basis for this conclusion will be provided to the NRC Resident Inspector."

R1DO(Dimitriadis) have been notified.

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Non-Agreement State Event Number: 51162
Rep Org: ECS MID-ATLANTIC, LLC
Licensee: ECS MID-ATLANTIC, LLC
Region: 1
City: ABERDEEN State: MD
County:
License #: 19-31269-01
Agreement: Y
Docket:
NRC Notified By: IRVIN FISCHER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/17/2015
Notification Time: 14:23 [ET]
Event Date: 06/16/2015
Event Time: 15:00 [EDT]
Last Update Date: 07/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(4) - FIRE/EXPLOSION
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MOISTURE/DENSITY GAUGE INVOLVED IN AUTOMOBILE FIRE

A licensee employee working at a job site in Claymont, Delaware went to leave the job site at 1500 EDT on June 16, 2015. The employee got in his vehicle and turned on the ignition. A fire started under and around the dashboard. The employee exited his vehicle and called 911 and the licensee Radiation Safety Officer. The local fire department responded. The front portion of the vehicle had been totally engulfed. The vehicle trunk, where the gauge was stored, received heat and smoke damage. The carrying case of the gauge was partially melted. No visible damage occurred to the gauge itself. The gauge was transported to a service vendor for inspection and repair if needed.

The gauge was a Troxler 3440 Moisture/Density gauge, serial number 20118, containing an 8 mCi Cesium-137 source and a 40 mCi Am-241source.

The licensee notified NRC R1(Ragland), Delaware Department of Natural Resources and Environmental Control, Division of Waste and Hazardous Substances, Emergency Prevention and Response Section, and Delaware Health and Social Services, Division of Public Health.


* * * UPDATE ON 07/01/15 AT 1827 EDT FROM IRVIN FISCHER TO STEVEN VITTO * * *

The licensee provided the following update via email:

"The gauge is back in service after being evaluated and recalibrated. "

Notified R1DO (Dimitriadis) and NMSS Events (via email).

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Agreement State Event Number: 51172
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: PROFESSIONAL SERVICE INDUSTRIES, INC.
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-27064-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/22/2015
Notification Time: 23:54 [ET]
Event Date: 06/22/2015
Event Time: 17:30 [CDT]
Last Update Date: 06/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was obtained from the State of Oklahoma via email:

"PSI (Professional Service Industries, Inc.) has reported the theft of a Troxler Model 3430 portable [moisture density] gauge from a truck located at a gas station in El Reno, OK about 1730 [CDT on 6/22/15]. The gauge was removed from the shipping container. A report has been filed with the Oklahoma City Police and a $500 dollar reward has been offered."

The serial number of the gauge is 67614. The State of Oklahoma will be conducting a reactive inspection and submitting an NMED report on this event.

Troxler Model 3430 typically contains 8 mCi Cs-137 and 40 mCi Am-241/Be sources.

* * * UPDATE FROM KEVIN SAMPSON TO DANIEL MILLS AT 1445 EDT ON 6/23/15 * * *

The following information was obtained from the State of Oklahoma via email:

"Professional Service Industries, Inc. (PSI) has informed [the State of Oklahoma] that a Troxler 3430 portable gauge was stolen from a road construction site in Oklahoma City, OK on June 22, 2015. The technician finished his work about [1600 CDT], secured the gauge in the truck, then went to talk to the road construction workers. He returned to the truck and drove to a nearby gas station/convenience store where he went in for a few minutes, then drove back to the PSI office. He then went to unload the gauge and discovered that the case was unlocked and the gauge missing. The calibration block needed to use the gauge was not taken. The case was secured with two chains and two padlocks. When the theft was discovered, one padlock was missing, the other was undamaged and appeared to have been opened with a key. The case was also undamaged. When last seen, the source rod was locked in the retracted position. The investigation is on-going.

"NMED # OK150007"

Notified R4DO (Campbell), NMSS (email) and ILTAB (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

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Agreement State Event Number: 51175
Rep Org: NC DEPT OF HEALTH AND HUMAN SVCS
Licensee: EAS PROFESSIONALS INC
Region: 1
City: Greensboro State: NC
County:
License #: SC 849
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/23/2015
Notification Time: 17:45 [ET]
Event Date: 06/23/2015
Event Time: 09:30 [EDT]
Last Update Date: 06/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ADAM TUCKER (ILTAB) (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

"[The State of North Carolina] is writing to provide notification of a stolen portable moisture/density gauge from a reciprocal license in NC [North Carolina]. Below are the current details:

"The licensee is EAS Professionals, Inc. - SC [South Carolina] Radioactive Material License No. 849. They entered the state under an expired NC reciprocity approval.

"The gauge was stolen 6/22/15 between 1700 [EDT] and 2230 [EDT] from a hotel parking lot in Greensboro, NC. Licensee contacted SC about the stolen gauge on 6/23/15 at about 0930 [EDT], SC immediately notified NC.

"The stolen gauge is an InstroTek Model 3500, Serial Number 1360. Sources contained include 11 mCi of Cs-137 and 44 mCi of Am-241/Be.

"The Greensboro Police Department was called by the licensee and performed an investigation that included taking fingerprints and looking for hotel surveillance footage. There was evidence that bolt cutters were used to free the case from the truck. Another note, there was a separate police report filed for a different vehicle break-in around the same time and hotel location. This suggests the thief did not target the radioactive gauge, but rather a perceived value in the locked up container.

"NC notified various other local, state, and federal law enforcement agencies.

"There is no mention of a press release at this time, but [The State of North Carolina] will encourage the licensee to publish a statement and possibly a reward to motivate the device's return.

"Please do not hesitate to contact [The State of North Carolina] should you have additional questions. [The State of North Carolina] will update NMED with any additional details as they unfold."

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

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Agreement State Event Number: 51176
Rep Org: WASHINGTON STATE DEPT OF HEALTH
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City: SEATTLE State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/23/2015
Notification Time: 19:53 [ET]
Event Date: 06/19/2015
Event Time: [PDT]
Last Update Date: 06/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDER DOSE

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

"This appears to be a medical event. Eleven Y-90 TheraSphere infusions were performed on eight patients. Five of the infusions involved the use of a smaller catheter, and for all five of these infusions the full dosage was not administered. This was determined when the nuclear medicine physician - who was the authorized user for all of the infusions - determined the percentage of dose delivered to the patient was less than 80 percent of the prescribed dose. The percentage of dose delivered calculation was performed in accordance with the procedure provided in the package insert. Waste for all five infusions was imaged using PET/CT and it was determined that a large amount of radioactive material was present at a hub in the catheter. The radiation safety officer was informed, who informed the hospital health physicist. The referring interventional radiology physicians were notified that the percentage of dose delivered was less than 80 percent, and that further investigations were underway. For these five infusions, the difference in prescribed dose and delivered dose for the organ (liver) exceeded 0.5 Sv; and the total dosage delivered differed from the prescribed dosage by 20 percent or more. The licensee is investigating this matter further and will provide a written report to the Washington State Department of Health within 15 days as required."

WA Item # WA150003

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: 51177
Rep Org: NEW YORK STATE DEPT OF HEALTH
Licensee: APPLUS RTD USA INC
Region: 1
City: BUFFALO State: NY
County:
License #: C5610
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/24/2015
Notification Time: 14:48 [ET]
Event Date: 06/22/2015
Event Time: 14:45 [EDT]
Last Update Date: 06/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE RUN OVER BY BULLDOZER

The following was received from the State of New York via email:

"On 6/23/15, at 0953 [EDT], the Radiation Safety Officer (RSO) of APPLUS RTD USA Inc., called The New York State Department of Health to report that on 6/22/15, a bulldozer ran over a Troxler Model 3440 Moisture Density Gauge, containing 8 mCi Cs-137 and 40 mCi Am-241/Be. This occurred at the University of Buffalo, South Campus in front of Clark Hall. From the RSO's description and the emailed photographs, the yellow casing was severely damaged on one side, the side farthest from the sources. The rod and source were not extended at the time of the accident. The East Region RSO for APPLUS RTD USA Inc. used a Teletector Model 6112M with an 8 foot arm while approaching the unit to ensure the sources were in the shielded position. No unusual radiation reading has been noted. The regional RSO secured the gauge in the transport container and it was transported back to the licensee's office for storage with 15 other Moisture Density Gauges. The RSO contacted MJW Technical Services for disposal of the damaged unit. The RSO of University of Buffalo has been notified.

"This event is not a reportable event since the sources were in their shielded positions at the time of the incident. This event report is for informational purposes only."

NYDOH - 15 - 05

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Power Reactor Event Number: 51195
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TOM PLOWER
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/01/2015
Notification Time: 10:39 [ET]
Event Date: 05/04/2015
Event Time: 20:27 [EDT]
Last Update Date: 07/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
LADONNA SUGGS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

INVALID AUXILIARY FEEDWATER ACTUATION SYSTEM PARTIAL ACTUATION

"On May 4, 2015 with Unit 1 in Mode 1 at 100 percent power, during performance of the 'A' channel Auxiliary Feedwater Actuation System (AFAS) monthly functional test, an invalid 'A' channel AFAS actuation occurred. The monthly functional test resulted with AFAS-1 in a half trip condition. Due to a poor contact on a manual actuation switch, a pathway was dropped out causing the partial AFAS actuation to occur. The faulty mechanical switch was replaced and the post maintenance testing was satisfactory.

"The partial AFAS actuation resulted in the successful start of 'A' AFW electric driven pump and the opening of its motor control valve, feeding the 'A' steam generator. The system responded to the invalid actuation as designed.

"In accordance with 10 CFR 50.73(a)(1), this notification of the invalid actuation is provided in lieu of a written LER."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, July 02, 2015
Thursday, July 02, 2015