Event Notification Report for April 08, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/07/2014 - 04/08/2014
EVENT NUMBERS
5000950010500115001250019500065000750127
Research Reactor
Event Number: 50009
Rep Org: U. S. GEOLOGICAL SURVEY
Licensee: U. S. DEPT. OF INTERIOR
Region: 4
City: DENVER State: CO
County: DENVER
License #: R-113
Agreement: Y
Docket: 05000274
NRC Notified By: TIM DeBEY
HQ OPS Officer: STEVE SANDIN
Licensee: U. S. DEPT. OF INTERIOR
Region: 4
City: DENVER State: CO
County: DENVER
License #: R-113
Agreement: Y
Docket: 05000274
NRC Notified By: TIM DeBEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2014
Notification Time: 13:56 [ET]
Event Date: 04/08/2014
Event Time: 10:27 [MDT]
Last Update Date: 04/08/2014
Notification Time: 13:56 [ET]
Event Date: 04/08/2014
Event Time: 10:27 [MDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LAWRENCE KOKAJKO (NRR)
LAWRENCE KOKAJKO (NRR)
REPORT OF TECHNICAL SPECIFICATION VIOLATION
"Event details:
"While performing a routine reactor pulse for surveillance purposes, the signal input cable to one of the power monitoring safety channels was disconnected, making the associated high power scram not functional. The pulsing procedure requires disconnecting this cable for preoperational testing, but states that the instrument input be returned to its normal operating status prior to actually performing the operation. Contrary to the procedure, this was not done and the reactor was operated at 2 watts for 7 minutes without that required safety channel operating. A second safety channel was fully operational during that time. The high power scrams are not required during pulse mode operations. The disconnected cable was subsequently discovered and reconnected."
The licensee informed the NRR Program Manager (Morlang).
"Event details:
"While performing a routine reactor pulse for surveillance purposes, the signal input cable to one of the power monitoring safety channels was disconnected, making the associated high power scram not functional. The pulsing procedure requires disconnecting this cable for preoperational testing, but states that the instrument input be returned to its normal operating status prior to actually performing the operation. Contrary to the procedure, this was not done and the reactor was operated at 2 watts for 7 minutes without that required safety channel operating. A second safety channel was fully operational during that time. The high power scrams are not required during pulse mode operations. The disconnected cable was subsequently discovered and reconnected."
The licensee informed the NRR Program Manager (Morlang).
Power Reactor
Event Number: 50010
Facility: MILLSTONE
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: TODD STRINGFELLOW
HQ OPS Officer: STEVE SANDIN
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: TODD STRINGFELLOW
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2014
Notification Time: 14:14 [ET]
Event Date: 04/08/2014
Event Time: 09:51 [EDT]
Last Update Date: 04/08/2014
Notification Time: 14:14 [ET]
Event Date: 04/08/2014
Event Time: 09:51 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1DO)
RAY POWELL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
LOSS OF STACK GAS EFFLUENT RADIATION MONITOR
At 0951 EDT Operators discovered that RM-8168 (Stack Gas Effluent Radiation Monitor) was inoperable due to a temporary loss of power to the motor. This resulted in a loss of assessment capability. The licensee followed the required steps in the Alarm Response Procedure and restored the Radiation Monitor to service at 1310 EDT.
The licensee informed State/local agencies and the NRC Resident Inspector.
At 0951 EDT Operators discovered that RM-8168 (Stack Gas Effluent Radiation Monitor) was inoperable due to a temporary loss of power to the motor. This resulted in a loss of assessment capability. The licensee followed the required steps in the Alarm Response Procedure and restored the Radiation Monitor to service at 1310 EDT.
The licensee informed State/local agencies and the NRC Resident Inspector.
Agreement State
Event Number: 50011
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MIAMI NEUROSCIENCE CENTER - LARKIN COMMUNITY HOSPITAL
Region: 1
City: SOUTH MIAMI State: FL
County:
License #: 2825-2
Agreement: Y
Docket:
NRC Notified By: RICH A. DAVIS
HQ OPS Officer: STEVE SANDIN
Licensee: MIAMI NEUROSCIENCE CENTER - LARKIN COMMUNITY HOSPITAL
Region: 1
City: SOUTH MIAMI State: FL
County:
License #: 2825-2
Agreement: Y
Docket:
NRC Notified By: RICH A. DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2014
Notification Time: 17:13 [ET]
Event Date: 04/08/2014
Event Time: 08:12 [EDT]
Last Update Date: 04/08/2014
Notification Time: 17:13 [ET]
Event Date: 04/08/2014
Event Time: 08:12 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
FSME_EVENTS RESOURCE (EMAI)
RAY POWELL (R1DO)
FSME_EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT INVOLVING PALLIATIVE DOSE ADMINISTERED TO THE WRONG TREATMENT SITE
The following report was received from the State of Florida via email:
"This treatment was set up by the treatment planner taking into account the previous two treatments performed on the right side back in 2008 and 2007. The treatment planner did not realize that the pain had resolved on the right side and that the treatment was to be performed on the left side. The treatment was reviewed and signed according to protocol and was started by [the Authorized User] at 8:12 am. The 19.14 minute treatment was stopped at 1.72 minutes when it was realized that the patient was to be treated on the left side. At 8:42 am [the Authorized User] had [the Neurosurgeon] inform the patient that we interrupted the treatment because we had started treating the right side instead of the left side. The treatment planner created a treatment plan for the left side, the patient was treated and the stereotactic frame was removed at 10:00 am. This Medical Event will have no detrimental effects on the patient. No further action will be taken on."
Florida Incident Number: FL14-035
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.
The following report was received from the State of Florida via email:
"This treatment was set up by the treatment planner taking into account the previous two treatments performed on the right side back in 2008 and 2007. The treatment planner did not realize that the pain had resolved on the right side and that the treatment was to be performed on the left side. The treatment was reviewed and signed according to protocol and was started by [the Authorized User] at 8:12 am. The 19.14 minute treatment was stopped at 1.72 minutes when it was realized that the patient was to be treated on the left side. At 8:42 am [the Authorized User] had [the Neurosurgeon] inform the patient that we interrupted the treatment because we had started treating the right side instead of the left side. The treatment planner created a treatment plan for the left side, the patient was treated and the stereotactic frame was removed at 10:00 am. This Medical Event will have no detrimental effects on the patient. No further action will be taken on."
Florida Incident Number: FL14-035
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.
Power Reactor
Event Number: 50012
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM MUFFLEY
HQ OPS Officer: STEVE SANDIN
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM MUFFLEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2014
Notification Time: 23:13 [ET]
Event Date: 04/08/2014
Event Time: 21:14 [EDT]
Last Update Date: 04/08/2014
Notification Time: 23:13 [ET]
Event Date: 04/08/2014
Event Time: 21:14 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY POWELL (R1DO)
RAY POWELL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 100 | Power Operation | 0 | Hot Standby |
UNIT 1 MANUALLY TRIPPED FOLLOWING THE LOSS OF AN OPERATING STEAM GENERATOR FEED PUMP (SGFP)
"This 4 and 8 hour notification is being made to report that Salem Unit 1 has performed an unplanned manual reactor trip and subsequent Auxiliary Feedwater system actuation. The trip was initiated due to loss of Steam Generator water level [SGWL] following the loss of one of the running SGFPs (#11 Steam Generator Feed Pump). The reactor was manually tripped prior to reaching the automatic SGWL low setpoints. #11/12/13 Aux Feedwater Pumps automatically started following the reactor trip on low Steam Generator water level.
"Salem Unit 1 is currently in Mode 3. Reactor Coolant system pressure is at 2235 PSIG and temperature is 547 degrees Fahrenheit with decay heat removal via the Main Steam Dumps and Auxiliary Feedwater Systems. Unit 1 has no active shutdown technical specification action statements in effect. All control rods inserted on the reactor trip. All ECCS [Emergency Core Cooling System] and ESF [Engineered Safety Feature] systems functioned as expected.
"There was no major primary or secondary equipment tagged for maintenance prior to this event. No personnel were injured during this event."
The licensee will inform the Lower Alloways Creek Township and the NRC Resident Inspector.
"This 4 and 8 hour notification is being made to report that Salem Unit 1 has performed an unplanned manual reactor trip and subsequent Auxiliary Feedwater system actuation. The trip was initiated due to loss of Steam Generator water level [SGWL] following the loss of one of the running SGFPs (#11 Steam Generator Feed Pump). The reactor was manually tripped prior to reaching the automatic SGWL low setpoints. #11/12/13 Aux Feedwater Pumps automatically started following the reactor trip on low Steam Generator water level.
"Salem Unit 1 is currently in Mode 3. Reactor Coolant system pressure is at 2235 PSIG and temperature is 547 degrees Fahrenheit with decay heat removal via the Main Steam Dumps and Auxiliary Feedwater Systems. Unit 1 has no active shutdown technical specification action statements in effect. All control rods inserted on the reactor trip. All ECCS [Emergency Core Cooling System] and ESF [Engineered Safety Feature] systems functioned as expected.
"There was no major primary or secondary equipment tagged for maintenance prior to this event. No personnel were injured during this event."
The licensee will inform the Lower Alloways Creek Township and the NRC Resident Inspector.
Agreement State
Event Number: 50019
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ATL INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-116
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: STEVE SANDIN
Licensee: ATL INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-116
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 19:02 [ET]
Event Date: 04/08/2014
Event Time: 00:00 [MST]
Last Update Date: 04/09/2014
Notification Time: 19:02 [ET]
Event Date: 04/08/2014
Event Time: 00:00 [MST]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)
AGREEMENT STATE REPORT - MISSING TROXLER GAUGE
The following information was received from the State of Arizona via email:
"On April 8, 2014, the Agency was contacted by the Licensee who indicated that an employee and a Troxler Gauge was missing. The licensee was informed around 6:00 AM that the employee did not show up on a job on the Indian Reservation. The licensee has notified both the Arizona Department of Public Safety and the New Mexico Department of Public Safety. The gauge is a Troxler Model 3430, Serial Number 7052 containing 9 millicuries of Cesium-137 and 45 millicuries of Am-241. The individual was discovered to have had a diabetic coma and the gauge was still with the individual and the licensee is sending another operator to retrieve the gauge. The individual is in Gallup, NM.
"The investigation into this event is ongoing.
"The U.S. NRC, New Mexico, and Arizona Governor's Office have been notified of this event."
Arizona First Notice: 14-006
* * * UPDATE AT 1930 EDT ON 4/9/14 FROM AUBREY GODWIN TO S. SANDIN * * *
The Troxler Gauge has been recovered and is in the licensee's possession at their Flagstaff, AZ office.
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
The following information was received from the State of Arizona via email:
"On April 8, 2014, the Agency was contacted by the Licensee who indicated that an employee and a Troxler Gauge was missing. The licensee was informed around 6:00 AM that the employee did not show up on a job on the Indian Reservation. The licensee has notified both the Arizona Department of Public Safety and the New Mexico Department of Public Safety. The gauge is a Troxler Model 3430, Serial Number 7052 containing 9 millicuries of Cesium-137 and 45 millicuries of Am-241. The individual was discovered to have had a diabetic coma and the gauge was still with the individual and the licensee is sending another operator to retrieve the gauge. The individual is in Gallup, NM.
"The investigation into this event is ongoing.
"The U.S. NRC, New Mexico, and Arizona Governor's Office have been notified of this event."
Arizona First Notice: 14-006
* * * UPDATE AT 1930 EDT ON 4/9/14 FROM AUBREY GODWIN TO S. SANDIN * * *
The Troxler Gauge has been recovered and is in the licensee's possession at their Flagstaff, AZ office.
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
Power Reactor
Event Number: 50006
Facility: VOGTLE
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN MONAHON
HQ OPS Officer: DANIEL MILLS
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN MONAHON
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/08/2014
Notification Time: 05:21 [ET]
Event Date: 04/08/2014
Event Time: 04:28 [EDT]
Last Update Date: 04/08/2014
Notification Time: 05:21 [ET]
Event Date: 04/08/2014
Event Time: 04:28 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
STEVEN VIAS (R2DO)
STEVEN VIAS (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL
"VEGP Unit 2 was at 100% power, normal activities, when digital feedwater trouble alarms were received on all 4 steam generators (SG) with level stable in all generators. Operating crew entered abnormal operating procedure for feedwater malfunction when SG #3 level began rapidly lowering. Operators attempted to take manual control of SG #3 main feedwater regulating valve and were unable to raise SG #3 level. SG #3 level lowered to the Lo-Lo Level setpoint causing an automatic reactor trip. All control rods fully inserted and SG #3 level remained off scale low on narrow range indications. Auxiliary feedwater and feedwater isolation actuated as expected. [Unit 2] is currently stable in Mode 3 at normal operating temperature and pressure. A forced outage response team has been formed to determine the cause of the low SG water level and determine restart criteria and time of restart."
All control rods fully inserted on the trip. Decay heat is being removed via auxiliary feedwater to steam generators steaming to the condenser steam dumps.
The licensee has notified the NRC Resident Inspector.
"VEGP Unit 2 was at 100% power, normal activities, when digital feedwater trouble alarms were received on all 4 steam generators (SG) with level stable in all generators. Operating crew entered abnormal operating procedure for feedwater malfunction when SG #3 level began rapidly lowering. Operators attempted to take manual control of SG #3 main feedwater regulating valve and were unable to raise SG #3 level. SG #3 level lowered to the Lo-Lo Level setpoint causing an automatic reactor trip. All control rods fully inserted and SG #3 level remained off scale low on narrow range indications. Auxiliary feedwater and feedwater isolation actuated as expected. [Unit 2] is currently stable in Mode 3 at normal operating temperature and pressure. A forced outage response team has been formed to determine the cause of the low SG water level and determine restart criteria and time of restart."
All control rods fully inserted on the trip. Decay heat is being removed via auxiliary feedwater to steam generators steaming to the condenser steam dumps.
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 50007
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAN WILLIAMSON
HQ OPS Officer: PETE SNYDER
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAN WILLIAMSON
HQ OPS Officer: PETE SNYDER
Notification Date: 04/08/2014
Notification Time: 09:45 [ET]
Event Date: 04/08/2014
Event Time: 06:18 [EDT]
Last Update Date: 04/08/2014
Notification Time: 09:45 [ET]
Event Date: 04/08/2014
Event Time: 06:18 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
RAY POWELL (R1DO)
RAY POWELL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 17 | Power Operation | 17 | Power Operation |
SHUTDOWN ACTION INITIATED BECAUSE HPCI AND RCIC WERE SIMULTANEOUSLY INOPERABLE
"U1 entered Technical Specification 3.0.3, and initiated actions to reduce power via control rod insertion in preparations to enter startup within the following 6 hours. Entry into Tech Spec 3.0.3 was a result of both HPCI and RCIC injection systems being inoperable at the same time.
"During startup from the U1 refueling outage, RCIC and HPCI full flow testing was unable to be completed at rated reactor pressure prior to the expiration of the 12 hour allowance per Tech Spec Surveillances 4.7.3.b* and 4.5.1.b.3** respectively. This occurred due to testing issues encountered while attempting to perform the rated pressure pump valve and flow tests.
"U1 HPCI testing was completed satisfactorily at 0830, and HPCI was restored to operable. Plant shutdown was terminated at 0830 [EDT] as conditions for 3.0.3 no longer existed."
The licensee will notify the NRC Resident Inspector.
"U1 entered Technical Specification 3.0.3, and initiated actions to reduce power via control rod insertion in preparations to enter startup within the following 6 hours. Entry into Tech Spec 3.0.3 was a result of both HPCI and RCIC injection systems being inoperable at the same time.
"During startup from the U1 refueling outage, RCIC and HPCI full flow testing was unable to be completed at rated reactor pressure prior to the expiration of the 12 hour allowance per Tech Spec Surveillances 4.7.3.b* and 4.5.1.b.3** respectively. This occurred due to testing issues encountered while attempting to perform the rated pressure pump valve and flow tests.
"U1 HPCI testing was completed satisfactorily at 0830, and HPCI was restored to operable. Plant shutdown was terminated at 0830 [EDT] as conditions for 3.0.3 no longer existed."
The licensee will notify the NRC Resident Inspector.
Agreement State
Event Number: 50127
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KAPSTONE KRAFT PAPER CORPORATION
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: STEVE SANDIN
Licensee: KAPSTONE KRAFT PAPER CORPORATION
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/20/2014
Notification Time: 19:03 [ET]
Event Date: 04/08/2014
Event Time: 00:00 [PDT]
Last Update Date: 05/20/2014
Notification Time: 19:03 [ET]
Event Date: 04/08/2014
Event Time: 00:00 [PDT]
Last Update Date: 05/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - OHMART FIXED GAUGE WITH A BROKEN SHUTTER HANDLE
The following information was received from the State of Washington via email:
"This incident is a report of a broken fixed gauge shutter handle which originally was reported to [Washington Division of Radiation Protection] as a GL [General Licensed] device. This incident is a failure of the on/off (shutter) mechanism with the shutter stuck in the closed (safe) position when the handle broke off. [Washington Division of Radiation Protection] learned later that this was not a GL device as reported . . . but a specific license gauge. [Washington Division of Radiation Protection] acted upon the reporting criteria as this meets 10 CFR 31.5 (c)(5) criteria that applies to general license radioactive material and a report within 30 days with a description and remedial action of actual or indicated failure to the on-off mechanism. This report falls into that 30 day time frame but the device is a specifically licensed device.
"Licensee informed Washington Department of Health (WA DOH) on 14 May 2014 that a shutter handle broke off a fixed gauge during shutdown for routine operations on 8 April 2014. Surveys by radiation safety officer and by health physics service provider consultant confirmed dose rates were within acceptable ranges and consistent with gauge SS&D sealed source and device data. The gauge manufacturer is scheduled to be onsite 23 May 2014 to assess and repair. An investigation continues and corrective actions are pending.
"WA DOH incident number WA-14-019.
"One Ohmart fixed gauge, model SH-F1, serial 2860GK. 100 millicuries original activity [Cs-137] in November 1996; now 67 millicuries today 20 May 2014. Source model pending, source serial believed same as device serial. Source and shutter and device conditions unknown, but believed to be undamaged and intact (dose rates similar to SS&D data). Problem with source and device to be determined by gauge manufacturer scheduled to be onsite 23 May 2014 to assess and repair."
The following information was received from the State of Washington via email:
"This incident is a report of a broken fixed gauge shutter handle which originally was reported to [Washington Division of Radiation Protection] as a GL [General Licensed] device. This incident is a failure of the on/off (shutter) mechanism with the shutter stuck in the closed (safe) position when the handle broke off. [Washington Division of Radiation Protection] learned later that this was not a GL device as reported . . . but a specific license gauge. [Washington Division of Radiation Protection] acted upon the reporting criteria as this meets 10 CFR 31.5 (c)(5) criteria that applies to general license radioactive material and a report within 30 days with a description and remedial action of actual or indicated failure to the on-off mechanism. This report falls into that 30 day time frame but the device is a specifically licensed device.
"Licensee informed Washington Department of Health (WA DOH) on 14 May 2014 that a shutter handle broke off a fixed gauge during shutdown for routine operations on 8 April 2014. Surveys by radiation safety officer and by health physics service provider consultant confirmed dose rates were within acceptable ranges and consistent with gauge SS&D sealed source and device data. The gauge manufacturer is scheduled to be onsite 23 May 2014 to assess and repair. An investigation continues and corrective actions are pending.
"WA DOH incident number WA-14-019.
"One Ohmart fixed gauge, model SH-F1, serial 2860GK. 100 millicuries original activity [Cs-137] in November 1996; now 67 millicuries today 20 May 2014. Source model pending, source serial believed same as device serial. Source and shutter and device conditions unknown, but believed to be undamaged and intact (dose rates similar to SS&D data). Problem with source and device to be determined by gauge manufacturer scheduled to be onsite 23 May 2014 to assess and repair."