Event Notification Report for May 07, 2015

INADVERTENT INTRODUCTION OF ALCOHOL INTO THE PROTECTED AREA

"On May 7, 2015, at 1515 hours, B&W NOG-L Security management determined alcohol had been inadvertently introduced into the Protected Area through the shipping and receiving process. 10 CFR 26.719(b)(1) requires that the licensee report to the Operations Center within 24 hours of discovery, the use, sale distribution, possession, or presence of illegal drugs, or the consumption or presence of alcohol within a protected area. The item in question was a six pack of bottled beer which was part of a box of promotional items personally delivered by a sales representative from Graybar Electric.

"The B&W employee addressee first became aware of the package through an email and voicemail left by the salesman advising of a package delivery and indicating the presence of alcohol in the package. The B&W employee immediately contacted Shipping and Receiving management at approximately 1300 hrs. in an effort to intercept the package before delivery; however the package had already been processed into the Protected Area.

"Shipping and Receiving Management contacted the delivery driver via radio and instructed the driver not to deliver the package. The delivery driver separated the package from the delivery items. The package was removed from the Protected Area and returned to the Shipping and Receiving Manager located in the Owner Controlled Area at approximately 1500 hrs. The package was returned unopened. B&W Security Management was notified of the incident at approximately 1515 hrs.

"All items processed through Shipping and Receiving undergo security x-ray inspection. Containers of liquid are commonly processed items and therefore did not create an elevated level of suspicion which would have led to the officers conducting a visual inspection.

"B&W NOG-L Management will conduct an evaluation of the incident to include root cause analysis and corrective actions to prevent recurrence."

The NRC Resident Inspector has been informed.

LOST IODINE-125 SEED

"On May 7, 2015, [Command Radiation Safety Officer (CRSO)] was notified by Brooke Army Medical Center [BAMC] Pathology that they could not find a I-125 seed. The seed was from a radioactive seed localization procedure for a breast biopsy. [The licensee's] Health Physics Service sent two personnel to investigate the loss and attempt to find the seed. After tracking the chain of custody and attempting to find the seed [the licensee] concluded that the seed was thrown away into the bio-hazard waste in pathology with the specimen tray.

"On May 6, 2015, the pathologist transferred a biopsy specimen from a receiving tray to an examination tray. [The pathologist] then discarded the receiving tray in the bio-waste and used an RSL [radioactive seed localization] node seeker to confirm seed presence in the specimen. [The pathologist] misread the meter, marking on the seed tracking chain of custody form that the seed was present. [The licensee] examined the radiograph of the specimen, taken just before arriving at pathology, and found that the seed was on the edge of the biopsy specimen. [The licensee] believes the seed fell into the receiving tray upon transfer of the specimen and the seed was discarded along with that tray.

"The bio-hazard waste was disposed after this point, [approximately] 0600 [CDT] on May 7, 2015. On May 7, 2015, during clinical examination of the specimen and during the procedure to extract the seed, the pathologist could not find the seed. The RSO was called at this point and the investigation began. [The licensee] notified our environmental services branch and the waste disposal company to notify them that they may encounter a radioactive seed.

"The seed is I-125. The initial activity was 0.300 mCi on March 27, 2015, and was 0.185 mCi as of May 7, 2015.

"Today, BAMC Health Physics Service conducted an inventory and has accounted for all other I-125 RSL seeds besides the one mentioned in this email. [The licensee] will retrain the pathology section on proper procedures and conduct an in-service on how to read the RSL node seeker for confirming the presence of the seeds. [The licensee] will also discuss with pathology additional physical measures that can be implemented to ensure this does not happen again.

"[The CRSO] will send a full report along with memorandums and status on measures taken to prevent future occurrences."

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

POTENTIAL PART 21 INVOLVING STRUTHERS DUNN RELAYS WITH CONTACT RESISTANCE GREATER THAN ONE OHM

The following is excerpted from a report submitted by QualTech NP, Nuclear Division, Curtiss-Wright Corporation:

"Subject:

"PSEG reported failures for Struthers Dunn 219BBX200 relays related to greater than 1 ohm contact resistance. Two relays were evaluated by Exelon Power Labs. Of these, one had a failure consisting of a contact resistance greater than one ohm. Struthers Dunn has also provided an evaluation in this regard and does not agree with the failure mode as inferred in the Exelon Power Labs report.

"Lab and OEM report key difference:

"The Power Labs' Report(s) shows fiberglass fiber(s) embedded into gold plated contacts on one relay believed to result in a contact resistance greater than one Ohm (1.7 Ohm Max). The second relay, from stock, had evidence of fiberglass present but was not considered to have affected functionality.

"The Struthers Dunn evaluation suggests that the fiber embedded on the gold contact is not at the mating point of the contacts and should not impact operability. Struthers Dunn also indicates that the relay's application is operating below their minimum current.

"Discussion:

"The actuator board on the evaluated relays is manufactured from a printed circuit board (PCB) type fiber board. The fibers from the edges of the board could become airborne. [. . . ] this specific board material was utilized beginning in March 2010. Since there have been no prior reports of this issue, it is possible that the 2010 material change introduced a foreign materials exclusion (FME) concern. Since then, and solely for those relays manufactured in the USA, the material changed again in November 2014 and was incorporated into the products starting January 2015. The newest version of the actuator board is a molded material that does not contain fiberglass fibers.

"Struthers Dunn relays with base part numbers 219, 236, 237, and 255 have the common PCB type fiber board. This fiber board was used in relays with date code 1009 through 1452 with or without letter suffix (where the letter indicates made outside of the USA).

"Customer Input:

"1st 219 series relay failed due to contact issue, considered a random failure & discarded. 2nd 219 series relay failed due to contact resistance & sent to Exelon Power Labs. Five parts from inventory bench tested. One had high resistance and it was sent to Power Labs

"Note: All parts provided were 100% functionally tested for contact resistance during dedication process and passed testing at QTNP.

"Vendor Input:

"Struthers Dunn has, since 2010, experienced only one field complaint (PSE&G) on continuity issues related to fiberglass on these 219 relays. The material change to ULTEM 2300 was considered an ongoing quality/process improvement process to reduce potential defects proactively. Over the four years using this PCB type material, 13,000 relays were sold.

"Struthers Dunn has also questioned the application having current below the manufacturer's recommended value of 50mA, requiring bifurcated contacts. Please see their attached report and current product catalog for details.

"Recommendation:

"The root cause of the failure is inconclusive. Exelon Power Labs said 'The irregular contact surface patterns in conjunction with the presence of the embedded fiberglass fibers are the most likely cause of the excessive resistance. This finding is considered to be a manufacturing defect.' While the manufacturer sees the failure as a misapplication of its product and that the fiber 'was not located at the 'mating point' of the 2 contacts so therefore has no effect on the performance of the contacts or relay.'

"QualTech NP recommends an application review for the named relays. A review of the Exelon Power Labs reports and the vendor's report should also be completed by the utility to evaluate the impact on the safety function."

OFFSITE NOTIFICATION DUE TO A BOATING ACCIDENT ON THE STATION COOLING LAKE

"This report is being made pursuant to 10CFR50.72(b)(2)(xi), News Release or Notification of Other Government Agency. Operations received a report from Security that a fishing boat has capsized on the station cooling lake. At 1530 [CDT] the LaSalle County Operating Department was notified that the LaSalle County Coroner confirmed that there was a fatality. The Illinois Department of Natural Resources (IDNR), LaSalle County Sheriff, Seneca Rescue Team, and NRC Senior Resident Inspector have been notified."

AUTOMATIC REACTOR SCRAM DUE TO TURBINE TRIP

"Today at 1727 EDT, an automatic scram from a turbine trip occurred. The cause of the turbine trip is currently under investigation. All rods inserted into the core and all systems functioned as expected during the scram.

"The event is reportable within 4 hours per 10CFR50.72(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."

Plant response to the scram was uncomplicated and the plant is stable in Mode 3.

The licensee has notified the NRC Resident Inspector.

OFFSITE NOTIFICATION DUE TO SHUTDOWN FOR AN UNISOLABLE STEAM LEAK

"At 0700 on 5/7/15, Indian Point Unit 3 commenced a shutdown due to the inability to isolate a steam leak on a feedwater instrument line.

"Offsite power is available.

"Indian Point Unit 2 is unaffected and remains in Mode 1 at 100% power.

"The NRC Resident Inspector, the NYISO (New York Independent System Operator), and NY Public State Commission have been notified."

TECHNICAL SPECIFICATION SHUTDOWN DUE TO REACTOR COOLANT PUMP TRIP

"This notification is being made as required by 10 CFR 50.72(b)(2)(i) due to a Farley Nuclear Plant Unit 1 shutdown required by Technical Specifications.

"At 0509 CDT on 5/7/2015, 1B Reactor Coolant Pump (RCP) tripped during transfer of 1B 4160V bus to 1B unit auxiliary transformer. Technical Specification LCO 3.4.4 Condition A was entered for loss of a Reactor Coolant System (RCS) loop. Unit 1 reactor was shut down per operating procedures and entered Mode 3 at 0740 CDT.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOST Co-57 SOURCE

"This event was reported by Digirad Imaging Solutions, Inc. that occurred at a client facility in Melrose, MA. Digirad Imaging Solutions is a mobile nuclear medicine company that provides imaging services at client facilities in MA. They are a licensee in Massachusetts under State License Number 44-0362.

"A Cobalt-57 flood source used for nuclear medicine camera imaging calibration was discovered to be missing. The source is 10 mCi (05/01/2015) in strength and is 8 inch x 8 inch in area. The source is typically stored in a leaded sleeve 12 inch x 12 inch in area. The date of discovery appears to be May 8, 2015, but the details are still uncertain at this point.

"Digirad Imaging Solutions is providing a 30 day report of the incident shortly. The incident was reported to us [Massachutetts Radiation Control Program] on the day of this report to the NRC (6/2/2015)."

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