Event Notification Report for June 30, 2016

REACTOR SHUTDOWN AFTER TECHNICAL SPECIFICATION VIOLATION

"At 0712 [MDT] on 6/30/16 a routine GSTR [Geological Survey TRIGA Reactor] startup and ascent to 900 kW was initiated after successful completion of the daily prestart checks and an excess reactivity check. At 0715 [MDT], as power was passing through [approximately] 200 kW, it was clear to the operator that one of the three power instruments (the NP1000) was not functioning since it was still reading 0% when it should have been reading [approximately] 20%. The reactor was then shutdown, Reactor Supervisor notified, and troubleshooting commenced. Shortly after this, the NP1000 signal cable was found to have the coaxial cable pulled out of one of the connectors in the signal path. Repair, troubleshooting, and testing were performed to resolve the problem. At 0804 [MDT] the reactor was started up and all power instrumentation operated correctly and the daily power operation was performed without further problems.

"The NP1000 is a required safety instrument for operation of the reactor, so malfunction of the instrument is a violation of the facility's Technical Specifications.

"Specifically, specification E.7 states: 'The type and minimum number of safety systems which shall be operable for reactor operation are shown in Table I.' Table I requires the NP1000 to provide a high power scram at 110% power, but the cable problem would have prevented the high power scram from occurring in that instrument."

The licensee will notify the NRC Project Manager.

BOTH PRIMARY CONTAINMENT ISOLATION VALVES FOR A PENETRATION POTENTIALLY INOPERABLE

"On June 30, 2016 at 1430 [EDT], with the reactor at 100 [percent] and the mode switch in RUN, Pilgrim Station determined both Primary Containment Isolation Valves (PCIVs) CV-5065-91 and CV-5065-92 for Drywell Penetration X-32A were inoperable due to the potential failure of relays relied on to perform the primary containment isolation function.

"The valves have been closed and deactivated in the isolated condition in accordance with Technical Specification Limiting Condition For Operation Action Statement 3.7.A.2.b.

"Preparations are in progress to replace the relays to restore the valves to operable status.

"This 8-hour notification is being made in accordance with 10 CFR 50.72 (b)(3)(v)(C) and 10 CFR 50.72 (b)(3)(v)(D).

"The licensee has notified the NRC Senior Resident Inspector.

"The licensee will notify the Commonwealth of Massachusetts."


* * * RETRACTION FROM KEN GRACIA TO DONALD NORWOOD AT 1720 EDT ON 8/29/2016 * * *

"This notification is being made to retract event notification EN 52056 made by Pilgrim Nuclear Power Station on June 30, 2016, that reported the potential failure of relays that could have prevented the fulfillment of the safety function of primary containment isolation valves (PCIVs) needed to control the release of radioactive material and mitigate the consequences of an accident.

"Post replacement testing of the removed relays associated with PCIV CV-5065-91 and CV-5065-92 demonstrated the ability of these relays to perform the required safety function. Based on the test results, no loss of PCIS safety function occurred while the relays were physically installed and operating. Therefore, Event Number 52056, made on June 30, 2016, is being retracted.

"The NRC Senior Resident Inspector has been notified."

Notified R1DO (Powell).

MULTIPLE VALID SPECIFIED SYSTEM ACTUATIONS DUE TO LOSS OF SERVICE TRANSFORMER 21

"On June 30, 2016 at 1715 CDT, Grand Gulf Nuclear Station (GGNS) experienced an electrical power supply loss from Service Transformer 21 which resulted in power supply being lost to Division 2 (16AB Bus) and Division 3 (17AC Bus) ESF buses. This resulted in a valid actuation of Division 2 and Division 3 Diesel Generators on bus under voltage. They both automatically started and energized their respective ESF buses as designed.

"During this event, the loss of power to the Division 2 (16AB Bus) resulted in a Division 2 RPS bus power loss, which actuated a Div 2 RPS half SCRAM signal.

"The power loss also resulted in a loss of the Instrument Air pressure resulting in some Control Rod Scram Valves to drift open. This in turn caused the Scram Discharge Volume to fill to the point where a Div 1 RPS half SCRAM signal was initiated from Scram Discharge Volume level high on Channel 'A'. This resulted in a valid full RPS Reactor SCRAM while not critical. Instrument Air pressure was restored and the SCRAM signal was reset at 1733 CDT.

"Appropriate off normal event procedures were entered to mitigate the transient. No ECCS initiation signals were reached. All safety systems performed as expected.

"GGNS was in Mode 4, Cold Shutdown, with MSIVs closed at the time of the event. Reactor water level was maintained in the normal water level band by Control Rod Drive system throughout this event. RHR 'A' was maintained in Shutdown Cooling operation and it was not affected by this event."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - TROXLER CRUSHED BY CONSTRUCTION VEHICLE

The following report was received from the California Department of Public Health via email:

"On June 30, 2016, around 2 pm [PDT], a Troxler model 3440 # 20303 (reference date 12/1979) containing 40 mCi of Cs-137 and 8 mCi of Am-241:Be was involved in an accident and was crushed by a construction vehicle. The gauge operator cordoned off the area and notified the San Bernardino County Fire/HazMat office and the CA Warning Center - Event # 16-3978. The gauge's housing was crushed and the Cs-137 source handle was bent and loose. A photograph of the damaged gauge was sent to Radiologic Health Branch (RHB) [California Department of Public Health] for evaluation. An RHB inspector responded to the construction site to assist with shielding the source rod and ensuring all radioactive material is placed into the Type A transportation box to travel to the licensee's storage area. Upon arrival, the inspector noted that the bottom plate had broken off of the shield assembly and the sliding block had fallen out of the assembly, exposing the source. The sliding block was placed back in the assembly and the bottom plate taped back onto the bottom of the shield assembly. The top and bottom halves of the gauge body were taped back together, allowing the gauge to be placed back into the transport case for transport back to storage. A survey of the area of the incident after the gauge was placed in the transport vehicle was at background, indicating the no radioactive material remained at the site. The licensee was notified to contact their service provider to arrange for the gauge to be evaluated and possibly disposed.

"Radiation level on the damaged gauge was 4 mR/hr on contact. Radiation level on the loaded Type A case was 0.6 mR/hr on contact."

California 5010 Number: 063016

AGREEMENT STATE REPORT - TROXLER GAUGE RUN OVER BY A DRUM ROLLER

The following report was received from the Washington State Department of Health, Office of Radiation Protection via email:

"On June 30, the operator of a Troxler 3411-B portable moisture-density gauge temporarily left the gauge unattended at a construction site in Chelan, Washington, and the gauge was run over by a drum roller. The top of the gauge housing was damaged, but there was no apparent damage to the sealed sources. At the time of the impact, the source rod was retracted inside the gauge and the handle was locked. After the licensee's radiation safety officer and the Washington State Department of Health were notified about this incident, the gauge was placed back into its transport case and transported to the licensee's licensed storage location in East Wenatchee, Washington. Then a leak test wipe was conducted on each of the sources, and the leak test wipes were mailed to a laboratory for analysis. The gauge is being stored at the licensee's storage location until the leak test results have been received, and then the gauge will be either repaired or sent for disposal.

"Device type: Troxler portable gauge
Model Number: 3411-B
Serial Number 14853
Activity: Cesium-137, 8 milliCuries; Americium-241/beryllium, 40 milliCuries"

Washington Item Number: WA160003

WHOLE BODY BADGE EXPOSURE READING OF 31 REM

The following report is a summary of information provided via email:

"We [Yale University] received notification from our dosimetry vendor (Mirion Dosimetry) of the following unusually high results on three dosimeters for individuals who all work at our PET [Positron Emission Tomography] Research Center, for the month of May:

"Nuclear Medicine Technologist - Whole Body Badge - 31 Rem; Contract Nurse - L Extremity Dosimeter - 35 Rem; Radiochemist - L Extremity - 37 Rem

"The Nuclear Medicine Technologist (NMT) was only at work for six days in May. She only handled radioactive material 4 of those 6 days. She used routine NMT amounts (milliCuries) of C-11 on those 4 days and reports nothing unusual about her work those days. She wears extremity monitors as well and although I [Yale University Radiation Safety Officer (RSO)] don't have the official report from Mirion on these rings, the raw data I have indicates 50 to 85 mRem on her rings. These readings would be considered typical for her work. She is currently on medical leave and has not been at work since May 10th. She does not believe the reading to her whole body badge can be accurate. She does not recall anything unusual for the time period in question.

"The Contract Nurse only worked three days in May. Her other ring badge and her whole body badge recorded no exposures. She does not recall anything unusual for the time period in question and questions the validity of the result.

"The Radiochemist worked his typical schedule in May and handled radioactive materials as part of his work most days. He recalls nothing unusual. His other ring badge and his whole body badge recorded no exposures.

"We [Yale University] immediately collected all [the] PET Research Center staff June monthly badges and have sent in these three individual's badges (and several others) for emergency reads and the remaining for quick reads. [The RSO] expects to get the emergency results today and the remainder early next week. We [Yale University] also reviewed dosimetry of others in the facility, reviewed surveys conducted in May in the facility and conducted a radiation survey at the facility yesterday and find nothing unusual or out of the ordinary.

"We [Yale University] are in contact with several dosimetry experts at Mirion Dosimetry and they are assisting in our investigation. [The RSO] has asked for several pieces of information in writing as related to their processing of the badges including:

"Verification that the results of the three high readings have been scrutinized and reanalyzed for validity and accuracy.
"A description of the type of radiation believed to have caused the exposure on the whole body badge and the energy range of this radiation.
"Can any information about the orientation of the whole body badge when exposed be determined? Was it exposed upside down or backwards, for instance? If you can make any judgments about this please indicate in report.
"Review and confirmation that the TLD chips from each of the dosimeters in question were tracked correctly and are indeed from the badge and rings from the individuals reported.
"Verification that nothing unusual happened with the badges once received by Mirion. Please include the dates the badges were received by Mirion and track them each through processing. I'd like to know when each of the TLD's were analyzed at your facility and if they were analyzed on the same readers and such.

"[The RSO doesn't] believe that any of the three readings reflect actual doses to people. Nonetheless, We [Yale University] are taking the situation very seriously and are expending significant time and effort to try to determine the cause in a timely manner. Our RSC [Radiation Safety Committee] is aware of the situation as is senior Yale leadership."