Event Notification Report for February 16, 2017

SHUTTERS STUCK OPEN ON TWO FIXED BERTHOLD GAUGES

"Company Name: Ciner Wyoming LLC
Address: 254 County Road 4-6, Green River, WY 82935
RSO Name: Hilary Huckfeldt
License #: 49-11578-01
Issue: Shutters on two fixed gauges did not operate during the semi-annual inventory shutter operation check.
Date of Discovery: February 16, 2017 at 3:00 PM MST

"Gauge 1
Manufacturer: Berthold
Serial #: FN-782-14-11-97
Activity: 20 milliCuries
Isotope: Cs-137
Model: LB7440D
Issue: Shutter stuck in open position. Currently in use on pipe.

"Gauge 2
Manufacturer: Berthold
Serial #: FR411-22-01-98
Activity: 50 milliCuries
Isotope: Cs-137
Model: LB7440D
Issue: Shutter locked in open position. Currently in use on pipe.

"Corrective Action: Contacted manufacturer to repair/replace the failed components. Working with manufacturer to get this corrected as soon as possible."

HPCI SYSTEM INOPERABLE DUE TO BLOWN FUSE

"On February 16, 2017 at 1052 CST, Unit 2 received a High Pressure Coolant Injection (HPCI) System 120V Power Failure alarm. Troubleshooting identified a cleared fuse for the HPCI System Flow Controller, 2-FIC-73-33, which would have prevented automatic or manual HPCI System initiation and rendered the HPCI System inoperable. At 1145 CST, the cleared fuse was replaced and the HPCI system was declared available. The HPCI System remains inoperable for additional troubleshooting.

"This constitutes an unplanned HPCI System inoperability and requires an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(D), due to the failure of a single train system affecting accident mitigation and a 60 day written report in accordance with 10 CFR 50.73(a)(2)(v)(D).

"The Senior NRC Resident Inspector has been notified."

UNEXPECTED AUTOSTART OF AN EMERGENCY DIESEL GENERATOR

"On February 16, 2017 at 1320 EST, the 2A Emergency Diesel Generator (EDG) started in response to a valid actuation signal due to the momentary loss of the 2C Startup Transformer (SAT). While performing maintenance activities on the 2D SAT, the alternate supply breaker tripped and reclosed, allowing the 4160 2E Emergency Bus to be momentarily de-energized. When the 4160 2E Emergency Bus de-energized, the 2A EDG received a valid autostart signal due to emergency bus low voltage. Although, the 2A EDG did autostart, it did not tie to the 4160 2E Emergency Bus as the 4160 2E Emergency Bus was re-energized from the 2C SAT.

"This event is reportable per 10 CFR 50.72(b)(3)(iv)(A) since the autostart of the 2A EDG was not part of a pre-planned sequence and the event resulted in the valid actuation of an emergency ac electrical power system.

"CR 10332134

"The NRC Resident has been notified."

AGREEMENT STATE REPORT - CPN INSTROTEK NOTIFIED CALIFORNIA OF MISSING CPN NUCLEAR GAUGE LOCATION

The following information was received from the State of CA via email:

"[The] President of CPN InstroTek in North Carolina called Thomas G. Miko of Los Angeles County Radiation Management, the LEA for Radiologic Health Branch [RHB], on February 16, 2017, from his office in North Carolina. [The CPN President] received a phone call from an anonymous caller in California who found a nuclear gauge from CPN InstroTek. The anonymous caller told [the CPN President] that the gauge is in a shed on a ranch in Southern California. [The CPN President] provided the anonymous caller's cell phone number. Thomas G. Miko spoke with the anonymous caller at 4:30 p.m. on February 16, 2017. The anonymous caller stated that he is in Palm Springs, and that the gauge is in a storage shed of items removed from a pawn shop in Temecula, California, after it went out of business. He said that this shed is in Desert Hot Springs, California, outside of Los Angeles County's jurisdiction.

"Arrangements were made with the anonymous caller for him to drop off the gauge in its original case at the Riverside County Fire Station, where he would contact [a designated] Firefighter.

"[The CPN President] requested that Radiologic Health Branch provide him with the serial number of the gauge for his own reference, once Radiologic Health Branch employees take possession of the gauge from Riverside County Fire Department.

"Arrangements were made for [a] Radiologic Health Branch employee to drive from the Brea, Orange County, California office to take possession of the device from Riverside County Fire Department on Friday, February 17, 2017.

"RHB Brea will follow up to see if they can match the gauge's serial number with that of any previously reported lost or stolen gauges."

CA 5010 Number: 021617

* * * UPDATE AT 1229 EST ON 2/17/17 VIA EMAIL * * *

The missing gauge was not in the case. Law Enforcement is conducting an investigation. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).

* * * RETRACTION AT 1603 EST ON 2/17/17 FROM THOMAS MIKO TO S. SANDIN * * *

The State of California is retracting this report since no gauge was identified or recovered. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).

* * * UPDATE AT 0116 EST ON 2/22/17 VIA EMAIL * * *

The missing radiological source was returned tonight (2/21/17) and is currently at a fire station in Riverside County. The gauge will remain at the station overnight and will be picked up by California Department of Public Health, Radiologic Health Branch tomorrow (2/22/17).

Notified R4DO (Pick), ILTAB (Whitney) and NMSS (McIntosh).

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

COLORADO AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"The general license section of the Radioactive Materials Program [at the Colorado Department of Public Health and Environment] sent out annual notifications requesting response regarding tritium exit signs reported in use at locations given by the manufacturer. Upon an audit of the annual mailing for non-responders, Elkco Properties & Olson's Greenhouse were contacted. After a complete inspection of the greenhouse and several confirmations, only 3 tritium exit signs remain in the facility. It is unknown as to the disposition of the lost 3 exit signs as further information is unavailable due to time of reporting loss. Elkco has plans to remove the existing signs and replace them with non-tritium signs. They will inspect each building they lease and should any tritium exit signs be found, follow the regulations in the Colorado Rules and Regulations Pertaining to Radiation Control.

"Event Description: Manufacturer; SRB Technologies, 3 exit signs are reported as lost, Model#; BX10WH, Serial number's; C12805, C12806, C12810; Isotope H-3 Tritium; Activity; 9.21 Ci, they were shipped from SRB Technologies on 10/23/2004.

"Event is completed/closed."

Colorado Event Report ID No.: CO17-0006.

See similar EN#s 52494, 52538, and 52553

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

SECONDARY CONTAINMENT INOPERABLE DUE TO INTERLOCK FAILURE

"This report is being made in accordance with 10 CFR 50.72(b)(3)(v)(C), for an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material and 10 CFR 50.72(b)(3)(v)(D) for an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. An employee entered a secondary containment airlock and identified that both doors of the airlock opened simultaneously when the door on the reactor building side was opened. The employee immediately secured both doors in the airlock and notified the Main Control Room Supervisor. Both doors in the airlock were open for approximately 5 seconds.

"With both doors open, Technical Specifications (TS) Surveillance Requirement (SR) 3.6.4.1.2 was not met. This rendered secondary containment inoperable in accordance with TS 3.6.4.1. Reactor Building differential pressure, as observed in the Main Control Room, has remained more negative than -0.25 inches of vacuum water gauge at all times. Initial investigation determined that the interlock for the doors was malfunctioning. Administrative controls have been put in place to ensure the doors remain closed pending repairs to the interlock."

The licensee informed the NRC Resident Inspector.

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was received from the Commonwealth of Kentucky via email:

"Hardin Memorial Hospital (HMH) reported that a patient only received 106 mCi of I-131, instead of the prescribed 150 mCi post-thyroidectomy on 2/16/17. Two capsules of I-131 were received from the radiopharmacy in a single vial. When the technologist gave the patient the vial, the patient shook the contents of the vial into her mouth only swallowing one capsule. The tech did not see one capsule remained in the vial. Surveys on the package (containing the vial) that was to be sent back to the radiopharmacy were higher than background so [it] was held for decay. Another survey on 2/28/17 was taken and was still higher than background so the tech opened the package and discovered the remaining pill."

Kentucky Event Report ID No.: KY170002

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.