Event Notification Report for February 24, 2017

UCI TERMINAL BOXES P/N 005650-01 DISCOLORATION AND CORROSION

The following information is excerpted from an email submitted by the reporting organization:

"In July of 2016, UCI [United Controls International] identified extensive discoloration and corrosion on P/N: 005650-01, terminal box enclosures, that were fabricated under UCI's Quality Assurance Program in April of 2015. The identified discoloration and corrosion was not present at the completion of fabrication and became evident when pulled from stock in July of 2016. It was determined that the fabrication process was changed during fabrication of the April of 2015 items to utilize a different vendor for fabrication activities. Evaluation of the fabrication process performed on the subject items identified that this new vendor utilized a polishing process that was not performed on previously fabricated items. Particles/crystals from the discolored areas of the affect items were analyzed by Fourier Transform Infra-Red (FTIR) method and it was identified that ammonium phosphate crystals had formed on the items. It is the determination of UCI that the affected items were cleaned/polished with unknown chemicals during the polishing process of fabrication that resulted in the formation of these crystals and degradation of the enclosure material overtime. The items manufactured utilizing this new process were supplied to Clyde Union Limited under purchase orders 4500109863/4 (Qty. 1) and 4500113688/4 (Qty. 1). Clyde Union Limited was notified of the subject issue on January 13, 2017 and UCI is awaiting concurrence from Clyde Union Limited that the affected items are to be returned for replacement items manufactured per the original manufacturing process.

"If you have any questions or wish to discuss this matter or this report, please contact:
Wesley Hackle
Engineering Manager
whickle@unitedcontrols.com
770-496-1406 x 165"

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO HIGH DOSE

The following information was supplied via email from the State of North Carolina:

"On 2/27/2017 the North Carolina Radiation Protection Section (RPS) received the following notification from Duke University Medical Center, License number 0247-4.

"A possible Medical Event occurred at Duke University Medical Center on February 24, 2017 involving Y-90 microspheres during a liver embolization procedure. Duke personnel reported to North Carolina Radiation Protection Section (RPS) on February 27, 2017 of the event meeting the reporting requirements for a Medical Event as dictated in NRC Licensing Guidance, Rev. 9 under:

"Medical Event [ME] Reporting: The licensee shall commit to report any event, except for an event that results from intervention of a patient or human research subject, in which: the total dose or activity administered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more, except when stasis or emergent patient conditions are documented and resulted in a total dose or activity administered that was less than that prescribed;

"At this time, the details provided by Duke University Medical Center for this ME are as follows: Delivered dose was 94 percent higher than the prescribed dose in the Written Directive to the treatment site. The apparent cause appears to be an error in reading the prescribed radioactivity (in GBq) before converting to the administered activity (in mCi), indicating operator error that occurred in the radio pharmacy at Duke University Medical Center.

"RPS has dispatched an investigator to perform a reactive inspection at Duke University Medical Center. This investigation is ongoing and RPS will have additional information to complete this report."

The State on North Carolina does not know if the patient has been notified of the received dose being higher than the prescribed dose.

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.

OFFSITE NOTIFICATION TO STATE OF WISCONSIN DUE TO INADVERTENT RELEASE OF CONTAMINATED WATER

"The Wisconsin Department of Natural Resources (WDNR) was notified today at 1245 [CST] of an inadvertent release of radioactively contaminated water [as required by the licensee's site permit to report any release of contaminated water into the Mississippi River].

"At approximately 0715 on February 23, 2017, Solutions Management was notified by a Radiation Protection Technician (RPT) that the containment berm of the East (immediately north of Turbine Building) Baker Tank (20,000 gallon storage tank) was full and spilling out of the containment berm. The water that spilled out of the containment berm had pooled to the north of the tank and eventually began draining into the Radiological Controlled Area (RCA) storm sewer drain.

"Upon discovery and initial investigation the RPT ascertained that a sump pump hose which was left in the tank overnight was siphoning into the containment berm. The RPT immediately removed the hose from the water in the Baker Tank to stop the water from siphoning. Once the water was secured actions were taken [to minimize the contamination].

"Approximately 400 gallons had been lost from the tank. The 400 gallons was siphoned from the tank through a garden hose attached to a sump pump which was sitting in the containment berm. Over the course of approximately 16 hours the water siphoning from the tank filled the containment berm which holds a little over 3,100 gallons and spilled on to an asphalt surface. The water then traveled approximately 30 feet over the asphalt surface to the storm sewer which contained inlet protection in accordance with the Storm Water Pollution Prevention Plan. After filtering through the inlet protection the water remained in the storm water drain until the volume was sufficient enough to reach the 10 inch discharge piping (approximately 12 inches). The water traveled approximately 100 feet to the next storm water drain where it remained until the volume was sufficient enough to reach the 10 inch discharge piping (approximately 8 inches). When the manhole was opened, the level of the water was just above the bottom of the 10 inch discharge piping and was flowing slowly. The water leaving the 10 inch discharge piping flowed to a 60 inch discharge pipe that discharges to the Mississippi River.

"Water samples and smear surveys were analyzed, documented and reviewed by the Lacrosse Solutions (Solutions) Radiation Protection Manager (RPM) and NRC Region 3 Inspector Dr. Peter Lee, who was on site performing a routine inspection. Analytical results of the released water showed that it contained only Cs-137 in concentrations ranging from 1.1E-06 uCi/ml to 2.86 E-06 uCi/ml. The concentration levels exceed the 10CFR20 Table 2 limits for effluents (water) for Cs-137 which is 1 E-06 uCi/ml. The concentration levels exceed the 10CFR20 Table 2 limits for effluents(water) for Cs-137 which is 1 E-06 uCi/ml. Although the concentration levels exceed the 10CFR20 Table 2 limits for effluents (water) for Cs-137 they did not exceed the criteria for reportability which is 20 times the Table 2 effluent limit for Cs-137. The smear surveys of the storm sewer piping, manhole vaults taken during entries into the RCA yard drain & Administration Building drain manholes were all considerably less than CA posting criteria. The Standard Dose Calculations used for planned water releases were utilized for the water release assuming no dilution. Using the Standard Dose Calculations it was calculated that 1.05 E-02 mRem was the worst case for organs and 5.72E-03 mRem for total body dose.

"Following the RPM's review, it was determined that the asphalt area of the RCA could be down posted as a CA and the storm drain vault to the north of the Administration Building could be unplugged to allow regular flow of storm water.

"Solution's has issued a Conditions Report (CR) and initiated an investigation to prevent this occurrence from happening again.

"Regulatory reportability limits for liquid effluent releases were not exceed as result of this event."

SECONDARY CONTAINMENT DIFFERENTAIL PRESSURE EXCEEDED TECHNICAL SPECIFICATIONS

"At approximately 2239 [CST] on 2/24/17, the Main Control Room received numerous annunciators that indicated a loss of the 138 kV off-site feed to the Emergency Reserve Auxiliary Transformer (ERAT). As a result of the voltage transient, the Division 1 Fuel Building ventilation (VF) system isolation dampers closed causing a trip of VF supply and exhaust fans. With no running VF fans, secondary containment differential pressure rose to slightly greater than 0 inches water gauge which exceeded the Technical Specification requirement of greater than 0.25 inches vacuum water gauge. The Control Room entered EOP-8, Secondary Containment Control. This event is being reported as a Condition that Could Have Prevented Fulfillment of a Safety Function under 10CFR50.72(b)(3)(v)(C). Secondary Containment differential pressure was restored within Technical Specification requirements at 2242 [CST] by starting the Standby Gas Treatment HVAC (VG) system.

"The NRC Resident [Inspector] has been notified."