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Event Notification Report for July 29, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/26/2013 - 07/29/2013

** EVENT NUMBERS **


49203 49204 49206 49207 49217 49219 49220

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Agreement State Event Number: 49203
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: COOPER HEALTH SYSTEMS AT CAMDEN
Region: 1
City: CAMDEN State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/18/2013
Notification Time: 09:30 [ET]
Event Date: 07/16/2013
Event Time: 11:30 [EDT]
Last Update Date: 07/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT DUE TO EQUIPMENT FAILURE

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

"At 11:30 a.m. [EDT] on July 16, 2013, a patient was being treated for three lesions with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, at Cooper Health System in Camden, New Jersey. The prescribed total dose for all three lesions was 58 Gray.

"The first two lesions were treated as planned without incident.

"During treatment of the third lesion, treatment was interrupted because of mechanical failure. A 'Sensor Failure' error occurred, which caused the patient couch to retract and the shielding doors to close. An Elekta service engineer was called and no other treatments were attempted after the 'Sensor Failure'. Treatment of the third lesion was to be re-scheduled.

"It is estimated that only 44.8 Gray out of the prescribed dose of 58 Gray was actually delivered, which is an underdose of greater than 20%."

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.

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Agreement State Event Number: 49204
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON OFFICE OF THE STATE FIRE MARSHAL
Region: 4
City: SALEM State: OR
County:
License #: ORE-93209
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/19/2013
Notification Time: 12:00 [ET]
Event Date: 09/01/2010
Event Time: [PDT]
Last Update Date: 07/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENT RESOURCE (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING DEVICE CONTAINING RADIOACTIVE MATERIAL

The following was received from the State of Oregon via email:

"On February 17, 2011 at 0800 PDT, OR Radiation Protection Services was notified by phone by [the licensee], HazMat Resource Coordinator, a representative of the Oregon Office of the State Fire Marshal (OSFM) regarding a missing Smith's Detection model APD2000 ECD device (s/n 1276) containing 10 mCi of Nickel-63 (source s/n is the same as device, 1276). There were no equipment problems noted.

"The device was stored at Hazmat Team 7, stationed in Redmond, Oregon. The team was disbanded in late 2008 and the device was believed returned to the Salem, Oregon main OSFM office in early 2009. During equipment inventory in September (no date given, 1-30th supplemented), 2010, the device was discovered missing. OSFM personnel wrote a memo dated Sept. 2010, and addressed 'MEMO to File' stating the device was missing and that this was reported to Oregon RPS. No record of the memo having been received was found in RPS records for the license

"[The licensee] stated that the remaining seventeen APD2000 units in possession were to be disposed of through the CRCPD's SCATR program sometime in the next 2 months. An incident report was started by OR RPS on this date (February 17th) for the missing device/radioactive source.

"On April 8, 2011, the seventeen APD2000 units were shipped by waste broker (Thomas Gray and Associates) to affiliate company EMC in Turlock, CA.

"On May 26, 2011 during regular equipment inventory at the Corvallis, Oregon Hazmat team 5B office, the missing APD2000 was located at the back of a storage cabinet. The device was removed and brought to Salem and [the State was] contacted for disposal of this device through the CRCPS SCATR program.

"A leak test was taken June 7th and analyzed June 8th showing detection less than .005 microCurie for Ni-63. On June 15, 2011, the device was transferred to Thomas Gray and Associates for disposal and the license terminated on July 1, 2011. On July 16, 2013, a review was performed of this incident and it was discovered that it was not reported to the US NRC HOO as per the NRC's Reporting Material Events (SA-300), Appendix A. The specific requirement is 10 CFR 20.2201(a)(1)(ii) which states, in part, that reports of missing licensed material > 10X Appendix C value and still missing is to be reported (30 day requirement). The report was written and submitted via e-mail to the HOO on July 19th."

State Event Number: OR-11-0007

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

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Agreement State Event Number: 49206
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: GOOD SAMARITAN REGIONAL MEDICAL CENTER
Region: 4
City: CORVALLIS State: OR
County:
License #: ORE-90202
Agreement: Y
Docket:
NRC Notified By: DARYL A. LEON
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/19/2013
Notification Time: 19:00 [ET]
Event Date: 11/30/2010
Event Time: 23:59 [PDT]
Last Update Date: 07/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME Events Resource ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - BADGE EXPOSURE EXCEEDING 5 REM ANNUAL DOSE LIMIT

The following was received from the State of Oregon via email:

"Oregon Radiation Protection Services was notified by phone on January 19, 2011 at 1119 PDT, a representative of Good Samaritan Regional Medical Center, of a whole body (collar) badge report for the wear period of November 1-30, 2010 that exceeded the 5 rem dose limit. The monthly badge report was received by the licensee sometime after December 28, 2010 for an authorized user showing monthly/quarterly/annual dose as follows:

"Monthly (Nov 2010):
DDE, LDE = 5230 mrem
SDE = 5032 mrem

"Quarterly (4Q2010):
DDE, LDE = 5290 mrem
SDE = 5091 mrem

"Annual (2010) and Lifetime (hired in 2010):
DDE, LDE = 5376 mrem
SDE = 5175 mrem

"The vendor (Landauer) performed a second read of the dosimeter that agreed with the reported doses above and stated that the imaging indicated an 'irregular exposure.' The authorized user stored his badge and ring in a 'cubby' along with his lab jacket.

"On January 24th, the licensee emailed Oregon RPS with results from the licensee's investigation stating that the badge user was a student on rotation to the nuclear medicine dept. for the month of November. The user's previous WB badge results were 'normal' and no other nuclear medicine worker received a high dose reading during November. The student was '100% supervised' and is described as 'very conscientious about spills or drops.' Regardless, the licensee determined after eliminating several factors, that contamination was the most probably factor since the collar badge result was higher than the user's finger ring (4480 mrem SDE November, 5220 mrem SDE for 2010) and 'irregular exposure' noted by the dosimetry vendor. It remains unknown what isotope caused the overexposure and any Tc-99m has decayed to background. Surveys of the cubby and lab jacket were performed with negative results. In addition, the licensee stated that no 'large' iodine doses were administered for November. Remedial actions were not noted on the report.

"On July 16, 2013, a review was performed of this incident and it was discovered that it was not reported to the US NRC HOO as per the NRC's Reporting Material Events (SA-300), Appendix A. The specific requirement is 10 CFR 20.2203(a) which states, in part, that radiation doses that exceed the regulatory requirements (5 rem) are to be reported (30 day requirement). The licensee was e-mailed for any remedial actions taken after this event.

"On July 19, the licensee responded by e-mail stating that without a definitive cause for the overexposure, no change in procedure was instituted except heightened awareness of badge placement/location. The report was written and submitted via e-mail to the HOO on this same date.

"Oregon Radiation Protection Services noted on the Incident report that US NRC Operations Center was to be notified but this was not done."

State Event Number: OR-11-0004

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Agreement State Event Number: 49207
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BLANCHARD REFINING COMPANY LLC
Region: 4
City: TEXAS CITY State: TX
County:
License #: 06526
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/19/2013
Notification Time: 21:08 [ET]
Event Date: 07/19/2013
Event Time: [CDT]
Last Update Date: 07/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT

The following information was received via E-mail:

"On July 19, 2013, the Agency was notified by a licensee that a TFS model 5221 nuclear gauge containing two, 300 millicurie Cesium 137 sources failed to function as designed when attempting installation of the device on a process vessel.

"When the source was inserted into the vessel, the chain connecting one of the sources to the nuclear gauge broke allowing the source to travel to the bottom of the insertion tube. This is the normal operating position for the source. A radiation survey was conducted by the licensee indicating radiation levels to the general public were normal. The manufacturer has been contacted and is responding. It is anticipated that an attempt will be made by TFS to retrieve the source from inside of the vessel between July 20, 2013 and July 22, 2013 and then proceed to immediately repair the device.

"There is no additional risk of radiation exposure to members of the general public as a result of this failure. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9098

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Part 21 Event Number: 49217
Rep Org: WESTINGHOUSE ELECTRIC COMPANY
Licensee: WESTINGHOUSE ELECTRIC COMPANY
Region: 1
City: CRANBERRY TWP. State: PA
County: BUTLER
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES GRESHAM
HQ OPS Officer: PETE SNYDER
Notification Date: 07/26/2013
Notification Time: 13:15 [ET]
Event Date: 07/26/2013
Event Time: [EDT]
Last Update Date: 07/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
GEORGE HOPPER (R2DO)
PATTY PELKE (R3DO)
DON ALLEN (R4DO)
PART 21 REACTORS (EMAI)

Event Text

POTENTIAL EXISTENCE OF DEFECTS IN SHIELD PASSIVE THERMAL SHUTDOWN SEAL SYSTEM

"The defect being reported concerns an identified inconsistency between the intended design functionality of the SHIELD passive thermal shutdown seal (SDS) and that observed during post-service testing.

"The purpose of the SDS is to reduce current reactor coolant system inventory losses to very small leakage rates for a plant that results in the loss of all reactor coolant pump (RCP) seal cooling. The SDS is a thermally actuated, passive device integral to the RCP Number 1 seal insert and is positioned between the Number 1 seal and the Number 1 seal leak-off line to provide a near leak-tight seal once activated.

"There are two delivered components associated with this report: 1. the SDS hardware, and 2. the Probability Risk Assessment (PRA) SDS model and the assigned SDS reliability. The hardware component is the SHIELD passive thermal shutdown seal. The associated PRA SDS model and assigned reliability basic component is WCAP-17100-P-A, Supplement 1, Rev. 0, 'PRA Model for the Westinghouse Shut Down Seal Supplemental Information for All Domestic Reactor Coolant Pump Models' (dated December 2012).

"The SDS has only been delivered and installed in the following plants: Beaver Valley Unit 2, Callaway, D.C. Cook Unit 1, Farley Units 1 and 2, and Wolf Creek.

"Westinghouse has concluded that the hardware itself will not adversely impact safe plant operation.

"Westinghouse has completed a root cause analysis (RCA) and an independent third party review of this RCA is expected to be completed by August 2013. In parallel, SDS design improvements are being considered and may be completed during the third quarter of 2013. Additionally, and if necessary, Westinghouse will revise WCAP-17100 and its Supplements, as needed, to reflect any new information that is developed.

"Affected customers have been informed via their respective Customer Project Managers of the post-service test failure."

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Power Reactor Event Number: 49219
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JIM BAYLOR
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/27/2013
Notification Time: 01:14 [ET]
Event Date: 07/26/2013
Event Time: 23:49 [CDT]
Last Update Date: 07/27/2013
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DON ALLEN (R4DO)
JOHN MONNINGER (NRR)
JANE MARSHALL (IRD)
THOMAS BERGMAN (R4)
JENNIFER UHLE (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

UNUSUAL EVENT DECLARED DUE TO A FIRE IN THE TURBINE BUILDING LASTING GREATER THAN 15 MINUTES

On July 26, 2013, at 2349 CDT, the Callaway nuclear power plant declared an Unusual Event due to a fire not extinguished within 15 minutes of control room notification, EAL HU 2.1. The fire was located in the turbine building near the main generator. Concurrent with the fire, the reactor tripped due to a turbine trip. All control rods fully inserted and all reactor coolant pumps (RCPs) tripped. The fire has been extinguished and the licensee is in progress of restoring RCPs.

The licensee notified the NRC Resident Inspector, State Emergency Management Agency and Local Authorities.

Notified DHS SWO, FEMA, and DHS NICC.

* * * UPDATE ON 7/27/13 AT 0201 EDT FROM MARK COVEY TO BILL HUFFMAN * * *

The licensee terminated the Unusual Event at 0101 CDT. Decay heat is being removed via aux feed water from the steam generators to the condenser. Visual inspection determined the location of the fire to be in the phase B generator bus duct.

Notified R4DO (Allen), NRR EO (Monninger), IRD (Marshall), DHS SWO, FEMA, and DHS NICC.

* * * UPDATE ON 7/27/13 AT 0430 EDT FROM MARK COVEY TO DONG PARK * * *

The licensee made notifications under 10CFR50.72(b)(2)(iv)(B) [RPS Actuation], 10CFR50.72(b)(2)(xi) [Offsite Notification] and 10CFR50.72(b)(3)(iv)(A) [ESF Actuation - AFW]. The licensee will be making a press release and notifying the NRC Resident Inspector.

Notified R4DO (Allen).

* * * UPDATE ON 7/27/13 AT 0826 EDT FROM MARK COVEY TO BILL HUFFMAN * * *

Upon further review, the licensee believes that the initially reported EAL for the UE notification, HU 2.1, was not applicable. Although indications of a fire were present for greater than 15 minutes, the criteria at Callaway apply to a fire within 50 feet of safety related equipment. There was no safety related equipment within 50 feet of where the fire occurred. The proper EAL classification should have been HU 3.1 due to release of potentially toxic gas or asphyxiant or flammable gas that could impact plant operation. This EAL is applicable due to the heavy smoke release from burning electrical insulation and melted bus and ductwork which prevented access to the turbine building area where the fire took place.

The licensee will notify the NRC Resident Inspector of this update. Notified R4DO (Allen).

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Power Reactor Event Number: 49220
Facility: COOK
Region: 3 State: MI
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DEAN BRUCK
HQ OPS Officer: PETE SNYDER
Notification Date: 07/28/2013
Notification Time: 13:43 [ET]
Event Date: 07/28/2013
Event Time: 10:18 [EDT]
Last Update Date: 07/28/2013
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
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP FOLLOWING SECONDARY PLANT TRANSIENT

"On July 28, 2013, at 1018 EDT, DC Cook Unit 2 Reactor was manually tripped due to lowering steam generator level caused by an automatic trip of the west main feed pump. The west main feed pump tripped on low suction pressure resulting from a secondary plant transient. The cause of the secondary transient is still under investigation.

"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation, as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an (8) hour report.

"The DC Cook Sr. Resident NRC Inspector has been notified.

"The electrical grid is stable and Unit 2 is being supplied by offsite power. All control rods fully inserted. Decay heat is being removed via steam dumps to the main condenser. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the post trip review. No radioactive release is in progress as a result of this event."

There was no affect on Unit 1.

Page Last Reviewed/Updated Monday, July 29, 2013
Monday, July 29, 2013