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Event Notification Report for July 30, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/29/2013 - 07/30/2013

** EVENT NUMBERS **


49204 49206 49207 49220 49221 49222

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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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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: 07/29/2013
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.


* * * UPDATE FROM DEAN BRUCK TO DONALD NORWOOD AT 1753 EDT ON 7/29/13 * * *

"Additional information received determined the Turbine Driven Auxiliary Feedwater Pump discharge valve to Steam Generator #2 did not position, as required, following the reactor trip. The affected discharge valve opened as expected during pump start. The valve closed instead of throttling to the intermediate position upon subsequent high flow demand. Feedwater flow to Steam Generator #2 was maintained by the East Motor Driven Auxiliary Feedwater Pump.

"The NRC Resident Inspector has been notified of this update."

Notified R3DO (Orth).

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Power Reactor Event Number: 49221
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: ALYSSA HEYDT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/29/2013
Notification Time: 13:31 [ET]
Event Date: 07/29/2013
Event Time: 10:00 [EDT]
Last Update Date: 07/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GORDON HUNEGS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - CONFIRMED POSITIVE FFD TEST

A non-licensed, supervisory employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been restricted.


The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 49222
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STUART BYRD
HQ OPS Officer: PETE SNYDER
Notification Date: 07/29/2013
Notification Time: 17:19 [ET]
Event Date: 07/29/2013
Event Time: 10:42 [EDT]
Last Update Date: 07/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEORGE HOPPER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FIRE RELATED UNANALYZED CONDITION THAT COULD IMPACT CREDITED SAFE SHUTDOWN ANALYSIS

"This is a non-emergency notification. In preparation for converting from 10 CFR 50. Appendix R, to NFPA (National Fire Protection Association) 805, a review of the Brunswick Steam Electric Plant (BSEP) Safe Shutdown Analysis identified conditions that may not ensure required equipment remains available under certain postulated fire scenarios. The analysis determined that the effects of a postulated fire in specific fire areas could prevent critical systems or components from performing their intended functions, potentially resulting in the inability to achieve and maintain safe shutdown. Alternate safe shutdown procedures currently credited with bringing about operator actions to mitigate a postulated fire have been found not to contain needed actions.

"Affected fire areas are RB1-N, RB1-S, RB2-N, RB2-S, DG-07, and DG-08E. A fire in one of these areas could potentially adversely affect Emergency Diesel Generators (EDGs) 2, 3, and 4 along with EDG Building ventilation system components that could fail vital auxiliaries (HVAC) to the affected switchgear rooms.

"This is reportable as an unanalyzed condition that significantly degrades plant safety in accordance with 10 CFR 50.72(b)(3)(ii)(B). Most required fire watches were already in place as a result of a previous similar event reported in Brunswick ENS Report 47341 and Brunswick LER 1-2011-002. Two additional actions have been taken to establish fire watches in areas containing electrical busses E6 and E7.

"This condition has been entered into the Corrective Action Program (i.e., CR 619341).

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Tuesday, July 30, 2013
Tuesday, July 30, 2013