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Event Notification Report for August 20, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/19/2013 - 08/20/2013

** EVENT NUMBERS **


49254 49255 49258 49264 49266 49268 49269 49289 49290

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Agreement State Event Number: 49254
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: FLAKEBOARD AMERICA, LLC
Region: 4
City: MALVERN State: AR
County:
License #: ARK-0664-0312
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/09/2013
Notification Time: 10:26 [ET]
Event Date: 02/09/2011
Event Time: [CDT]
Last Update Date: 08/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - SHUTTER PROBLEM ON A GAMMA GAUGE

The following report was received via e-mail from the State of Arkansas Radiation Control Program:

"During an on-site inspection on August 8, 2013, the licensee stated that a VEGA Americas Corporation model A-2102 gamma gauge shutter was vibrating shut. The source rotor and top plate was replaced on February 9, 2011. The gauge is serial number 6757GK and contains 10 mCi of Cesium-137.

"The licensee indicated the gauge was locked out and unused until it was repaired.

"In accordance with RH-1502.f.2. (10 CFR 30.50(b)(2)) the stuck shutter should have been reported to the State of Arkansas within 24 hours.

"The State of Arkansas is awaiting a written report from the licensee. "

Arkansas Report: ARK-2013-005.

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Agreement State Event Number: 49255
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: GEOTECHNICAL ENVIRONMENTAL TESTING SOLUTIONS, INC
Region: 1
City: VIRGINIA BEACH State: VA
County:
License #: VA-810-333-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/09/2013
Notification Time: 10:40 [ET]
Event Date: 08/08/2013
Event Time: 23:00 [EDT]
Last Update Date: 08/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
FSME EVENT RESOURCES ()

Event Text

AGREEMENT STATE REPORT - FIRE DAMAGES A TROXLER MOISTURE DENSITY GAUGE

The following report was received via fax:

"An employee of GET [Geotechnical Environmental Testing] went home with a Troxler 3430 portable gauge in the bed of his work truck. The employee mishandled charcoal embers after cooking dinner on a grill, which caused the bed of the truck to start on fire. A neighbor noticed the fire and called 911 . When the fire trucks arrived, the employee discovered it was his truck on fire and talked with the VA Beach fire personnel. He stated that a portable gauge containing radioactive material was in the bed of the truck. The VA Beach hazmat team was contacted and arrived on scene. The fire was extinguished and surveys were performed by the hazmat team indicating 1 mR/hr, a normal. reading for a secured gauge. The GET employee began to contact management regarding the situation. The VA Beach GET RSO was on vacation so the North Carolina GET RSO responded and also performed surveys when he arrived. Survey readings indicated the sources were in their shielded position. The RSO was able to package the damaged gauge into another transportation case and return it to the VA Beach office. GET has contacted Troxler and has sent a swab for leak test analysis. The gauge will be returned to Troxler after verification of the sources not leaking. There is no threat to public health or safety from this event. The Virginia RMP [Radiological Materials Program] will be performing an investigation and inspection.

"Media attention: Yes, two local news stations ran a story this morning on the incident."

VA Report ID: VA-13-06

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Fuel Cycle Facility Event Number: 49258
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: KENNY KIRBY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/09/2013
Notification Time: 16:20 [ET]
Event Date: 08/09/2013
Event Time: 13:00 [EDT]
Last Update Date: 08/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
SCOTT SHAEFFER (R2DO)
BRIAN SMITH (NMSS)
FUELS OUO GROUP (EMAI)

Event Text

STORAGE RACKS DETERMINED TO BE IN AN UNANALYZED CONDITION

EVENT DESCRIPTION:

"At B&W's NOG-L [Nuclear Operations Group - Lynchburg] facilities, scrap and waste material is generated during fuel bearing operations. Certain streams are collected in favorable volume less than or equal to 2.5 liter containers and eventually transferred to the Drum Count Area for U-235 assay. Because the U-235 content of such containers is not known until they have been assayed, they are referred to as 'unknowns' and are subject to a bulk weight limit. These containers are limited to a maximum of 7,000 grams net weight (approximately 15 pounds). The unknowns are stored on designated less than or equal to 2.5 liter container storage racks.

"The construction of the storage racks controls the spacing between storage locations and the distance from the floor. The racks' materials of construction are credited as a fixed neutron poison. Some of the unknown racks are fitted with an additional poison plate which allows the rack-to-rack spacing to be reduced.

"On August 9, 2013, at approximately 1:00 p.m., a contract Nuclear Criticality Safety (NCS) engineer working with B&W's NCS staff identified a safety concern. While working to consolidate information in several Safety Analysis Reports, it was determined that the poisoned less than or equal to 2.5 liter storage racks fitted with a horizontal poison plate were improperly analyzed.

EVALUATION OF THE EVENT:

"The NCS evaluation of the poisoned less than or equal to 2.5 liter storage racks fitted with a horizontal poison plate was completed in October of 2000. The analysis was based on an evaluation of a poisoned transport cart completed earlier the same year. However, a review by the B&W NCS staff indicated the conclusions of this earlier analysis were not properly applied to the analysis of the poisoned less than or equal to 2.5 liter storage racks fitted with a horizontal poison plate. The racks were improperly analyzed.

"The requirement of 10 CFR 70.61 (d) states in part: '...the risk of nuclear criticality accidents must be limited by assuring that under normal and credible abnormal conditions, all nuclear processes are subcritical, including use of an approved margin of subcriticality for safety.'

"Further evaluation of the poisoned less than or equal to 2.5 liter storage racks fitted with a horizontal poison plate indicated that under optimal moderation the keff exceeds the safety limit of 0.95 in NRC License SNM-42. Therefore the performance requirement of 10 CFR 70.61 (d) was not maintained.

NOTIFICATION REQUIREMENTS:

"B&W is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1) - 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.'

"There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. A portion of the storage locations in the poisoned less than or equal to 2.5 liter storage racks fitted with a horizontal poison plate were removed from service. This action was taken to restore compliance with the performance requirements of 10 CFR 70.61.

STATUS OF CORRECTIVE ACTIONS:

"An investigation of the root causes of this event is ongoing. Corrective actions will be determined as a result of the investigation."

The licensee has notified the NRC Resident Inspector.

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Agreement State Event Number: 49264
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AMC THEATRES FASHION VALLEY 18
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/11/2013
Notification Time: 23:26 [ET]
Event Date: 07/02/2013
Event Time: [PDT]
Last Update Date: 08/11/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

Event Text

AGREEMENT STATE REPORT - SEVEN STOLEN TRITIUM EXITS SIGNS

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

The California Department of Public Health received the following information from the licensee:

"Please be advised that during a survey of the location seven missing exit signs were discovered in the exit corridors.

"Having been stolen prior to site survey we are unable to provide the specific manufacturer or serial number of the stolen units. A police report was filed (case: 13705804) within the jurisdiction of San Diego with the San Diego Police Department. The state of California has also been notified."

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Agreement State Event Number: 49266
Rep Org: NYC OFFICE OF RADIOLOGICAL HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: Not Provided
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2013
Notification Time: 13:54 [ET]
Event Date: 09/20/2012
Event Time: [EDT]
Last Update Date: 08/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - PATIENT BEING TREATED WITH Y-90 THERASPHERES RECEIVED ONLY 9.5% OF A TOTAL DOSE

The following report was received from New York City via email.

"Summary: Patient being treated with Y-90 Theraspheres received only 9.5% of a total dose of Y-90. The rest remained in the tubing.

"Details of the incident: A patient [at the NYC Mount Sinai Medical Center] was being treated with Y-90 Theraspheres. The target organ was the liver. Due to the need to access the liver via the radial artery in the arm, the angiocatheter was too short to connect to the delivery apparatus directly, thus requiring an extension tubing. The entire contents of the dose vial was emptied and flushed 4 times. It was discovered by the radiochemist [after the patient's treatment] that only 9.5% of the total dose was delivered. The rest remained in the extension tubing. [The prescribed dose was 120 Gy and the delivered dose was 11.4 Gy].

"Corrective action taken by the facility: More time will be taken to reposition the patient proximal to the delivery system. Also, the use of extension tubing will be avoided if possible. Policy and procedures will be updated to include when the use of extension tubing is allowed.

"Causes/Contributing Factors: Inadequate policy and procedures.

"RSO's review summarization: The failure to administer the correct dose to the patient was due to the addition of extension tubing. Because of the additional 40cm of IV tubing, which was used to bridge the distance between the Y-90 delivery system and the radial catheter, the intended dose remained lodged inside the extension. The additional flush used was not enough to push the dose through to the target."

The dose deviation was greater than 50%, and no additional patient testing or extended hospital stay was required. The patient and referring physician have been notified.

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: 49268
Rep Org: NYC OFFICE OF RADIOLOGICAL HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2013
Notification Time: 15:05 [ET]
Event Date: 01/31/2013
Event Time: 12:38 [EDT]
Last Update Date: 08/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - EQUIPMENT FAILURE RESULTED IN NO PRESCRIBED DOSE DELIVERED TO PATIENT

The following report was received from New York City via email.

"Summary: Zero percent of prescribed dose delivered due to patient catheter occlusion.

"Details of the incident: On January 31, 2013 a male patient, 83 years of age, was scheduled to receive Theraspheres treatment in Interventional Radiology.

"The patient has a history of hepatitis C and hepatocellular carcinoma (HCC) with multiple HCC tumors in the liver, progressive in spite of previous chemoembolization and radiofrequency ablation therapy, was referred by oncology for Yttrium-90 microspheres therapy. At the time of a nuclear medicine consultation of December 21, 2012, it was determined that the patient is a candidate for Yttrium-90 (Y90) Therasphere therapy, the preferred radioembolization agent (device) for HCC. A lung shunt fraction of 3.3% (predetermined), and a desired dosimetry of 120 Gray, the Y90 Therasphere activity of 3.83 GBq was ordered for the patient.

"Interventional Radiology Physicians placed a 0.021 inch microcatheter, inside of a Sarah 5 Fr. Radial catheter, via the left radial artery, into the right hepatic artery, into the same position as during the January 11, 2013 diagnostic study. When the catheter was in place, a Y90 Therasphere administration kit was brought into position for dose delivery. The administration kit was prepared by the Authorized User according to standard operating procedure, using a manufacturer's checklist. The delivery line was connected to the angiocatheter in the patient's arm. Just prior to that, the catheter was first flushed with IV contrast to ensure position, followed by flushing with normal saline, and then connected to the Therasphere kit infusion line.

"The infusion was started at 12:18 PM [EST] by Interventional Radiology Physician and the Authorized User, according to standard protocol, with sufficient pressure applied to result in periodic drops of saline dripping into the pressure relief bottle. At the end of the first 20cc bolus of saline, the reading on the radiation meter outside of the container failed to drop to 0.0 as usual. This was an indication that most of the radioactivity was still present in the vial. There were 10 more attempts to infuse the activity. In spite of additional attempts, only some of the Theraspheres moved forward into the catheter. The infusion attempt was terminated at 12:38 PM. At that point, the catheter was disconnected, taking care not to spill any contents inside. Towels were positioned under the catheter opening, a syringe was connected directly to the catheter, and an attempt was made to flush the catheter, but it was not possible, as it was blocked.

"At this point the catheter was withdrawn from the patient, and was placed together with the connecting line, dose vial and infusion kit container into a plastic bag for containment. The Interventional Radiology Physicians and the Authorized User underwent the standard survey procedure for removal contamination, the outer gloves were surveyed. Indicating some activity. The gloves were removed and placed into the administration box. The booties were removed and the principles stepped away after testing negative for contamination. The absorbent lining, which was wet from the infusion saline over-flow and box platform supporting the infusion kit, was also placed into a plastic bag. The floor absorbent mat was rolled up and also placed in a plastic bag, and replaced with a new floor mat to allow patient transfer onto a stretcher. The patient sterile covering was also rolled up and placed in a plastic bag. Both the Nuclear Pharmacist and the Nuclear Medicine Technologist were surveyed and found free of contamination. Once the plastic bags with the infusion materials were removed from the immediate area and the patient taken for imaging in nuclear medicine, the procedure room (Number 1) was surveyed by the Radiation Safety Office staff and was declared free of removable contamination and cleared for routine clinical use.

"The patient underwent a whole body scan in Nuclear Medicine, but was found to have no radioactivity in his body. A survey of all the plastic bags with the materials involved in the procedure, revealed that all the activity was contained in one bag (containing the catheter, administration set and dose vial), independently documenting that the patient received no Y90 activity.

"Corrective action taken by the facility: Facility is working with the manufacturer to determine the cause of the incident. Corrective action will not be developed until the manufacturer determines what was the cause of the failure to deliver the prescribed dose.

"How was it discovered: The physician discovered the event when the reading on the radiation dosimeter outside of the delivery system failed to drop to 0.0 mR/hr as usual.

"Causes/Contributing Factors: Equipment malfunction.

"Equipment used: NORDION TheraSphere Administration Accessory Kit Part #: K125914-001
-RADOS Model: RAD 60R Personal Dosimeter
-Fluke Victoreen Ion Chamber Model: 451B-RYR-SS
-0.021" Microcatheter and a Sarah 5 Fr. Radial Catheter

"RSO's review summarization: The Radiation Safety Office was notified on January 31, 2013 at 12:40 PM that an incident had just occurred in the Interventional Radiology suite which may have resulted in contamination. The RSO staff immediately responded to the location and was informed of the details of the event by the Authorized User. The Authorized User had already collected all of the equipment associated with the Y-90 infusion kit in a large plastic bag which was on a cart. The RSO survey of this cart indicated that the entire dose activity was still within the infusion kit and associated delivery tubing. Thorough survey of the patient, floor, table, hands and feet of staff (who had remained in the room waiting for RSO arrival) did not find any contamination. The whole body scan of the patient confirmed that no radioactive material was injected into the patient. The RSO immediately informed the local regulatory authority by phone followed by a written report of the incident. The Authorized User contacted the manufacturer of the radiopharmaceutical and infusion kit and requested an engineer to come to the medical center to determine the cause of the incident. The referring physician also was informed. On February 6, 2013 an inspector from the local regulatory authority visited the medical center and reviewed the incident. At the conclusion of this meeting the inspector collected all the documentation including the Standard Operating Procedure and training materials to investigate further to see if this incident was a Medical Event since 0% of the prescribed dose had been administered. The inspector also requested that a date be scheduled where they could witness kit preparation as well as an actual patient procedure. The engineer from the manufacturer was in contact with the Authorized User and agreed to come to the medical center to examine the used equipment associated with the Y -90 infusion kit to reveal the cause of the incident."

The patient and referring physician have been notified.

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: 49269
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2013
Notification Time: 17:11 [ET]
Event Date: 08/07/2013
Event Time: [EDT]
Last Update Date: 08/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - PATIENT RECEIVED 20% LOWER THAN I-131 PRESCRIBED DOSE

The following Georgia Agreement State report was received via email.

"Event Description: Patient was scheduled for an I-131 prescribed dose of 100-150mCi for the treatment of Thyroid Carcinoma. The patient instead was administered a dose that deviated 20% lower than the prescribed dose. This incident was reported to the [Georgia] State per Rule 391-3-17.05(115)(a)1.(i):

'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin; and either (i) The total dose delivered differs from the prescribed dose by 20 percent or more.'"

The State will provide the corrective action information when provided by the licensee.

GA State Report ID: CTS 71850

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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Power Reactor Event Number: 49289
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GREG KANDA
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/19/2013
Notification Time: 08:46 [ET]
Event Date: 08/19/2013
Event Time: 09:00 [EDT]
Last Update Date: 08/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN GIESSNER (R3DO)
ERDS GROUP (EMAI)

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

LOSS OF EMERGENCY PREPAREDNESS CAPABILITIES DUE TO UNIT 1 PPC REPLACEMENT

"The Unit 1 DC Cook Nuclear Plant (CNP) Plant Process Computer (PPC) will be removed from service on Monday, August 19, 2013 at 0900 EDT to support planned replacement. The Unit 1 PPC, including the Emergency Response Data System (ERDS), will be unavailable to the NRC Operations Center. Planned replacement also affects the Safety Parameter Display System (SPDS), the Real Time Data Repository (RDR), and PPC data to Emergency Response Facilities at CNP. Safety system annunciators and indications in the control room remain available.

"The scheduled replacement, returning of equipment to service and post maintenance testing is expected to be completed by 2000 EDT on Saturday, September 7, 2013.

"Compensatory measures exist within the DC Cook emergency response procedures to provide plant data via the Emergency Notification System to the NRC Operations Center until the ERDS can be returned to service.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system)."

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Power Reactor Event Number: 49290
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MICHAEL STODICK
HQ OPS Officer: PETE SNYDER
Notification Date: 08/19/2013
Notification Time: 17:23 [ET]
Event Date: 08/19/2013
Event Time: 10:13 [PDT]
Last Update Date: 08/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG WERNER (R4DO)

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

Event Text

INCREASING BACKGROUND NOISE IN STACK RADIATION MONITOR RENDERS IT NON-FUNCTIONAL

"At 1013 hours PDT on August 19, 2013 the Reactor Building Stack Radiation Monitor High Range Detector was declared nonfunctional due to increasing background noise. The Reactor Building Stack Radiation Monitor Intermediate Range Detector remains functional and shows no increase in effluent radioactivity.

"To compensate for the loss of assessment capability due to the nonfunctioning radiation monitoring equipment, an additional Health Physics (HP) Technician trained to acquire offsite dose assessment information on offsite releases will be available. The additional personnel will be pre-staged in support of the Radiation Monitoring System outage and will be mobilized in accordance with guidance in the compensatory measure instructions.

"This event is being reported as a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). A follow-up notification will be made when the equipment has been returned to service.

"The licensee will notify the NRC Resident Inspector."

* * * UPDATE FROM MICHAEL STODICK TO PETE SNYDER AT 2028 EDT ON 8/19/13 * * *

"Initial investigation into the cause of the malfunction of the Reactor Building Stack Radiation Monitor High Range Detector revealed that the condition also affected the Reactor Building Stack Radiation Monitor Intermediate Range Detector. Therefore, this monitor has also been declared non-functional as of 1633 hours PDT on August 19, 2013. Compensatory measures remain in effect to provide emergency response capability for assessing and monitoring actual or potential offsite consequences of a radiological release through this pathway. Corrective actions are being pursued to restore the affected monitors to functional status."

The licensee notified the NRC Resident Inspector. Notified R4DO (Werner).

Page Last Reviewed/Updated Tuesday, August 20, 2013
Tuesday, August 20, 2013