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Event Notification Report for August 23, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/22/2013 - 08/23/2013

** EVENT NUMBERS **


49282 49283 49284 49290 49292 49294 49295 49296 49298 49299 49300

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Agreement State Event Number: 49282
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: LEGACY MERIDIAN PARK MEDICAL CENTER
Region: 4
City: TUALATIN State: OR
County: WAHINGTON
License #: ORE 90293
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: VINCE KLCO
Notification Date: 08/15/2013
Notification Time: 14:05 [ET]
Event Date: 11/03/2011
Event Time: [PDT]
Last Update Date: 08/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT- DELIVERED PATIENT DOSE DIFFERENT THAN PRESCRIBED

The following information was received by email:

"Based on protocol, a dose of 120 Gy (1.79 GBq) was prescribed. Upon completion of the treatment, survey of the Nalgene waste container measured higher than expected. Ensuing calculations resulted in dose delivered to be 85 Gy (1.24 GBq); greater than 20% variation from prescribed dose. All drapes, towels, etc were surveyed with no evidence of radioactivity present, therefore assuring no contamination present. Contents of the waste container were measured separately to locate the source of residual activity. The readings indicated minimal activity in the Y -90 vial; readings of the patient delivery microcatheter were indicative of residual microspheres. The treatment protocol was followed with no variations of procedure. As is typical, 3 saline flushes were made of the catheter including several vigorous flushes to dislodge any microspheres as recommended by Nordion, the product manufacturer. No high pressure was detected at any point during infusion which would trigger the pressure valve and deliver saline in the overflow vial. There was no build up of particles in the hub of the delivery catheters as inspected throughout the procedure. Measurements over the length of the catheter revealed greatest activity in the proximal portion of the catheter with little-to-no activity in the tip. Nordion has been contacted. In the future, survey of the catheter prior to disconnecting it for disposal may help detect the build-up of particles."

Oregon Incident: 11-0037

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: 49283
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BAYFRONT MEDICAL CENTER
Region: 1
City: ST. PETERSBURG State: FL
County:
License #: 4374-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2013
Notification Time: 14:45 [ET]
Event Date: 08/07/2013
Event Time: [EDT]
Last Update Date: 08/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - VENTILATION PERFUSION LUNG SCAN ADMINISTERED INSTEAD OF CT LUNG SCAN

The following event report was received from the State of Florida via facsimile:

"Received notification of a medical event on 15 Aug 2013 at 10:30 am [EDT] from Bayfront Medical Center, license number 4374-1. Date of procedure was 7 Aug 2013. A patient was prescribed a CT lung scan by the physician. Technologist entered, by mistake, Ventilation Perfusion Lung Scan into the computer (9 mCi's of Xenon-133). Patient's physician was notified, patient was on a ventilator and was not able to communicate. [This incident was] assigned to the Tampa Office for investigation. No further action will be taken on this incident."

Florida Incident Number: FL13-056

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: 49284
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: CARESTREAM HEALTH, INC.
Region: 4
City: WHITE CITY State: OR
County:
License #: ORE-90879
Agreement: Y
Docket:
NRC Notified By: DARYL A. LEON
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2013
Notification Time: 15:46 [ET]
Event Date: 02/06/2013
Event Time: [PDT]
Last Update Date: 08/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

The following information was received by email:

"Oregon Radiation Protection Services was notified by email on 2/20/13 at 11:28 a.m. [PDT], by Curtis Kreil, RSO, a representative of Carestream Health, Inc., of one tritium exit sign discovered missing during a 6-month radioactive material inventory check on 2/6/13. The sign was last inventoried on 8/1/12. A site-wide email alert was issued regarding the missing sign.

"Exit sign details are:
Manufacturer: SRB Technologies
Model: Betalux E
Serial Numbers: 258030
Radioactive material: H-3
Activity: Nominal 20 Ci (on 10/2/02), currently 11.2 Ci (2/20/13)

"Engineers and technicians are currently aware of the location of the [remaining] exit signs and monitor their presence. The licensee added discussion information into their Radiation Safety Training document regarding the exit signs and awareness of their location to assist in timely reporting of any future issues as a corrective action."

Oregon Incident: OR-13-0011

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

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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: 08/22/2013
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).

* * * UPDATE FROM MOT HEDGES TO HOWIE CROUCH AT 1236 EDT ON 8/21/13 * * *

"The cause of the increased background noise for the Reactor Building Stack Radiation Monitor-High Range was due to failing cooling components for the instrumentation, resulting in increased electronic background noise in the instrumentation. There has been no change in the radiation levels at the plant.

"The NRC Resident Inspector has been notified."

Notified R4DO (Werner).

* * * UPDATE FROM MOT HEDGES TO MARK ABRAMOVITZ ON 8/22/2013 AT 1630 EDT * * *

"Repairs have been completed and both the Intermediate and High Range Reactor Building Stack Radiation Monitors have been returned to service. The licensee has notified the NRC Resident Inspector."

Notified the R4DO (Werner).

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Fuel Cycle Facility Event Number: 49292
Facility: WESTINGHOUSE HEMATITE
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 3
City: HEMATITE State: MO
County: JEFFERSON
License #: SNM-33
Agreement: N
Docket: 07000036
NRC Notified By: KEVIN DAVIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2013
Notification Time: 17:56 [ET]
Event Date: 08/20/2013
Event Time: 11:15 [CDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
LAURA KOZAK (R3DO)
ANTHONY HSIA (NMSS)

Event Text

24 HOUR REPORT RELATED TO CRITICALITY CONTROL BULLETIN 91-01

"The Hematite Decommissioning Project (HDP) is excavating burial pits containing enriched uranium. HDP has established criticality safety controls to ensure the safe handling of the buried waste as it is excavated. These controls involve redundant surveys and visual inspections at the time of excavation. These controls failed to identify an item upon excavation that was 400,000 ncpm [net counts per minute] on contact and had dimensions of 6 inches or greater. Instead, the item was identified and placed in criticality safety controls (collared drum) after it had reached the Waste Holding Area.

"The item appeared to be a crushed container, estimated at 10 gal. in original size, and had contents primarily consisting of gloves and plastic. After the contents were removed, the empty container was confirmed to have only contamination that was below the threshold of criticality safety controls. The detailed assay of the contents was 22 g of U-235, which does require criticality safety controls.

"Work in the burial pit areas was stopped pending retraining of those workers on the requirements and criticality safety controls regarding survey and visual inspection during excavation. Excavated burial pit area waste that has not reached the Waste Holding Area will be resurveyed and inspected prior to proceeding to the Waste Holding Area."

The licensee notified NRC R3 (Tapp).

* * * UPDATE FROM KEVIN DAVIS TO PETE SNYDER ON 8/22/13 AT 1054 EDT * * *

"[HDP's] controls failed to identify and control an item upon excavation that was 100,000 ncpm on contact had dimension 6 inches or greater. Instead, the item was identified to require and be placed in criticality safety controls (collared drum) after it had been counted at the Material Assay Area.

"The item appeared to be the mangled remnant of a container. There were no contents, but there was soil-like material adhering to the surfaces. The soil-like material was separated from the remnant for detailed assay. Detailed assay identified the remnant contained 3 g of U-235 and the soil like material contained 21 g of U-235, which requires criticality safety controls.

"Work in the burial pit areas was stopped pending retraining of those workers on the requirements and criticality safety controls regarding survey and visual inspection during excavation, and pending development of additional engineered measures. In addition, shipment of railcars has been suspended pending additional evaluation.

"Excavated burial pit area waste that has not reached the Waste Holding Area will be resurveyed and inspected prior to proceeding to the Waste Holding Area."

The licensee notified the NRC R3. Notified R3DO (Kozak) and NMSS (Hsia).

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Power Reactor Event Number: 49294
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: SCOTT CIESLEWICZ
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/22/2013
Notification Time: 01:11 [ET]
Event Date: 08/21/2013
Event Time: 21:00 [CDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled

Event Text

INADVERTENT SIREN ACTUATION

"On 08/21/2013, the Kewaunee Power Station was notified by Kewaunee County Emergency Management of the inadvertent actuation of siren K-005 at 2100 [CDT]. At the time of the actuation, there was severe weather in the area. The siren stopped actuating at 2125. Kewaunee Power Station requested maintenance crews remove power from the siren to prevent additional actuation until repairs can be made. The resulting loss of siren coverage is 4%. Siren K-005 is a shared siren with Point Beach Nuclear Power Plant. Point Beach control room has been notified."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49295
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: KILE HESS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/22/2013
Notification Time: 01:28 [ET]
Event Date: 08/21/2013
Event Time: 21:00 [CDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3DO)

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

INADVERTENT SIREN ACTUATION

"Point Beach was notified via our EP [emergency plan] manager that emergency plan siren K 5 actuated inadvertently at 2100 [CDT] on 8/21/13, during severe weather. Initial notification of this occurrence was made by Kewaunee County Emergency Management to the Kewaunee Nuclear Plant EP manager. The Kewaunee EP manager in turn notified the Point Beach EP manager. The siren stopped sounding at 2125 on 8/21/13, and was removed from service to prevent additional inadvertent actuations before it is repaired. The loss of coverage for siren K-5, which is the only Point Beach siren out of service at this time, is 1.9%, which is below the 50% loss of coverage requiring additional notifications."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49296
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ROBERT ONEILL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/22/2013
Notification Time: 11:39 [ET]
Event Date: 08/22/2013
Event Time: 07:55 [EDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
WAYNE SCHMIDT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 98 Power Operation 0 Hot Shutdown

Event Text

REACTOR PROTECTION ACTUATION (SCRAM)

"On Thursday, August 22, 2013 at 0755 hours [EDT], with the reactor critical at approximately 98% core thermal power, and the mode switch in RUN, a manual reactor scram was inserted due to lowering reactor water level. The cause of the lowering reactor water level was due to the trip of all three Feedwater Pumps. The cause of the Feedwater Pump trip event is currently under investigation.

"Following the reactor scram, all control rods were verified to be fully inserted. All 4kV busses transferred to the Startup Transformer as designed. Following the scram the reactor water level lowered to +12 inches initiating the Primary Containment Isolation System (Group II, Reactor Building Isolation System (RBIS); and Group VI - Reactor Water Cleanup System) automatically as per design.

"Reactor water level lowered to -46 inches initiating Primary Containment Isolation System Group I - Main Steam Isolation Valves (MSIVs); Emergency Core Cooling Systems (ECCS) actuated which included automatic start and injection of the High Pressure Coolant Injection (HPCI) System and the Reactor Core Isolation Cooling (RCIC) System and an automatic start of the Emergency Diesel Generators as designed. Reactor water level was promptly restored to normal level.

"Currently a cooldown is in progress with reactor pressure is being maintained by the HPCI System operating in the pressure control mode and reactor water level is being maintained by the RCIC System. Reactor Water Clean-up System and normal reactor building ventilation have been restored. Off-site power is being supplied to the station by the Start-up Transformer (normal power supply for shutdown operations).

"This event had no impact on the health and/or safety of the public. The USNRC Senior Resident Inspector has been notified. This 4-hour notification is being made in accordance with 10 CFR 50.72 (b)(2)(iv)(A) and (B)."

The plant is transferring from decay heat removal to the torus to decay heat removal to the main condenser. Reactor pressure is 371 psig.

Initial indications are that a main feedwater power supply breaker tripped.

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Power Reactor Event Number: 49298
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/22/2013
Notification Time: 15:05 [ET]
Event Date: 08/22/2013
Event Time: 10:48 [EDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
LAURA KOZAK (R3DO)

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

VIOLATION OF THE FITNESS FOR DUTY PROGRAM

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

The licensee informed the NRC Resident Inspector and will inform stakeholders at their scheduled meeting.

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Power Reactor Event Number: 49299
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: ADAM MCGUIRE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/22/2013
Notification Time: 16:09 [ET]
Event Date: 08/22/2013
Event Time: 14:50 [EDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WAYNE SCHMIDT (R1DO)

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

Event Text

OFFSITE NOTIFICATION OF A FATALITY AT MILLSTONE UNIT 3

"On August 22, 2013, a contract worker was discovered unresponsive at Millstone Power Station in the plant's condensate polishing facility. The worker was transported offsite to a local hospital. At 1450 [EDT], the Millstone Power Station Unit 3 Shift Manager was informed the individual had been pronounced dead at the hospital.

"The cause of the fatality is under investigation. The injury does not appear to be related to industrial work activities. The person was not contaminated. Local law enforcement and other government agencies have been notified.

"OSHA is being notified of the event under the requirements of 29 CFR 1904.

"No press release is planned. This event is reportable pursuant to 10 CFR50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

The woman was found at the bottom of a staircase at 1258 EDT.

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Power Reactor Event Number: 49300
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT MOG
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/22/2013
Notification Time: 17:08 [ET]
Event Date: 08/22/2013
Event Time: 16:26 [EDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
WAYNE SCHMIDT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 81 Power Operation

Event Text

UNIT 1 COMMENCED A TS REQUIRED SHUTDOWN DUE TO UNIDENTIFIED RCS LEAKAGE > 1 GPM

"Salem Unit 1 has initiated a unit shutdown in accordance with TS (Technical Specification) Action Statement 3.4.6.2(b) for unidentified leakage greater than 1 gpm [gallon per minute] (Entered on 8/22/13 at 1029 EDT). TS 3.4.6.2 Action Statement (b) requires a reduction of leakage rate to within limits within 4 hrs. or be in at least Hot Standby within the following 6 hours. Initial investigation has indicated that the leakage source is from packing on Pressurizer Spray Valve 1PS1 located in the RCS [Reactor Coolant System] Pressurizer shroud area inside Containment. Unidentified leakage is currently indicating 4 gpm. NRC Resident [Inspector] has been notified. Manual isolation is in progress.

"Additionally, TS Action Statement 3.6.1.4 Primary Containment Internal Pressure was entered at 1510 [EDT] for exceeding 0.3 psig. Action requires restoration of containment pressure to within specification in 1 hour or be in hot standby within the next 6 hours. Containment pressure was restored to less than 0.3 psig at 1647 [EDT] and TS 3.6.1.4 was exited. Peak containment pressure reached [was] 0.33 psig.

"Location of leak: Unit 1 RCS (containment), Pressurizer, 1PS1 Pressurizer Spray Valve Packing
"Time & date leak started: 1019 [EDT] on 08/22/2013
"Leak rate: 4 gpm, T/S leak limits: 1 gpm
"Last known coolant activity: Primary (DEI [Dose Equivalent Iodine]-microCuries/cc) 5.973E-5 microCuries/cc
"Secondary (gbg [Gross Beta Gamma]-microcuries/cc) < LLD [Lower Limit of Detectability]
"Was this leak a sudden or long-term development? Sudden"

The licensee is reducing power at 30%/hour and anticipates entering Mode 3 in approximately 3 hours. The 1PS1 Pressurizer Spray Valve was replaced and the air operator rebuilt during the last refueling outage in April/May of 2013.

The licensee informed the State of New Jersey and will 9inform the Lower Alloways Creek [LAC] Township.

Page Last Reviewed/Updated Friday, August 23, 2013
Friday, August 23, 2013