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Event Notification Report for September 25, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/24/2013 - 09/25/2013

** EVENT NUMBERS **


49346 49347 49348 49350 49352 49382

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Agreement State Event Number: 49346
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAYER MATERIALSCIENCE LLC
Region: 4
City: BAYTOWN State: TX
County:
License #: 01577
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2013
Notification Time: 13:49 [ET]
Event Date: 09/16/2013
Event Time: [CDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RONAN FIXED GAUGE WITH STUCK SHUTTER

The State of Texas submitted the following information via email:

"On September 16, 2013, the Agency [Texas Department of State Health Services] received notice that one of the licensee's fixed gauges had a stuck shutter. This [stuck shutter] had been discovered during the morning shutter check that morning. The licensee is in contact with the manufacturer for repair. The gauge is a Ronan SA-1 and contains a Cesium-137 20 mCi source, with serial # M3824. The licensee is compiling a written report and is acquiring authorization to operate while awaiting repairs. Additional information will be provided as it is received in accordance with SA-300."

Texas State Report # I 9115

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Agreement State Event Number: 49347
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MISTRAS GROUP INC.
Region: 4
City: DEER PARK State: TX
County:
License #: LO6369
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: PETE SNYDER
Notification Date: 09/16/2013
Notification Time: 13:58 [ET]
Event Date: 09/12/2013
Event Time: [CDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILS TO RETRACT

"On September 16, 2013, the Agency [Texas Department of Health] received notification from the licensee that on September 12, 2013, one of its radiography crews working at a temporary work site in Tilden, Texas, had been unable to retract an Iridium-192 source back into its SPEC 150 exposure device. After several attempts, the connector on the end of the cable came off which allowed the cable to come all the way through the device and left the source inside the guide tube.

"Source retrieval was performed by authorized person who received 120 millirem, an assistant who received 55 millirem, the radiographer trainer who also assisted received 100 millirem (including the day's work) and the radiographer trainee who received 32 millirem (including the day's work).

"The licensee will have the crank assembly, cable, and connector evaluated. No member of the public received any radiation exposure as a result of this event. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas State Report # I-9113

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Agreement State Event Number: 49348
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MISTRAS GROUP INC.
Region: 4
City: LA PORTE State: TX
County:
License #: LO6369
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: PETE SNYDER
Notification Date: 09/16/2013
Notification Time: 13:58 [ET]
Event Date: 09/13/2013
Event Time: [CDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILS TO RETRACT

"On September 16, 2013, the licensee notified the Agency [Texas Department of Health] that on September 13, 2013, one of its radiography crews had been unable to retract a Iridium-192 source back into a SPEC 150 exposure device at a temporary work site in Tilden, Texas. Following the first exposure of the morning, the source pigtail would not retract fully into the device. An authorized person performed the source retrieval. This individual received 20 millirem and the individual that assisted him received 10 millirem. No member of the public received any exposure as a result of this event.

"The licensee's radiation safety officer inspected the inside of the source guide tube using a tube scope and found that the coil in the source guide tube was pushed out into the inside of the tube where the connector fitting was crimped onto the guide tube. The connector had just been replaced by a local service company. An investigation into this event is ongoing. Information will be provided as it is obtained in accordance with SA-300."

Texas State Report # I-9114

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Non-Agreement State Event Number: 49350
Rep Org: KALISPELL REGIONAL MEDICAL CENTER
Licensee: KALISPELL REGIONAL MEDICAL CENTER
Region: 4
City: KALISPELL State: MT
County:
License #: 25-15463-01
Agreement: N
Docket:
NRC Notified By: ANDREA VANTERPOOL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2013
Notification Time: 16:50 [ET]
Event Date: 09/11/2013
Event Time: 14:00 [MDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

LOST BRACHYTHERAPY MEDICAL SOURCE

The licensee reported that a brachytherapy source/seed was lost after completion of a medical procedure. After the seed was removed from the patient, the device was improperly placed in the rack for sterilization and cleaning and it is believed the seed was lost as part of this cleaning process. Normally, the device would have been placed in a surgical bowl and moved to a flash chamber for seed recovery. The seed was a Best Double Walled I-125 seed with a 204 microcurie source, model #2301.

There was no harm to the patient or exposures to other personnel. The licensee is continuing their investigation and will provide additional information when it becomes available.

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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Agreement State Event Number: 49352
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: CARLSON TESTING, INC.
Region: 4
City: TIGARD State: OR
County:
License #: 90410
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/17/2013
Notification Time: 11:42 [ET]
Event Date: 09/14/2013
Event Time: 01:30 [PDT]
Last Update Date: 09/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE WITH POTENTIAL EXPOSURE FROM AN UNSHIELDED SOURCE ROD

An operator did not maintain direct control of a Troxler Model 3440 Gauge and it was run over by a roller at a work site in Portland, Oregon. This resulted in severe damage to the gauge and the source rod being separated from the device.

The licensee's CRSO (Corporate Radiation Safety Officer) responded to the work site to check for elevated radiation levels and determined that the sources were still intact.

Personnel shielded the rod and transported the gauge and the rod back to the licensee's facility. The damaged gauge has been placed in a locked storage room at the licensee's corporate office with warnings attached to the door to prevent entry. The dose received by the CRSO was 4.36 mrem.

The licensee will provide refresher training and review and revise procedures as necessary. The licensee will ship the gauge back to Troxler Laboratories in the near future.

The gauge is a Troxler Model 3440, Serial # 37190, with 9.0 mCi Cs-137 and 44.0 mCi Am-241/Be sources.

State Event Report # OR 13-0037.

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Power Reactor Event Number: 49382
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MARK MOEBES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/24/2013
Notification Time: 23:21 [ET]
Event Date: 09/24/2013
Event Time: 15:30 [CDT]
Last Update Date: 09/24/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARVIN SYKES (R2DO)

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

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE DUE TO AN UNQUALIFIED ELECTRICAL SPLICE

"On 9/24/13 at 1530 CDT, the Browns Ferry Nuclear Plant Unit 2 High Pressure Coolant Injection (HPCI) System was declared inoperable due to inoperability of the minimum flow valve (2-MVOP-073-0030). Engineering identified during review of EQ [Environment Qualification] WO [Work Order] # 113598388 that the motor leads for 2-MVOP-073-0030 were taped instead of terminated with a Raychem splice. The valve actuator is an EQ component and requires termination of the motor leads to the incoming power cable by Raychem splice or a Marathon 300 terminal block. Engineering evaluation was requested and operability of 2-MVOP-073-0030 could not be supported due to the tape being unanalyzed for harsh environmental conditions. The HPCI Minimum Flow valve has a required OPEN safety function to prevent overheating the HPCI pump and a CLOSED safety function to provide containment isolation. Technical Specification 3.5.1, Emergency Core Cooling System-Operating, Condition C was entered for HPCI system inoperability. In addition, the actions of Technical Specification 3.6.1.3, Primary Containment Isolation Valves, were entered due to the inoperability of the primary containment isolation function of the HPCI Minimum Flow valve.

"This incident is reportable as an 8-hour ENS notification under 10 CFR 50.72 (b)(3)(v)(D) as any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. It also requires a 60 day written report in accordance with 10 CFR 50.73(a)(2)(vii).

"The NRC Resident Inspector has been notified.

"SR number associated with this report: 784462"

The licensee is in a 14-day LCO action statement to return HPCI to operable under TS 3.5.1. The LCO for TS 3.6.1.3 was satisfied.

Page Last Reviewed/Updated Wednesday, September 25, 2013
Wednesday, September 25, 2013