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Event Notification Report for November 18, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/15/2013 - 11/18/2013

** EVENT NUMBERS **


49513 49519 49520 49521 49523 49543 49544 49545 49546 49547

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Agreement State Event Number: 49513
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNKNOWN
Region: 1
City: COATESVILLE State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/07/2013
Notification Time: 14:40 [ET]
Event Date: 10/31/2013
Event Time: [EST]
Last Update Date: 11/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

ORPHAN SEALED SOURCE RECOVERED AT A SCRAP YARD

The following Agreement State Report was received via facsimile:

"Notifications: The Southeast Regional (SER) Office was contacted by Coatesville Scrap on October 31, 2013 regarding a radiation alarm on an outbound trailer load. The event is reportable within 24 hours per 10 CFR 20.2201(a)(1)(i).

"Event Description: On Thursday, October 31, 2013, a radioactive source was detected when a radiation alarm sounded on an outbound trailer load. The alarm was caused by a small metal object. It was located, placed in a lead pipe, crimped and moved to a remote area of the scrapyard behind a large steel piece of equipment. A SER inspector was sent to the site to determine the isotope and activity. It was identified as cesium-137 and a measurement on the surface of the lead pipe was 320 mR/hr. On Wednesday, November 6th the activity was estimated at approximate 10 mCi. It was determined that three members of the public were involved in locating the source, however one had the longest contact with the source; approximately 2.5 hours on and off. It took site staff some time to find the material via shoveling through the solid material and metal of the load. When found, the radioactive source was carried by a shovel approximately 150 to 200 feet away. An individual then carried the source by hand to an adjoining property and placed it in a lead pipe, which was crimped. This took approximately 10 to 15 minutes. A whole body dose documented from the uncalibrated dosimetry that was being worn by this individual was 364 micro-roentgens (microR). SER staff estimate a possible 10 rad dose to this individual's hand. Hands and feet of all parties were surveyed, with no contamination found. Caution tape was used to create a boundary to help notify other employees to stay away from the area. Meter readings at the caution tape boundary were approximately 60 microR/hr.

"CAUSE OF THE EVENT: Loss of control of a Cs-137 sealed source.

"ACTIONS: The DEP [Department of Environmental Protection] plans a full investigation of this event. The scrap yard has hired a consultant health physicist to assist with this event and Cs-137 source. The DEP will recommend that the individual who handled the source have their hands photographed and be examined by a physician."

Event Report ID No: PA130026

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Non-Agreement State Event Number: 49519
Rep Org: E.I. DUPONT
Licensee: E.I. DUPONT
Region: 1
City: WASHINGTON State: WV
County:
License #: 47-01876-01
Agreement: N
Docket:
NRC Notified By: RICHARD BONAR
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/08/2013
Notification Time: 11:52 [ET]
Event Date: 11/05/2013
Event Time: 12:30 [EST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

MISSING NICKEL-63 SOURCE

The licensee called to report a missing 15 milliCurie Nickel-63 source. This source is used in an unknown nuclear device. The licensee believes that the device, which was previously removed from a wall was taken to a scrap metal yard. The licensee has searched the scrap yard and is still searching for the source. The licensee is investigating and will update this report when more information is obtained.

The following was received via email:

"Serial number of 466AN. The plant number for this device is J-128.

"Below is a brief sequence of events:
"06/04/2013 - J-128 was observed mounted in place and a leak test was performed (A035645).

"We [E.I. DuPont] are not sure of the date, but we have evidence that sometime in August maintenance removed the analyzer from the wall to make space for other equipment. There was a clear 'Caution Radioactive Material' label on the front of the unit.

"10/30/2013 - J-128 was verified not in place.
"10/30/2013 - We have pictures of this device. An extensive plant wide search began. This search then intensified to include all metal dumpsters on site, all operating areas, all scrap metal trailers scheduled to go off site, and then off site locations where metal may have been sent. The local scrapyard with acres of storage piles was searched using heavy equipment.
"11/05/2013 - Even with all our efforts to locate the device, we were unable to locate it. On this date our formal investigation began and is ongoing.
"11/08/2013 - Called the NRC to report this incident."

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: 49520
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: TBA MOLECULAR NORTH AMERICA, INC.
Region: 1
City: HAVERHILL State: MA
County:
License #: 41-0618
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/08/2013
Notification Time: 13:43 [ET]
Event Date: 11/02/2013
Event Time: [EST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

RECEIVER SURVEY OF LICENSEE-SHIPPED PACKAGE DETECTED SURFACE CONTAMINATION

The following was received via email:

"On 11/8/13, a licensee shipper informed this Agency [MA Radiation Control Program] that on 11/2/13 the licensee receiver survey of a package containing one patient dose of Fluorine-18 (F-18), indicated removable surface contamination exceeding 49 CFR 173.443 levels. The receiver notified the shipper on 11/2/13. The shipper reviewed the outgoing package survey, as well as routine facility and personnel surveys for 11/2/13, and determined there were no contamination issues. Transports are made via courier vehicles. The shipper retrieved the empty subject package on 11/4/13 during a normal delivery run. F-18 has a half-life of less than two hours. The receiver did use the contained dose for patient administration as intended on 11/2/13. On 11/8/13, this Agency attempted to contact the receiver to confirm specific contamination results obtained by the receiver's package survey. The licensee receiver has not yet responded to this Agency's inquiry so specific results are not yet known at the time of this report.

"The Agency considers this matter to be OPEN pending results of ongoing Agency investigation."

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Power Reactor Event Number: 49521
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TOM GORDON
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/08/2013
Notification Time: 15:25 [ET]
Event Date: 11/08/2013
Event Time: 13:40 [CST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTINE LIPA (R3DO)
SCOTT MORRIS (IRD)
DAVID SKEEN (NRR)

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

OFFSITE NOTIFICATION DUE TO ONSITE DEATH OF AN EMPLOYEE

"At approximately 1104 CST on November 08, 2013, in the Owner Controlled Area, a station employee fell ill from an apparent personal medical condition. The employee was transported off site and passed away. The death was not related to activities impacting or related to the safety of the public or other on site personnel. Specifically, the individual collapsed and was promptly examined by Duane Arnold Energy Center Emergency Medical Technician(s). An ambulance evacuation was then ordered. The death was not work-related nor the result of an accident. The individual was outside of the Radiological Controlled Area and no radioactive material or contamination was involved. Duane Arnold Energy Center has not observed any heightened public or media concern as a result of the death. Since the death is apparently unrelated to Duane Arnold Energy Center industrial or radiological health and safety, no news release is planned.

"The individual's name has not yet been released, pending notification of next-of-kin.

"The Iowa Division of Occupational Safety and Health was notified of the death at 1340 CST.

"The licensee notified the NRC Resident Inspector."

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Agreement State Event Number: 49523
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MOUNT CARMEL HEALTH AT ST. ANN'S CANCER CENTER
Region: 3
City: WESTERVILLE State: OH
County:
License #: 02120250034
Agreement: Y
Docket:
NRC Notified By: CHUCK MCCRACKEN
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/08/2013
Notification Time: 17:30 [ET]
Event Date: 10/25/2013
Event Time: [EST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE TO A PATIENT

The following report was received via e-mail:

"10-25-2013 (Friday)
HDR [High Dose Rate] treatment to right breast with SAVI 9 Channel HDR unit: 1st channel treated appropriately but only fractional treatments to channel 2-8 of less than 50% of prescribed dose were delivered. Problems with the applicator's curvature caused source delivery problems. The manufacturer (Varian) was contacted but was unable to arrive before the next Monday.

"10-28-2013 (Monday)
Licensee made another attempt, but again only fractional treatments to channel 2-8 of less than 50% of prescribed dose was delivered.

"10-29-2013 (Tuesday)
The patient was taken to another Mount Carmel facility (MC West), parameters were recalculated and patient treatment was successfully concluded. The licensee stated they expect that no harm was done to the patient. The licensee stated that they didn't understand that this event was reportable until they were advised by Varian it was an equipment failure so it was a 24 hr. reportable event."

Event ID No: OH130015

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: 49543
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: AMY MCMARTIN
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 11/16/2013
Notification Time: 17:53 [ET]
Event Date: 11/16/2013
Event Time: 10:19 [CST]
Last Update Date: 11/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
KENNETH RIEMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

FAILURE OF SECONDARY CONTAINMENT INTERLOCK MECHANISM

"At 10:19:02 [CST] on November 16, 2013, indication was received in the Control Room that two Secondary Containment doors, in one access opening, were open simultaneously. The interlock mechanism preventing both doors from operating simultaneously did not operate as expected. A worker was staged in the interlock to operate the doors as an interim action while a modification to prevent additional failures was being developed. The worker reported that while opening the reactor building side door the Turbine Building side door opened several inches. Both doors were immediately closed and the interlock was removed from use. Secondary Containment differential pressure remained within Technical Specification required values during the short time both doors were open.

"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2. As a result, entry into Technical Specification 3.6.4.1 Condition A was made momentarily due to Secondary Containment being inoperable. The doors were secured at 10:19:07 [CST] and Secondary Containment was declared Operable. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(C) as a condition that could have prevented the fulfillment of the safety function.

"The NRC Resident Inspector has been notified."

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Fuel Cycle Facility Event Number: 49544
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: WILLIAM WESSEL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/17/2013
Notification Time: 15:30 [ET]
Event Date: 11/17/2013
Event Time: 14:17 [CST]
Last Update Date: 11/17/2013
Emergency Class: ALERT
10 CFR Section:
76.120(a)(4) - EMERGENCY DECLARED
OTHER UNSPEC REQMNT
Person (Organization):
BINOY DESAI (R2DO)
WILLIAM GOTT (IRD)
CATHY HANEY (NMSS)
VICTOR McCREE (RA)
DENNIS DAMON (NMSS)

Event Text

ALERT DUE TO STORM DAMAGE ON SITE

"On 11/17/13, at 1417 CST, an alert was declared at the Paducah Gaseous Diffusion Plant due to an apparent tornado strike/severe weather event. Multiple facilities were damaged with no injuries and no hazardous material released. No damage to the security fence was observed and the protected area remained secured during the event.

"This event is reportable under 10 CFR 76.120(a)(4) where an emergency condition has been declared an Alert.

"NRC Branch Chief has been notified. PGDP has no NRC Resident Inspector.

"PGDP Event Report No. PAD-2013-08."

Notified DHS, FEMA, USDA, HHS, DOE, NICC, EPA, and Nuclear SSA via email.

* * * UPDATE FROM DAVID PETTY TO CHARLES TEAL AT 1746 EST ON 11/17/13 * * *

"On 11 /17/13, at 1638 CST, the Paducah Gaseous Diffusion Plant decided to issue press releases describing the Alert issued by the plant that afternoon. The Alert was declared due to an apparent tornado strike/severe weather event on 11/17/13 at 1417 CST.

"This event is reportable under Criteria P in Appendix D of USEC procedure CP2-RA-RE 1 030 as any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.

"NRC Branch Chief has been notified. PGDP has no resident inspector.

"PGDP Event Report No. PAD-2013-08."

Notified RA (McCree), NMSS EO (Damon), R2DO (Desai), IRD (Gott), NMSS (Haney), DHS, FEMA, USDA, HHS, DOE, NICC, EPA, and Nuclear SSA via email.

* * * UPDATE FROM DAVID PETTY TO CHARLES TEAL AT 1910 EST ON 11/17/13 * * *

The Alert was terminated at 1806 CST on 11/17/13 after a complete security check of the site perimeter and a compilation of the damages sustained by the site. There were no personnel injuries and no releases (HAZMAT or radiological).

Notified RA (McCree), NMSS EO (Damon), R2DO (Desai), IRD (Gott), NMSS (Haney), DHS, FEMA, USDA, HHS, DOE, NICC, EPA, and Nuclear SSA via email.

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Power Reactor Event Number: 49545
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: NICK RULLMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/17/2013
Notification Time: 16:13 [ET]
Event Date: 11/17/2013
Event Time: 09:55 [PST]
Last Update Date: 11/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS FARNHOLTZ (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

LOSS OF DRYWELL SAMPLING CAPABILITY

"This notification is being made due to a loss of emergency assessment capability. At 0955 (PST), on 11/17/2013 it was discovered that the CMS-SR-13 sample valves would not align to allow monitoring the drywell. The redundant sample rack, CMS-SR-14 is already out of service due to an issue with the sample pump, which is currently awaiting replacement parts. The capability to monitor the drywell for H2 and O2 remotely is non-existent if an emergency situation were to arise because of these two issues. The only method currently available to sample the drywall for H2 and O2 is manually via chemistry procedures. This method would be unavailable in accident conditions because the sample point isolation valves isolate on an accident signal (F or A). Even if the sample points were not isolated, the Chemist would be unable to draw a sample safely during an accident due to radiation levels in the Reactor Building and/or H2 and O2 levels in containment. PPM 13.1.1 Table 6 specifies DW/WW (Drywell/Wetwell) hydrogen and oxygen measurements as a method for determining potential loss of Primary Containment. PPM 13.14.11 does not specify an alternative method for the loss of CMS-SR-13 & 14. Based on this information and discussions with Licensing and Emergency Preparedness, the station has determined this issue is a loss of emergency assessment capability per 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 49546
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: THOMAS PHILLIPS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/17/2013
Notification Time: 19:27 [ET]
Event Date: 11/17/2013
Event Time: 12:33 [EST]
Last Update Date: 11/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (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

ALL CONTROL ROOM ANNUNCIATORS IN ALARM

"A station annunciator system malfunction caused all Control Room annunciator indications to be in alarm status. This condition resulted in a loss of normal audible and visual plant condition assessment capabilities and was assessed as being a significant loss of assessment capabilities. Backup assessment capability existed and was dependent upon redundant assets as described in existing station documentation and/or functionality of the Control Room Alarm Typer.

"At 1659 EST full annunciator capability was restored following cleaning of a disconnect switch.

"The NRC Resident Inspector has been notified."

State and local officials will be notified.

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Power Reactor Event Number: 49547
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: JEREMY SHARKEY
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/17/2013
Notification Time: 22:37 [ET]
Event Date: 11/17/2013
Event Time: 17:25 [EST]
Last Update Date: 11/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
J. LILLIENDAHL (R1DO)

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

Event Text

SECONDARY CONTAINMENT INTEGRITY MOMENTARILY DECLARED INOPERABLE

"Station personnel simultaneously opened the inner and outer air lock doors from the reactor building to the reactor control enclosure (Reactor Building 23 foot elevation North West airlock). Reactor Building secondary containment integrity was declared INOPERABLE per TS 3.5.B.2 due to both containment airlock doors being momentarily open at the same time. Reactor Building D/P (differential pressure) remained less than negative 0.25 inches water column.

"Reactor Building secondary containment integrity was declared OPERABLE following verification that at least one airlock door to each access of secondary containment was closed per TS 3.5.B.2. Total LCO time was approximately 10 seconds."

The NRC Resident Inspector has been informed.

Page Last Reviewed/Updated Monday, November 18, 2013
Monday, November 18, 2013