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Event Notification Report for November 19, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/18/2013 - 11/19/2013

** EVENT NUMBERS **


49519 49520 49521 49523 49538 49545 49548 49550 49551 49552 49553 49554

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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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT- 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."

* * * RETRACTION ON 11/18/13 AT 1310 EST FROM ANTHONY CARPENITO TO DONG PARK * * *

"11/14/13 information from the receiver confirmed exclusive use shipment was used. With the new information, the Agency [Massachusetts Radiation Control Program] determined this is not a reportable event because 49 CFR 173.443 contamination limits to be applied should be ten times higher than limits applied previously. The receiver's removable contamination survey results no longer exceed limits."

Notified R1DO (Bower) and FSME Events Resource via email.

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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: 49538
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SCOTT FORTIN
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 11/14/2013
Notification Time: 16:03 [ET]
Event Date: 11/14/2013
Event Time: 13:13 [EST]
Last Update Date: 11/18/2013
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):
BINOY DESAI (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO INDICATION OF DROPPED CONTROL RODS

"On November 14, 2013, at 1313 Eastern Standard Time, Unit 1 was manually tripped from 100% power due to indications of [four] dropped control rods. This manual reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The cause of the dropped rods is not confirmed at this time, but may be related to maintenance in a Rod Control Power Cabinet ongoing at the time of the event.

"The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. All control rods fully inserted into the core following the reactor trip and all plant systems operated as designed.

"The Auxiliary Feedwater (AFW) system [1A and 1B motor-driven pumps] was manually started for steam generator level control following reactor trip. The start of the AFW system is reportable per 10 CFR 50.72 (b)(3)(iv)(A) for a valid system actuation.

"Decay heat is being removed via the steam generators [via steam dumps to the main condenser]. This event does not impact public health and safety.

"Unit 2 was not affected by this event.

"The licensee notified the NRC Resident Inspector."


* * * UPDATE FROM WARREN MOORE TO DANIEL MILLS ON 11/18/13 AT 0950 EST * * *

A subsequent licensee evaluation determined that there were ten dropped control rods.

Notified the R1DO (Desai).

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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: 11/19/2013
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.


* * * UPDATE FROM DAVID HOLICK TO DONALD NORWOOD AT 0159 EST ON 11/19/13 * * *

"At 1351 PST on 11/18/13, repairs on CMS-SR-13 were completed returning the monitor to operable status of being able to sample both the drywell and wetwell for hydrogen and oxygen as required for emergency assessment capability.

"The NRC Resident Inspector has been notified."

Notified R4DO (PROULX).

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Power Reactor Event Number: 49548
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: REX REISSNER
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/18/2013
Notification Time: 10:39 [ET]
Event Date: 11/18/2013
Event Time: 05:12 [EST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRED BOWER (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

COMMUNICATIONS LOSS TO NEW YORK STATE WATCH TOWER

"R.E. Ginna Nuclear Power Plant was notified at 0512 [EST] by the New York State (NYS) Watch Center that the Radiological Emergency Communications System (RECS) and commercial telephones were not available. The unavailability of the communications systems was a result of an unplanned computer server outage affecting the NYS Watch Center. While the RECS line remained operational, it was not available due to the relocation of personnel from the NYS Watch Center to an alternate location. An alternate method of communication was established via cell phone at the time of notification.

"This condition is reportable as a major loss of emergency offsite communications capability under 10 CFR 50.72(b)(3)(xiii).

"The NYS Watch Center network and communications systems have been restored and the facility staffed as of 0757 [EST]. The condition has been entered into the station's corrective action program."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 49550
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JAMES REVELLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/18/2013
Notification Time: 12:04 [ET]
Event Date: 11/18/2013
Event Time: 05:12 [EST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRED BOWER (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

COMMUNICATIONS LOSS TO NEW YORK STATE WATCH TOWER

"Nine Mile Point Nuclear Station (NMP1 and NMP2) was notified at 0512 [EST] by New York State (NYS) Watch Center that the Radiological Emergency Communications System (RECS) and commercial telephones were not available. The unavailability of the communications systems was a result of the relocation of personnel from the NYS Watch Center to an alternate location as a result of an unplanned computer server outage affecting the center network and some communications systems. While the RECS line remained operational, it was unavailable due to the relocation. An alternate method of communication was established via cell phone at the time of notification. The cause of the server loss is not known.

"This condition is reportable as a major loss of emergency offsite communications capability under 10CFR50.72(b)(3)(xiii).

"The NYS Watch Center network and communications systems have been restored and the facility staffed as of 0757 [EST]. The condition has been entered into the station's corrective action program."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49551
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVE RICHARDSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/18/2013
Notification Time: 12:08 [ET]
Event Date: 11/18/2013
Event Time: 05:12 [EST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRED BOWER (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

COMMUNICATIONS LOSS TO NEW YORK STATE WATCH TOWER

"James A. FitzPatrick Nuclear Power Plant (JAF) was notified at 0512 EST by the New York State (NYS) Watch Center that the Radiological Emergency Communications System (RECS) and commercial telephones were not available. The unavailability of the communications systems was a result of an unplanned computer server outage affecting the New York State Watch Center. While the RECS line remained operational, it was not available due to the relocation of personnel from the NYS Watch Center to an alternate location. An alternate method of communication was established via cell phone at the time of notification. This condition is reportable as a major loss of emergency offsite communications capability under 10 CFR 50.72(b)(3)(xiii). The NYS Watch Center network and communications systems have been restored and the facility staffed as of 0757 EST. The condition has been entered into the station's corrective action program."

The NRC Resident Inspector has been notified.

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Fuel Cycle Facility Event Number: 49552
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: SEAN PATTERSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/18/2013
Notification Time: 13:51 [ET]
Event Date: 11/17/2013
Event Time: 14:00 [CST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BINOY DESAI (R2DO)
DENNIS DAMON (NMSS)

Event Text

REMOTELY OPERATED ISOLATION VALVE FAILED TO CLOSE

"At approximately 1400 (CDT on 11/17 /2013) the facility suspended operations due to a tornado warning. Located on the first floor of the Feed Materials Building, it was determined that a remotely operated valve closing mechanism at the #2 fill spot failed to close a UF6 cylinder valve. The cylinder valve was then closed manually by operations personnel. There was no damage, no release, or employee exposure due to this event."

"NRC Region II informed: Richard Gibson"

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Power Reactor Event Number: 49553
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: SCOTT WILLIAMSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/18/2013
Notification Time: 15:03 [ET]
Event Date: 11/18/2013
Event Time: 08:00 [EST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BINOY DESAI (R2DO)

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

Event Text

ULTRASONIC EXAMINATION IDENTIFIED FLAW IN REACTOR VESSEL HEAD PENETRATION

"On November 18, 2013, while the Harris Nuclear Plant was shut down for a scheduled refueling outage, the reactor vessel head penetrations were being examined in accordance with lnservice Inspection Program. Ultrasonic examinations identified a flaw in a head penetration nozzle. Bare metal visual inspection of the outer surface of the reactor vessel head revealed no indications of leakage. The unit is in a safe and stable condition and structural integrity of the reactor vessel was maintained. The flaw will be repaired prior to startup from the refueling outage.

"The flaw and repair have no impact to the health or safety of the public.

"The NRC Senior Resident Inspector has been informed."

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Research Reactor Event Number: 49554
Facility: REED COLLEGE
RX Type: 250 KW TRIGA MARK I
Comments:
Region: 4
City: PORTLAND State: OR
County: MULTNOMAH
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: MELINDA KRAHENBUHL
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/18/2013
Notification Time: 16:24 [ET]
Event Date: 11/16/2013
Event Time: 12:11 [PST]
Last Update Date: 11/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
GEOFFREY WERTZ (NPR)
ALEXANDER ADAMS (NPR)
ELIZABETH REED (NPR)

Event Text

CONSOLE KEY LEFT UNATTENDED

"At 12:11 pm on 11/16/2013, the console key was found inserted and unattended in the console. Based on the log book, the key had been unattended since 11:00 am 11/16/2013.

"The relevant Technical Specification is: 6.1.3 (Staffing): the minimum staffing when the reactor is operating shall be: a licensed reactor operator in the control room.

"The control room was locked. There was no unauthorized access while the key was unattended. There was no reactivity manipulation while the key was unattended. We [the licensee] have started a corrective action report.

"[The licensee notified NRC] Project Manager Geoff Wertz."

Page Last Reviewed/Updated Tuesday, November 19, 2013
Tuesday, November 19, 2013