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Event Notification Report for April 11, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/10/2014 - 04/11/2014

** EVENT NUMBERS **


49986 49989 50020 50021 50022 50023 50025 50026

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Agreement State Event Number: 49986
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GREATER BALTIMORE MEDICAL CENTER
Region: 1
City: BALTIMORE State: MD
County:
License #: 005-002-03
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/02/2014
Notification Time: 14:25 [ET]
Event Date: 04/01/2014
Event Time: 09:00 [EDT]
Last Update Date: 04/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - BROKEN I-125 SEED DURING IMPLANTATION

The following information was received from the State of Maryland via email:

"This is a synopsis of an I-125 seed breaking during an implant procedure at GBMC [Greater Baltimore Medical Center]. We [GMBC] will be meeting as a team to discuss corrective action and how to avoid something like this happening again.

"An I-125 implant was performed at GBMC Hospital on Tuesday, April 1, 2014. 78 Bard I-125 seeds, activity 0.319 mCi/seed, were ordered for the procedure, 71 seeds were used, and 70 seeds were confirmed after the procedure on CT evaluation in Radiation Oncology. The unused seeds (7.5 seeds) were returned to Radiation Oncology and recorded as per policy and procedure.

"The chief physicist and dosimetrist were called to Cysto at approximately 0900 EDT when the case was completed to [the attending physician's] satisfaction. Upon entry of the Cysto room [the attending physician] informed the physics staff that a seed had jammed in the Mick applicator and he had to use force to continue and complete the case.

"On arrival, the physics staff surveyed the patient 1 meter above the umbilicus and found 1.7 mR/hr reading using Model 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). The patient was removed from the OR and sent to recovery room.

"Upon additional survey of the room, it was discovered that a seed was fractured, when a portion of the seed was found on the sterile table. At that time, a thorough and complete area survey was performed. The reading was found to be 1.2 mR/hour on the table, trash, and blood drain. [A staff member] was called to bring an additional survey meter (Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13). All contaminated items were collected for proper storage in the hot lab in Radiation Oncology. All staff and personnel involved in the case were thoroughly monitored and cleared using 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). After the removal of the contaminated items the Cysto room was thoroughly monitored and clear of radiation contamination.

"The patient was then brought down to the Radiation Oncology department where a CT scan was performed to ensure seed count. VeriSeed program was used to confirm that the patient was implanted with 70 seeds.

"[The Chief Medical Physicist] contacted Bard to discuss the shattered seed. It was suggested that radiation oncology staff be monitored for thyroid uptake. Bioassay studies were thereby performed and the results were found to match background readings.

"On Wednesday, April 2, 2014, the patient's recovery area was scanned using Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13. A reading of 300 CPM was recorded. The background was also recorded to be 300 CPM. "

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Agreement State Event Number: 49989
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: INTERNATIONAL PAPER COMPANY
Region: 4
City: QUEEN CITY State: TX
County:
License #: 01686
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/02/2014
Notification Time: 17:21 [ET]
Event Date: 04/02/2014
Event Time: [CDT]
Last Update Date: 04/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON TWO NUCLEAR GAUGES

The following information was received from the State of Texas via email:

"On April 2, 2014, the licensee notified the Agency [Texas Department of Health] that earlier that morning, while it was doing lockouts on fixed nuclear gauges in preparation for the annual shutdown of its facility, the handles on two shutters broke. The handles sheared their roll pins. The two gauges are mounted on digesters and are used for level control. The licensee was able to close one of the shutters, but the other shutter remains stuck in the open position. There is no exposure risk to any person. The licensee contacted a service company and arrangements have been made for the company to come on-site and make repairs next week.

"Device #1 Information: Kay Ray, Model 7063, 1.5 curies cesium-137 (original activity in 1972)
"Device #2 Information: Kay Ray, Model 7063P, 1.0 curie cesium-137 (original activity in 1972)

"Further information will be provided per SA-300 as it is obtained."

Texas Incident #: I-9175

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Part 21 Event Number: 50020
Rep Org: ROSEMOUNT NUCLEAR INSTUMENTS, INC
Licensee: ROSEMOUNT NUCLEAR INSTUMENTS, INC
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DUYEN PHAM
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/10/2014
Notification Time: 11:50 [ET]
Event Date: 04/10/2014
Event Time: [CDT]
Last Update Date: 04/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
PATTY PELKE (R3DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - MODEL 1154HP TRANSMITTERS WITH INTEGRAL 1159 REMOTE DIAPHRAGM SEALS MAY EXHIBIT DEGRADED FUNCTIONAL RELIABILITY

"Pursuant to 10 CFR Part 21, section 21.21(b), Rosemount Nuclear Instruments, Inc. (RNII) is writing to inform you that certain Model 1154HP transmitters with integral 1159 Remote Diaphragm Seals may exhibit degraded functional reliability.

"The standard maximum working pressure for Model 1154 transmitters with integral 1159 Remote Diaphragm Seals is 2000 psi.

"Per the unique requirements of Point Beach Nuclear Generating Station, Model 1154HP5RAGN0080 pressure transmitters with integral 1159A50AS0111 Remote Diaphragm Seals were manufactured to operate at a non-standard maximum working pressure of 2750 psi.

"Once installed in the field, two transmitters exhibited unexpected drift in the output signal when operated at line pressures of approximately 2235 psi.

"To date there are no known additional reported functional reliability issues with other Model 115x Series transmitters with integral 1159 Remote Diaphragm Seals in a similar configuration.

"RNII does not have complete information relating to specific plant applications and therefore cannot determine the potential effects of the condition on plant operation.

"This notification affects seven Model 1154HP transmitters with integral 1159 Remote Diaphragm Seals shipped to Point Beach Nuclear Generating Station since March 2013."

Name and address of the individual providing the information:

Mr. Marc D. Bumgarner
Vice President & General Manager
Rosemount Nuclear Instruments, Inc.
8200 Market Boulevard
Chanhassen, MN 55317

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Power Reactor Event Number: 50021
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID HECKMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/10/2014
Notification Time: 13:52 [ET]
Event Date: 11/06/2013
Event Time: 13:07 [MST]
Last Update Date: 04/10/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JAMES DRAKE (R4DO)
SAMSON LEE (NRR)
JEFFERY GRANT (IRD)

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

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION - UNUSUAL EVENT DUE TO EXPLOSION

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"This notification describes a previously undeclared event that is now reported pursuant to the requirements of 10 CFR 50.72(a)(3). No emergency situation exists at this time.

"On November 6, 2013, while operating at 100% reactor power under steady state conditions, a U-1 control room alarm was received indicating low fluid pressure in the Train 'A' hydraulic accumulator of Main Steam system isolation valve MSIV-170. A plant operator was dispatched according to the alarm response procedure to perform a pre-charge check of the accumulator. A pre-charge check returns hydraulic fluid from the accumulator to a vented tank that serves as a fluid reservoir. During this operation the fluid reservoir tank and supporting piping were damaged by the rapid expansion of nitrogen gas that had entered the hydraulic system by way of a leak across an accumulator piston O-ring. As a result of the damage and loss of hydraulic fluid, MSIV-170 and its associated hydraulic accumulators were declared inoperable at 1307 Mountain Standard Time. It was determined at that time that the failure of the fluid reservoir due to rapid expansion did not constitute an explosion and a declaration of an Unusual Event was not made according to Emergency Action Level (EAL) HU2, 'Fire within the Protected Area not extinguished within 15 minutes of detection or explosion within the Protected Area.'

"Subsequent review has determined that the reservoir failure should have been characterized as an explosion within the Protected Area and that a declaration of an Unusual Event should have been made per EAL HU2.

"The NRC Resident Inspector has been notified."

The licensee has notified the State of Arizona and Maricopa County.

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Power Reactor Event Number: 50022
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRADDOCK LEWIS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/10/2014
Notification Time: 14:33 [ET]
Event Date: 04/10/2014
Event Time: 05:55 [EDT]
Last Update Date: 04/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
PATTY PELKE (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

FITNESS FOR DUTY REPORT INVOLVING A LICENSED EMPLOYEE

A licensed employee violated the site Fitness-for-Duty (FFD) policy. The affected individual will be evaluated under for-cause FFD testing. The employee's plant access has been suspended.

The NRC Resident Inspector has been informed.

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Fuel Cycle Facility Event Number: 50023
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: JACK BRITT
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/10/2014
Notification Time: 15:40 [ET]
Event Date: 09/10/2013
Event Time: 15:05 [MDT]
Last Update Date: 04/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
MALCOLM WIDMANN (R2DO)
JAMES RUBENSTONE (NMSS)

Event Text

UF6 PRESENT IN THE SMALL COMPONENT DECONTAMINATION TRAIN

"(1) Radiological or chemical hazards involved, including isotopes, quantities, and chemical and physical form of any material released Uranium-hexafluoride (UF6):

"3.1 grams of solid UF6 was present in the Small Component Decontamination Train (SCT) and was assumed to be enriched to 5 weight percent U235. Thus 0.16 grams of U235 were present. Neither criticality nor chemical release occurred.

"(2) Actual or potential health and safety consequences to the workers, the public, and the environment, including relevant chemical and radiation data for actual personnel exposures to radiation or radioactive materials or hazardous chemicals produced from licensed materials (e.g. level of radiation exposure, concentration of chemicals, and duration of exposure):

"None; the administrative limit to ensure criticality is prevented is 730 grams of U235. The mass present was about two ten-thousandths of the administrative mass limit. This administrative mass limit is less than one half of the analyzed 0.95 keff safe mass.

"(3) The sequence of occurrences leading to the event, including degradation or failure of structures, systems, equipment, components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences:

"The IROFS prevent the accumulation of U235 above the administrative mass limit of 730 grams U235 in the SCT. The IROFS determine a net weight of residual material in a container by comparing the initial, prior to first use, tare weight to the empty weight, after outgassing.

"It was discovered that upon cleaning, the technicians were determining a net weight using the most recent empty weight, not the prior to first use tare weight. This resulted in the potential to nullify the weight of remaining trace quantities of residual material.

"This represents a failure of management measures such that no IROFS, as documented in the ISA summary, remain available and reliable, in an accident sequence evaluated in the ISA, to perform their function. Therefore, this one hour event report being completed in accordance with 10 CFR 70 Appendix A (a)(4).

"(4) Whether the remaining structures, systems, equipment, components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences are available and reliable to perform their function:

"All structures, systems, equipment, components, or activities of personnel remain available and reliable to perform their safety functions.

"(5) External conditions affecting the event;

"There were no external conditions that affected this event.

"(6) Additional actions taken by the licensee in response to the event:

"The area was isolated, operations in the SCDT were halted and a criticality anomalous condition was declared per Operating Requirement Manual. An immediate reconciliation of the IROFS54a and 54b mass record logs was completed and it was determined that the mass present in the SCDT, 0.155 grams U235, was well below the administrative mass limit of 730 grams.

"(7) Status of the event (e.g., whether the event is on-going or was terminated);

"No event occurred; there was insufficient material present for criticality to be possible. No release of licensed material occurred. This event was the discovery of a failed management measures related to an IROFS.

"(8) Current and planned site status, including any declared emergency class;

"Plant is running at full capacity. This event did not warrant any change in plant status. No declared emergency occurred nor are any planned.

"(9) Notifications, related to the event, that were made or are planned to any local, State, or other Federal agencies;

"No notifications other than this report have been made nor are any planned.

"(10) Status of any press releases, related to the event that were made or are planned.

"No press releases have occurred nor are any planned."

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Part 21 Event Number: 50025
Rep Org: CAMERON MEASUREMENT SYSTEMS
Licensee: CAMERON MEASUREMENT SYSTEMS
Region: 4
City: INDUSTRY State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHUCK ROGERS
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/10/2014
Notification Time: 20:21 [ET]
Event Date: 04/10/2014
Event Time: [PDT]
Last Update Date: 04/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RAY POWELL (R1DO)
MALCOLM WIDMANN (R2DO)
PATTY PELKE (R3DO)
JAMES DRAKE (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - BARTON MODEL 288A AND 289A DIFFERENTIAL PRESSURE SWITCH DEFECT

Cameron Measurement Systems is reporting a defect affecting versions of the Barton Model 288A and 289A differential pressure indicating switches and spare switch assemblies for these products. The defect being reported is an out of specification concentricity issue with the roller that actuates the switches. This represents a switch setpoint repeatability concern.

Any additional safety significant issues that might be identified in our ongoing investigation will be addressed in subsequent advisories that will be published. If you have any questions please contact Chuck Rogers, Director of Quality and Safety, at (281) 582-9507 or Jim Greer, Engineering Manager, at (800) 291-3550.

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Power Reactor Event Number: 50026
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KIRK DUEA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/10/2014
Notification Time: 22:40 [ET]
Event Date: 04/10/2014
Event Time: 21:00 [CDT]
Last Update Date: 04/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 88 Power Operation 88 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO A DEAD DUCK FOUND ON SITE

"Monticello Nuclear Generating Plant personnel discovered the remains of what appeared to be a deceased duck on plant property. The cause of death was not immediately apparent, no work was ongoing within the vicinity at the time. Notifications to the Minnesota Department of Natural Resources and the Division of Fish and Wildlife will be made for this discovery. This event is reported per 10CFR50.72(b)(2)(xi).

"The licensee has notified the NRC Senior Resident Inspector."

Plant personnel could not determine if the duck was an endangered species.

Page Last Reviewed/Updated Friday, April 11, 2014
Friday, April 11, 2014