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Event Notification Report for February 27, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/26/2014 - 02/27/2014

** EVENT NUMBERS **


49836 49839 49843 49856 49857 49859

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Agreement State Event Number: 49836
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: INTEGRATED MEDICAL PROFESSIONALS LLC
Region: 1
City: LAKE SUCCESS State: NY
County:
License #: NYS 5335
Agreement: Y
Docket:
NRC Notified By:
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/18/2014
Notification Time: 10:28 [ET]
Event Date: 02/14/2014
Event Time: 15:30 [EST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENT RESOURCE (EMAI)
JIM WHITNEY (ILTA)
CANADA (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST CESIUM-131 SEEDS

The following was received from the State of New York via email:

"NYS DOH BERP [New York State Department of Health Bureau of Environmental Radiation Protection] received a call from Chief Physicist for Integrated Medical Professionals, PLLC. NYS RAM License No. 5335, Lake Success, NY.

"A shipment of fifty-seven (57) Cs-131 seeds was sent to ISORAY MEDICAL, in Washington State (license WN-L0213-1). The shipment was received 2/14/14 and the receipt survey showed high radiation readings. The package was isolated and opened to reveal that the shipping pig was open inside of the outer package. Forty-four (44) seeds were found in the box. The shipment of seeds contained three activities, 1.28 millicurie, 1.1 millicurie, and 2.1 millicurie. It is not currently known which batch the missing seeds were from. The common carrier has been notified. Washington State DOH [Department of Health] has been notified. The root cause investigation is ongoing. A press release has not been issued. A reward has not been offered"

Event Report ID: NY-14-01

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: 49839
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: DBI, INC.
Region: 4
City: OVERLAND PARK State: KS
County:
License #: 21-B805
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/18/2014
Notification Time: 11:00 [ET]
Event Date: 02/17/2014
Event Time: [CST]
Last Update Date: 02/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POSSIBLE DISCONNECT OF INDUSTRIAL RADIOGRAPHY EQUIPMENT SOURCE

The following information was provided by the State of Kansas via email:

Industrial radiography equipment failed to function as designed which resulted in a possible source disconnect. The radiography equipment was located at a work site in Winfield, Kansas. The radiography equipment contained a 56 Curie Ir-192 source. The State of Kansas will update the event as more information becomes available.

Kansas Item Number: KS140003

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Agreement State Event Number: 49843
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNKNOWN
Region: 4
City: BAUXITE State: AR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2014
Notification Time: 17:41 [ET]
Event Date: 02/07/2014
Event Time: [CST]
Last Update Date: 02/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON ALLEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNKNOWN RADIOACTIVE MATERIAL DISCOVERED IN GARBAGE TRUCK AT LANDFILL

The following is a summary of information provided via email from the State of Arkansas:

On February 7, 2014, the Environmental Manager of Republic Services, Inc. contacted the Arkansas Department of Health (ADH) to inform the State that a gate radiation monitor at a landfill near Bauxite, AR had alarmed for an incoming garbage truck. ADH sent three health physicists to inspect the truck. Initial surveys indicated the highest reading on contact on the bottom of the truck of 3.7 mR/hr. ADH was unable to identify the specific isotope. The truck was isolated and ADH returned on February 10, 2014 to survey and evaluate the material on the truck. ADH observed removal of the trash from the truck and identified a vacuum cleaner bag inside a bag of trash that contained the radioactive material. The vacuum cleaner bag was removed and placed in a five gallon plastic bucket which was posted and securely stored in a storage room at the landfill. The survey readings on the side of the bucket were 20 mR/hr.

ADH returned on February 12, 2014 to survey the vacuum cleaner bag and evaluate for radioactive decay. The plastic bucket continued to read 20 mR/hr on contact. Further radiation surveys showed highest reading on contact with the plastic bucket were 42 mR/hr and 200 mR/hr localized near the bottom of the vacuum cleaner bag. ADH notified Republic Services, Inc. of the necessity to hire a consultant for identification and disposal of the radioactive material. ADH plans to be present when the consultant is onsite.

Arkansas Report Number: AR-2014-002

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Part 21 Event Number: 49856
Rep Org: NUCLEAR LOGISTICS, INC.
Licensee: NUCLEAR LOGISTICS, INC.
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/26/2014
Notification Time: 17:19 [ET]
Event Date: 01/28/2014
Event Time: [CST]
Last Update Date: 02/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BOB HAGAR (R4DO)
DANIEL RICH (R2DO)
ANNE DeFRANCISCO (R1DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT INVOLVING A POTENTIAL MANUFACTURING DEFECT IN REPLACEMENT MASTERPACT CRADLES

The following information was received via facsimile:

"Part 21 Report No: P21-01312014

"Subject: Report of potential defect per 10CFR Part 21 primary disconnect assembly

"Pursuant to 10CFR 21.21(d)(3)(ii), AZZ/NLI is providing written notification of the identification of a defect. This letter is to notify you of a potential manufacturing defect concerning primary disconnect assemblies used on Masterpact replacement cradles. These assemblies are used in the replacement of the circuit breakers in low voltage switchgear.

"The following information is required per 10CFR 21.21(d)(4),

"(i) Name and address of the individual or individuals informing the Commission.

Aron Seiken, Vice President
Nuclear Logistics, Inc.
7410 Pebble Drive
Ft. Worth, TX 76118

"(ii) Identification of the facility, activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect.

Facility:

Nuclear Logistics, Inc.
7410 Pebble Drive
Ft. Worth, TX 76118

"The specific part which fails to comply or contains a defect:

"Primary disconnect (p/n AHX30701) for Square D replacement low voltage switchgear breaker cradles (model LGSB4).

"(iii) Identification of the firm constructing or supplying the basic component which fails to comply or contains a defect.

"The primary disconnect was manufactured by Square D Services (Schneider Electric) and supplied as a dedicated component by Nuclear Logistics, Inc.

"(iv) Nature of defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.

"The cradle is an adaptor between the replacement circuit breaker and the existing switchgear cubicle. Part of the interfaces is the primary disconnects (fingers). The cradle primary disconnects connect to the bus stabs in the switchgear. The cradle primary disconnects are designed to account for vertical misalignment of the stabs in the switchgear. The primary disconnect fingers have vertical flexibility (float) that maintains the finger pressure on the bus stabs when the bus stabs are not completely aligned in the vertical axis.

"The fabrication drawing for the primary disconnect fingers had an incorrect tolerance. If the fingers are made with a dimension at the low end of the specified tolerance, there will be interference with a mating part. This reduces or eliminates the vertical float for the fingers. If the cradle is installed in a switchgear cubicle with vertically misaligned bus stabs, the disconnect fingers may have inadequate contact pressure. This condition may result in a higher than normal contact resistance from the cubicle stab to the cradle primary disconnect. The higher contact resistance at any one finger contact could cause an unacceptable temperature rise at that connection point. At very high temperatures, the springs that maintain the finger contact pressure could relax, which would further increase the connection resistance and cause additional overheating.

"This would not be an issue if there was no vertical misalignment of the switchgear cubicle stabs. See the additional clarifications in section (vi) below.

"(v) The date on which the information of such defect or failure to comply was obtained.

"The information that there is a defect was obtained on January 28, 2014.

"(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for being supplied for, or may be supplied for, manufactured or being manufactured for one or more facilities or activities subject to the regulations in this part.

"The issue is applicable to 1600amp cradles only. The same and similar disconnects are used in the different cradle designs identified below. A list of the cradle types, primary disconnect part numbers and affected facilities (plants) in Table 1 as follows:

"TABLE 1

Plant Name / Cradle-Breaker Type / Primary disconnect part number / Quantity / Original breaker type-Notes

OPPD-Ft. Calhoun/LGSB4 with Masterpact NW breaker/AHX30701/18/Original breakers: GE AK-50. OPPD replaced all AHX30701 with narrower disconnect p/n R300112

TVA-Browns Ferry/LGSB4 and LGSB21 with Masterpact NW breaker/AHX30701/28/Original breakers: GE AK-50.

Entergy-River Bend/LGSB9 Masterpact NW breaker/R300112/5/ Original breakers: AKR-50. Narrower disconnect.

FENOC-Beaver Valley/LGSB4 Masterpact NW breaker/AHX30701/20/Original breakers: GE AK-50

FPL-St. Lucie/LISB2 Masterpact NW breaker/AJF30101/15/Original breakers: ABB K-1600

FPL-Turkey Point/LISB2 Masterpact NW breaker/AJF30101/12/Original breakers: ABB K-1600

SCE-SONGS/LISB2 Masterpact NW breaker/AJF30101/8/Original breakers: ABB K-1600

Nextera Energy-Seabrook/LISB2 Masterpact NW breaker/AJF30101/4/Original breakers: ABB
K-1600

"Additional details:

"- This issue does not affect all of the cradles identified above. Since the issue is a result of incorrect manufacturing tolerances, it will not be present on all cradles.

"- The overheating issue could be a problem with replacement circuit breakers for GE AK-50 circuit breakers. Due to the construction of the switchgear cubicles, there can be vertical misalignment of the stabs in the switchgear. If the primary disconnect float is not adequate, the overheating issue identified above could occur.

"- The overheating issue is expected to be much less prevalent or non-existent on the replacements for GE AKR and ABB K-line circuit breakers. The construction of the switchgear cubicles results in good vertical alignment of the stabs in the switchgear, so the amount of cradle finger vertical float is not as critical.

"(vii) The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.

"NLI has generated Technical Bulletin TB-14-001 to direct the plants for inspections to determine if the manufacturing defect is present in the specific applications. The Technical Bulletin will be issued to the potentially impacted plants by March 4, 2014.

"NLl is in process of revising test plans to include verification of the proper operation of the primary disconnects during factory acceptance testing. The verification will be performed on 100% of supplied cradles.

"Square D Services is revising manufacturing drawings to eliminate any tolerance stack up issue that could limit the vertical movement of the finger contacts of the primary disconnect assemblies.

"(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"NLI Will submit NLI Technical Bulletin TB-14-001 to all facilities where the potentially impacted Masterpact breakers have been installed. The technical bulletin provides a summary of the issue and provides instructions for inspection and testing of the cradles. Please contact me with any questions or comments."

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Power Reactor Event Number: 49857
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID HURT
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/26/2014
Notification Time: 18:18 [ET]
Event Date: 02/26/2014
Event Time: 07:30 [CST]
Last Update Date: 02/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BOB HAGAR (R4DO)

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

24 HOUR FITNESS-FOR-DUTY REPORT INVOLVING FALSE NEGATIVE ERRORS DURING QUALITY ASSURANCE TESTING

"Contrary to the requirements in 10 CFR 26.137(b), a DHHS [Department of Health and Human Services] certified laboratory returned results for a blind specimen that were inconsistent with what was expected. On 02/25/2014, dilute blind specimens from the same lot # were sent to the three contracted DHHS laboratories. Upon review by the Callaway MRO [Medical Review Officer] at approximately 07:30 [CST] on 2/26/2014, it was discovered that one of the laboratories (Toxicology) reported results of negative. That result was inconsistent with the certification received from the blind provider (ProTox) certifying the specimen as negative and dilute. Later in the day on 2/26/14, the remaining two labs (Quest and CRL) also returned results of negative instead of negative and dilute.

"10 CFR 26.719(c)(3), reporting requirements requires that 'If a false negative error occurs on a quality assurance check of validity screening tests, as required in  26.137(b), the licensee or other entity shall notify the NRC within 24 hours after discovery of the error.'

"While it initially appears that the blind specimen certification provided by ProTox may be in error, since all three DHHS labs obtained the same testing result, additional investigation is necessary. This report is being made conservatively until the cause can be determined."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 49859
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL CRAWFORD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2014
Notification Time: 03:37 [ET]
Event Date: 02/27/2014
Event Time: 03:30 [EST]
Last Update Date: 02/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)

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 CORE SPRAY (HPCS) SYSTEM DECLARED INOPERABLE

"On February 24th at 0400 [EST], the Division 3 diesel (HPCS diesel) was declared inoperable for planned maintenance. Technical Specification (TS) 3.8.1 condition B was entered with a required action to restore the diesel to operable status within 72 hours. Shortly after starting the diesel for post maintenance testing, operations observed erratic voltage regulator operation. The diesel was secured at 1621 on 2/24/14 before completing the required post maintenance operability test and troubleshooting is ongoing.

"At 0330 on 2/27/14, the High Pressure Core Spray System (HPCS) was declared inoperable and TS 3.5.1 condition B was entered. With the HPCS system declared inoperable, TS 3.8.1 condition B was exited in accordance with the following note modifying TS 3.8.1: 'Division 3 AC electrical power sources are not required to be OPERABLE when High Pressure Core Spray (HPCS) System is inoperable.'

"The HPCS system is a single train system that is discussed in Chapters 6 and 15 of the Final Safety Analysis Report. The unplanned inoperability of the HPCS system is reportable in accordance with 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: (D) Mitigate the consequences of an accident.'

"The condition has been entered into the NMP corrective action program as CR-2014-001623.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014