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Event Notification Report for March 20, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/19/2014 - 03/20/2014

** EVENT NUMBERS **


49892 49896 49897 49899 49900 49928 49929 49932 49933

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Agreement State Event Number: 49892
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ABINGTON MEMORIAL HOSPITAL
Region: 1
City: ABINGTON State: PA
County:
License #: PA-0055
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/11/2014
Notification Time: 09:40 [ET]
Event Date: 03/10/2014
Event Time: [EDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
FSME RESOURCES GROUP (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTIUM-90

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

"Event type: [On March 10, 2014], A medical event involving the administration of yttrium-90 (Y-90) SirSpheres which is reportable under 10CFR35.3045(a)(3). Specifically, the licensee reported that an unintended organ received, as of yet, an undetermined dose during a prescribed treatment.

"Notifications: On March 10, 2014, the Department [PA Department of Environmental Protection] received notification about this medical event.

"Event Description: The patient underwent a Y-90 microsphere treatment. A gastric ulcer developed seemingly as a result of spheres migrating to the stomach.

"Cause of the Event: Non-target flow of microspheres through an aberrant hepatic arterial vasculature supplying the stomach.

"Actions: Details of the event are being developed. Further information will be given when received. The Department plans to do a reactive inspection."

PA Report ID NO: PA-140007

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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Agreement State Event Number: 49896
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: TRONOX LLC
Region: 4
City: HAMILTON State: MS
County:
License #: MS-149-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/11/2014
Notification Time: 13:40 [ET]
Event Date: 12/17/2013
Event Time: [CDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON FIXED INDUSTRIAL GAUGE WAS BROKEN IN THE OPEN POSITION

The following was received from the State of Mississippi via email:

"[The] shutter on Ohmart SH-F2 fixed gauge, (sealed source Ohmart Model A-2102, sealed source serial number 2597CG, source holder model SHF-2-45) was broken in the 'open' position. Source holder shielded, removed from location and transferred to source storage location where repairs could be made by Vega Americas. After repair, gauge returned to safe operation on 3/7/14."

The gauge contains 200 mCi of Cs-137.

Mississippi Report Number: MS-14001

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Agreement State Event Number: 49897
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: TRONOX LLC
Region: 4
City: HAMILTON State: MS
County:
License #: MS-149-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/11/2014
Notification Time: 14:00 [ET]
Event Date: 03/03/2014
Event Time: [CDT]
Last Update Date: 03/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED INDUSTRIAL GAUGE

The following was received from the State of Mississippi via email:

"[The] licensee reported a stuck shutter on an Ohmart Model SH-F2 level gauge, Source Holder Model No. SH-F2-30, during maintenance work to repair the gauge detector. The failure was identified on 3/3/2014 by the licensee while preparing/isolating the gauge for work to be performed on the gauge detector. A Vega Americas service engineer was on site at the time to complete the repair of the shutter mechanism. The shutter failure was identified to be caused from age and oxidation."

The gauge contains 200 mCi of Cs-137.

Mississippi Event Report Number: MS-14002

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Agreement State Event Number: 49899
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PARADIGM CONSULTANTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 04875
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/11/2014
Notification Time: 21:43 [ET]
Event Date: 03/11/2014
Event Time: [CDT]
Last Update Date: 03/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On March 11, 2014, the Agency [Texas Department of State Health Services] was notified of the theft of a Humboldt model 5001EZ moisture density gauge containing an americium-241 source and a cesium-137 source by the licensee. The licensee did not know the activity of the sources. The licensee stated a technician was working at a job site taking measurements every thirty minutes. The technician placed the gauge on the bed of their truck after taking a reading and left it there to talk to the site foreman. When they came back to the truck the gauge was missing. The technician and site foreman looked for the gauge, but did not find it. The technician notified his supervisor who notified the licensee's Radiation Safety Officer. The licensee stated they intend to notify the service providers they use of the theft. The licensee stated the operating rod for the cesium source was locked. Additional information will be provided as it is received in accordance with SA-300."

* * * UPDATE FROM TUCKER TO KLCO ON 3/12/14 AT 0908 EDT VIA EMAIL * * *

"On March 12, 2014 at 0745 [CDT], the Agency was notified by the licensee that the moisture density gauge had been recovered. The licensee had limited information on how the gauge was located and stated they will provide additional information as soon as it can be collected and verified. It did not appear to the licensee that any member of the general public received a significant exposure due to this event. Additional information will be provided to the HOO as it is received in accordance with SA-300."

Notified the R4DO(Farnholtz), FSME Events Resource via email and Mexico.

Texas Incident # I-9166

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: 49900
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: OXEA CHEMICAL CORPORATION
Region: 4
City: BISHOP State: TX
County:
License #: LO6079
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/12/2014
Notification Time: 09:59 [ET]
Event Date: 03/11/2014
Event Time: [CDT]
Last Update Date: 03/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE WITH STUCK OPEN SHUTTER

The following Agreement State Report was received from the State of Texas via telephone and email:

The Texas Department of State Health Services received a report from the licensee concerning a stuck open shutter on a level gauge mounted on a tank. The gauge is in operation with the shutter in the normal open position. The failure to the shutter to close was discovered during routine testing. The licensee will contact the Texas Radiation Program Licensing for authorization to continue using the gauge until repaired. The device does not represent any harm to workers or to the public and a vendor will repair the gauge in 3-4 days.

Follow up information will be provided in accordance with SA 300.

The gauge shutter is normally open during operation. The device is a Thermo Fisher Scientific model 5201 with a 100 mCi Cs-137 source.

TEXAS INCIDENT # I-9165.

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Power Reactor Event Number: 49928
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: BILL BALL
HQ OPS Officer: PETE SNYDER
Notification Date: 03/19/2014
Notification Time: 03:07 [ET]
Event Date: 03/18/2014
Event Time: 22:52 [CDT]
Last Update Date: 03/19/2014
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):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 35 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DUE TO FAILURE TO CONTROL MAIN TURBINE MOISTURE SEPARATOR LEVEL

"At 2252 on 03/18/2014, the Unit 3 reactor automatically scrammed due to a turbine trip from a high Main Turbine moisture separator level. Initial indications show the level controller for 3B2 Moisture Separator failed to adequately maintain level. Additionally local manual control attempts failed to restore moisture separator level. Main Steam Isolation Valves remained open with main turbine bypass valves controlling reactor pressure. Reactor feedwater pumps are in service to control reactor water level.

"Primary Containment Isolation System Groups 2, 3, 6 and 8 containment isolation and initiation signals were received. Upon receipt of these signals all required components actuated as required. Neither High Pressure Coolant Injection nor Reactor Core Isolation Cooling initiation signals were received.

"The reactor had been operating near 35% power during scheduled power ascension.

"This event is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49929
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MARK LINDAHL
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/19/2014
Notification Time: 09:36 [ET]
Event Date: 03/19/2014
Event Time: 07:45 [CDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JULIO LARA (R3DO)

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

Event Text

RADIATION MONITOR TAKEN OUT OF SERVICE FOR PLANNED MAINTENANCE

"On March 19th, 2014, at 0745 hours CST Kewaunee Power Station rendered the Auxiliary Building Service Water Return Monitor (R-20) non-functional for planned maintenance. R-20 is used for Emergency Action Level (EAL) classifications of an unplanned release of liquid radioactivity to the environment that would result in an Alert or Unusual Event and is being conservatively reported under 10CFR50.72(b)(3)(xiii) as a loss of emergency assessment capability.

"R-20 is planned to be restored to functional by 1230 CST today 03-19-2014.

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 49932
Rep Org: UNITED CONTROLS INTERNATIONAL
Licensee: UNITED CONTROLS INTERNATIONAL
Region:
City:  State:
County:
License #:
Agreement: N
Docket:
NRC Notified By: KORINA LOOFT
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/19/2014
Notification Time: 15:36 [ET]
Event Date: 03/18/2014
Event Time: [EST]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BLAKE WELLING (R1DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - THOMAS AND BETTS PRINTED CIRCUIT BOARDS

The following was received via fax:

"This report documents the supply of faulty Logic Power supply assembly printed circuit boards for a Cyberex 20KVA Model AC Power Supply. These power supplies have the incorrect strap installed on the transformers of Cyberex P/N [Part Number] 30-80-56620 which potentially can lead to the transformer being loose and can cause failure of the power supply. Per the manufacturer, the band should have been made of stainless steel but the bands on the installed transformers were made of carbon steel and a corrosion resistant coating. The details of the potential failure of the power supply and the root cause are being evaluated and will be documented in the final report.

"UCI [United Controls International] reviewed all the orders that were supplied to the customers and determined that two UCI orders are affected and the customer was notified on the day the issue was identified."

Part Number 90-41-974313 (UCI serial numbers 03996-01 -0001, -0002, -0003) and P/N 41-01-596701 (UCI serial numbers 03967-03 -0001, -0002, -0003) supplied to Public Service Electric and Gas (PSEG) are affected.

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Power Reactor Event Number: 49933
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: SEAN BLOOM
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/20/2014
Notification Time: 00:29 [ET]
Event Date: 03/19/2014
Event Time: 22:02 [EDT]
Last Update Date: 03/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
SCOTT SHAEFFER (R2DO)

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

Event Text

POTENTIAL LEAK DISCOVERED AROUND PRESSURIZER HEATER BANK

"This report is in accordance with 10 CFR 50.72(b)(3)(ii)(A).

"During an inspection, a small amount of boric acid residue was noted in the vicinity of the Pressurizer heater components. Subsequent examination revealed a small flaw in Pressurizer Backup heater Bank B element 11. This component is part of the primary system boundary. Repair options are being evaluated. Currently, Unit 3 is in Mode 5 in preparation for refueling. The repair will be performed prior to restart."

The NRC Resident Inspector has been informed.

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