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Event Notification Report for April 17, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/16/2014 - 04/17/2014

** EVENT NUMBERS **


49875 50008 50011 50014 50016 50018 50019 50039

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 49875
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: CESAR GARCIA
HQ OPS Officer: VINCE KLCO
Notification Date: 03/05/2014
Notification Time: 14:10 [ET]
Event Date: 03/05/2014
Event Time: 09:12 [CST]
Last Update Date: 04/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JAMES DRAKE (R4DO)

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

Event Text

POTENTIAL IMPACT ON UNFUSED DIRECT CURRENT AMMETER CIRCUITS IN THE MAIN CONTROL ROOM

"A review of industry operating experience regarding the impact of unfused Direct Current (DC) ammeter circuits in the control room has determined that a similar condition is applicable to the Waterford 3 Nuclear Station resulting in a potentially unanalyzed condition with respect to 10 CFR 50 Appendix R requirements. The original plant wiring design and associated analysis for an ammeter measuring current from the train AB Class 1E battery to its associated power distribution panel does not include overcurrent protection features to limit the fault current and is routed through multiple fire areas. The ammeter is located on the train AB power distribution panel in the train AB switchgear room.

"In the postulated event, a fire could cause one of the ammeter wires to short to ground. Simultaneously, it is postulated that the fire could cause another DC wire from the opposite polarity on the same battery to also short to ground. This could cause a ground loop through the unprotected ammeter wiring. This event could result in excessive current flow (i.e., heating) in the ammeter wiring to the point of causing a secondary fire in the raceway system. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10 CFR 50 Appendix R.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). There is no effect on plant operation. Fire watches have been implemented for affected areas of the plant as an interim compensatory measure."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 4/16/14 AT 1814 EDT FROM MARK CARTER TO DANIEL MILLS * * *

"Subsequent engineering evaluation has determined that the circuit for an ammeter measuring current from its Class 1E battery to its associated power distribution panel is not routed through multiple fire areas. Therefore, the IER 13-54 related condition is not, and was not, an unanalyzed condition at Waterford 3 that significantly degraded plant safety, and thus not required to be reported under 10 CFR 50.72(b)(3)(ii)(B)."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Gaddy).

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Agreement State Event Number: 50008
Rep Org: LOUISIANA DEPT OF ENVIRONMENTAL QUA
Licensee: BOARDWALK LA MIDSTREAM, LLC
Region: 4
City: PLAQUEMINE State: LA
County: IBERVILLE
License #: GL-238
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/08/2014
Notification Time: 11:27 [ET]
Event Date: 02/06/2014
Event Time: [CDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - CONTROL OF RADIOACTIVE MATERIAL

The following was received from the State of Louisiana via fax:

"A general licensed device gauge, containing [decay] corrected 30.47 mCi of Cs-137, serial number B-0187 was improperly disposed of. A recycling company had with a torch burned into the gauge and had come within one (1) mm of the source capsule. The Department of Energy had exercised eminent domain and taken over the oil well next to a strategic reserve for their use during November 2011 from Boardwalk LA Midstream, LLC. The gauge was not leaking and the source capsule was still intact. QSA Global has accepted the gauge for disposal. The Department [Louisiana Department of Environmental Quality] considers this matter closed."

Louisiana report # LA-140004

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Agreement State Event Number: 50011
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MIAMI NEUROSCIENCE CENTER - LARKIN COMMUNITY HOSPITAL
Region: 1
City: SOUTH MIAMI State: FL
County:
License #: 2825-2
Agreement: Y
Docket:
NRC Notified By: RICH A. DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/08/2014
Notification Time: 17:13 [ET]
Event Date: 04/08/2014
Event Time: 08:12 [EDT]
Last Update Date: 04/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT INVOLVING PALLIATIVE DOSE ADMINISTERED TO THE WRONG TREATMENT SITE

The following report was received from the State of Florida via email:

"This treatment was set up by the treatment planner taking into account the previous two treatments performed on the right side back in 2008 and 2007. The treatment planner did not realize that the pain had resolved on the right side and that the treatment was to be performed on the left side. The treatment was reviewed and signed according to protocol and was started by [the Authorized User] at 8:12 am. The 19.14 minute treatment was stopped at 1.72 minutes when it was realized that the patient was to be treated on the left side. At 8:42 am [the Authorized User] had [the Neurosurgeon] inform the patient that we interrupted the treatment because we had started treating the right side instead of the left side. The treatment planner created a treatment plan for the left side, the patient was treated and the stereotactic frame was removed at 10:00 am. This Medical Event will have no detrimental effects on the patient. No further action will be taken on."

Florida Incident Number: FL14-035

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: 50014
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ACUREN INSPECTION, INC.
Region: 3
City: DAYTON State: OH
County:
License #: 03320 99 0006
Agreement: Y
Docket:
NRC Notified By: KARL VONAHN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/09/2014
Notification Time: 14:28 [ET]
Event Date: 04/09/2014
Event Time: 11:30 [EDT]
Last Update Date: 04/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
ANGELA MCINTOSH (FSME)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following information was received from the Ohio Bureau of Radiation Protection via email:

"The corporate RSO for Acuren Inspection made an immediate telephone notification under OAC [Ohio Administrative Code] 3701:1-38-21(B)(1) [same as 10 CFR 20.2202(a)(1)] to the Ohio Department of Health Bureau of Radiation Protection at 1320 [EDT on] April 9, 2014, to report a radiographer overexposure at a temporary job site in Marietta, OH. The event happened about 1100-1130 [EDT] this morning. The initial estimates regarding the male radiographer is that he may have received a 15 Rem whole body exposure and an estimated 3000-5000 Rem to the hand. The radiographer's whole body dosimeter is being sent off for immediate processing.

"The radiographer has been sent for medical attention. REAC/TS [Radiation Emergency Assistance Center/Training Site] was contacted by the licensee who gave REAC/TS the contact information for the attending physician of the radiographer.

"The radiographer was working with an 88 Ci Ir-192 source at the time. The radiographer supposedly had all his dosimetry and a survey meter at the time of the incident.

"The corporate RSO and a local [RSO] are both enroute to the temporary job site.

"Sequence of events:
The radiographer had sat down and was chatting while waiting for an exposure to complete. At the end of the shot time, he had assumed that the other radiographer had retracted the source and proceeded to set up for the next shot. When he noticed that the other radiographer was not present he went back and checked to find that the source had not been cranked back.

"The [State of Ohio] Department will have an inspector on scene in the morning to investigate the incident and also to observe and review the incident reenactments.

"Ohio event report number 2014-007."

* * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/10/14 AT 1530 EDT * * *

"On April 10, 2014, the [State of Ohio] Department performed an onsite inspection and observed the licensee perform a reenactment of the incident scenario.

"It was determined that the radiographer did not handle the end of the source tube with the source in it and did not receive the initially assumed hand dose. The whole body deep dose is still expected to be about 15 Rem. The hand dose is expected to be on the order of the whole body dose, about 15 Rem.

"During the reactive inspection, the [State of Ohio] Department found that the radiographer's alarming rate meter had a dead battery, and the survey meter was not functional and had not been checked that day.

"The Assistant Radiographer was trailing the radiographer approximately one and a half minutes in entering the shielded bunker, and it was the assistant radiographer's alarming rate meter and survey instrument that identified the presence of the exposed source. The source collimator was not being used in the bunker, and so the 89 Ci Ir-192 source was not shielded."

Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.

* * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/11/14 AT 1234 EDT * * *

"The Acuren Inspection Services RSO has provided the Department [State of Ohio] with the following updates:

"(1) The radiographer's whole body dosimeter reading was 836 mRem.

"(2) Based on the dose estimates from the scene reenactments, Acuren will assign the radiographer a whole body dose of 13 Rem, and an extremity dose of 6.5 Rem. [The radiographer's chest was much closer to the source than his dosimeter was.]

"(3) The radiographer will be under continued medical surveillance and REAC/TS will remain involved."

Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.

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Agreement State Event Number: 50016
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOUTHERN SCRAP
Region: 4
City: SCOTT State: LA
County:
License #: LA-015AN01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/09/2014
Notification Time: 16:20 [ET]
Event Date: 04/13/2013
Event Time: [CDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DETECTED IN A LOAD OF SCRAP METAL

The following report was received from the Louisiana Department of Environmental Quality via fax:

"Event date and time: The source was detected in a load of scrap metal on April 13, 2013.

"Event location: Source was detected in a load of scrap metal, being loaded for transport to a smelting mill, at the Southern Scrap facility, [in Scott, LA.].

"Event type: The radioactive source was a rod source, later determined to be 3.29 mCi of Cs-137. The source was retrieved and stored [in a] shielded [location] until Southern Scrap's licensed consultant, ARS [American Radiation Services], was able to package and transport the unknown source to their facility in Port Allen, LA.

"Notifications: LDEQ [Louisiana Department of Environmental Quality] was notified by phone on April 18, 2013 at 1620 [CDT] of the discovery.

"Event description: On April 13, 2013, an unknown source of radiation was discovered in a load of scrap being sent to NUCOR Steel in TX. The source was detected before the load of scrap left the Southern Scrap yard. American Radiation Services (ARS), a licensed radiation safety contractor, was called to prepare [the source] for safe shipping, determine the isotope and activity, and do an appropriate disposal of the unknown source.

"ARS made the determinations and found the rod source to be 3.29 mCi of Cs-137. [ARS then] packaged [the source] for transportation and disposal. ARS contacted ADCO Services, in Illinois, for the disposal. (During an earlier attempt for a licensee to utilize ADCO Services, [LDEQ] learned that ADCO did not have a current Illinois license to provide services.) ARS was notified the ADCO Services was not licensed to provide services and that ARS would have to contact and contract with another licensee for these services.

"ARS contacted QSA Global in Baton Rouge, LA, and arranged for their receipt and disposal of the orphaned source. The origin and owner of the source could not be determined and Southern Scrap absorbed the cost of the safety services and disposal. QSA Global took possession of the source June 7, 2013. The initial notification was made to the NRC in April 2013; however, documentation of this call to the [NRC] OP Center could not be located. The supporting documents are attached to the fax.

Transport vehicle description: ARS Company Vehicles.

"Media attention: N/A"

Louisiana Event: #LA-140005

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Agreement State Event Number: 50018
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HI-TECH TESTING
Region: 4
City: LONGVIEW State: TX
County:
License #: L05021
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 16:46 [ET]
Event Date: 04/09/2014
Event Time: [CDT]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - CABLE DISCONNECT ON RADIOGRAPHY CAMERA

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

"The licensee called [Texas Department of Health] to report that a disconnect occurred due to a broken drive cable. The SPEC-150 radiography device contained a 28 curie iridium-192 source. The cable broke near the ball stop on the crank out connector. The source remained in the source guide tube. The radiography crew called the incident in and waited for an authorized person to retrieve the source. The source was retrieved with minimal exposure. Incident doses were based on pocket dosimeter readings. The radiographer received 15 mrem and the trainee received 2 mrem. The radiographer retrieving the source received 25 mrem and his assistant received 9 mrem.

"It is believed that the cable failed due to metal fatigue. The individual providing the report did not know when the cable was last tested."

Texas Incident #: I-9180

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Agreement State Event Number: 50019
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ATL INC.
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-116
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/09/2014
Notification Time: 19:02 [ET]
Event Date: 04/08/2014
Event Time: [MST]
Last Update Date: 04/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (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 - MISSING TROXLER GAUGE

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

"On April 8, 2014, the Agency was contacted by the Licensee who indicated that an employee and a Troxler Gauge was missing. The licensee was informed around 6:00 AM that the employee did not show up on a job on the Indian Reservation. The licensee has notified both the Arizona Department of Public Safety and the New Mexico Department of Public Safety. The gauge is a Troxler Model 3430, Serial Number 7052 containing 9 millicuries of Cesium-137 and 45 millicuries of Am-241. The individual was discovered to have had a diabetic coma and the gauge was still with the individual and the licensee is sending another operator to retrieve the gauge. The individual is in Gallup, NM.

"The investigation into this event is ongoing.

"The U.S. NRC, New Mexico, and Arizona Governor's Office have been notified of this event."

Arizona First Notice: 14-006

* * * UPDATE AT 1930 EDT ON 4/9/14 FROM AUBREY GODWIN TO S. SANDIN * * *

The Troxler Gauge has been recovered and is in the licensee's possession at their Flagstaff, AZ office.

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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Power Reactor Event Number: 50039
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC POWELL
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/16/2014
Notification Time: 10:48 [ET]
Event Date: 04/16/2014
Event Time: 09:08 [EDT]
Last Update Date: 04/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ART BURRITT (R1DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO MINOR HYDRAULIC OIL SPILL IN THE DELAWARE RIVER

"At 0908 EDT on April 16th, 2014, approximately one pint of hydraulic fluid was spilled into the Delaware River in front of the Unit One Circulating Water System (CWS) Intake trash racks at the Salem Generating Station. The spill of hydraulic fluid was caused by a leak from the crane used to rake debris from the Unit One trash racks. The crane was stopped and the leak terminated at the time of discovery. The oil was cleaned up by onsite personnel at 0930 EDT.

"Nuclear Environmental Affairs Department determined a 4 hr report to the NRC under RAL 11.8.2.a. was warranted due to the 15 minute notification to the New Jersey Department of Environmental Protection at 0922 EDT. Additionally, a report of the spill was made to the National Response Center at 1034 EDT."

The licensee informed the NRC Resident Inspector.

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