Event Notification Report for August 15, 2014

DAMAGED MOISTURE/DENSITY GAUGE

A moisture/density gauge was run over by a bulldozer at a construction site in Indianapolis, Indiana. The RSO performed surveys of the gauge and no abnormal dose rates were observed. The gauge was leak tested and the data has been sent to Seaman Nuclear Products for analysis. The gauge has been removed from service and is secured at the licensee's facility.

The gauge is a Seaman Model C-75 moisture/density gauge and typically contains 8 mCi of Cs-137 and 40 mCi of Am-241/Be.

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED INDUSTRIAL GAUGE

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

"Phillips 66 Co. (OK-07402-12) has reported the failure of the shutter mechanism on one of their fixed gauges. Earlier today the shutter was closed while the licensee collected a leak test sample. The RSO noted that the shutter was difficult to operate. When they returned the shutter handle to the 'open' position, the control room which monitors the gauge readings reported that the readout briefly returned to its normal level, then dropped back to zero when the shutter was supposed to be fully open. Repeated attempts showed that the gauge only operated when the shutter was approximately 75% of the fully 'open' position. The licensee has contacted the gauge manufacturer but they won't be able to supply a replacement for approximately 6 weeks. The licensee has requested permission to leave the gauge in service until a replacement is available. The gauge is installed on a stand pipe 18 feet above ground level in an oil refinery in Ponca City, OK. It is only accessible by catwalk which the RSO is going to cordon off. Material in the gauge is Cs-137, 25 mCi when new in 1993. We[State of OK] have told the RSO they may leave the gauge in operation pending the results of the leak test. If these show the source to be leaking they must immediately remove the gauge from service."

STANDBY GAS TREATMENT SYSTEM INOPERABLE

"On 8/15/2014 at 1218 CDT, the 'B' Standby Gas Treatment (SBGT) System was undergoing its monthly surveillance testing. With the 'B' fan running, as part of the surveillance, the 'A' Standby Gas Treatment Mode Select Switch was taken to Manual. This renders the 'A' SBGT subsystem inoperable. Almost simultaneously the 'B' fan Flow Indicating Controller went blank and flashed an error message although indicated flow through the 'B' train remained at 4073 SCFM. Based on the indication seen on 'B' controller, regardless of flow, the 'B' SBGT subsystem was also declared inoperable. In accordance with the surveillance the 'A' SBGT mode switch was placed back in the AUTO position on 8/15/2014 at 1220 CDT, restoring that train to operability. The 'B' SBGT was still considered inoperable based on its flow indicating controller being blank and flashing an error message. For a period of two minutes both SBGT subsystems were considered inoperable which is a condition that could have prevented the fulfillment of the safety function of SBGT system to control the release of radioactive material. This is considered a 8-hour reportable event per 50.72(b)(3)(v)(C) 'Any event or condition that at the time discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'

"During the 2 minutes that 'A' SBGT was in Manual, the 'B' SBGT train maintained 4073 scfm train flow which is at the required flow rate per STP 3.6.4.3-01B. In addition, the 'A' train could have been initiated manually at any time during that 2 minutes by the operator who was stationed at the panel performing the surveillance."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY BOB MURRELL TO DANIEL MILLS AT 0835 EDT ON 09/16/2014 * * *

"The purpose of this notification is to retract a previous report made on 08/15/2014 at 1802 (EDT) (EN 50375). Notification of the event to the NRC was initially made as a result of declaring both trains of the Standby Gas Treatment (SBGT) System inoperable. Specifically, during performance of planned surveillance testing required by Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.3.2, with the 'B' train of SBGT running as part of the testing, the 'A' SBGT train's mode switch was taken to manual. This action renders the 'A' train inoperable. Simultaneously with this action, the 'B' SBGT Flow Indicator Controller went blank and flashed an error message. This resulted in the 'B' train being declared inoperable.

"Subsequent to the initial report, NextEra Energy Duane Arnold (NextEra) has determined that TS SR 3.6.4.3.2 contains a note that states, 'When a SBGT subsystem is placed in an inoperable status solely for the performance of VFTP testing required by this Surveillance on the other subsystem, entry into associated Conditions and Required Actions may be delayed for up to 1 hour.' The 'A' SBGT train mode switch was in manual for approximately 2 minutes; therefore, entry into the associated conditions and actions was not required.

"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73.

"The NRC Senior Resident Inspector has been notified."

Notified R3DO (Dickson)

NOTICE OF DEVIATION REGARDING K-LINE CIRCUIT BREAKER SECONDARY CLOSE LATCH

The following information was excerpted from a facsimile received from ABB, Inc:

"This letter provides notification of a failure to comply with specifications associated with a secondary close latch, part number 716610K01, used in K-Line 225/800 and 1600/2000 amp electrically operated Model 7 circuit breakers. This does not affect previous models of these same breakers that have not been upgraded to include the interlocking primary and secondary close latches. It also does not affect manually operated Kline breakers or K3000/4000 circuit breakers. Information is provided as specified in 10CFR21 paragraph 21.21(d)(4).

"Notifying individual: Jay Lavrinc, Vice President & General Manager, ABB (Medium Voltage Service), 2300 Mechanicsville Road, Florence, SC 29501

"Identification of the Subject component: ABB part number 716610K01 secondary close latch. This secondary close latch is used on new legacy K-Line Model 7 electrically operated circuit breakers. It is also used during breaker refurbishments when a secondary close latch is required to be replaced because of damage or wear. The secondary close latch is available as a component part and is also used in K-Line Model 7 up-grade kits.

"If a breaker is sent in for refurbishment the primary and secondary latches are replaced unless it is required in the customer PO that they not be replaced unless they are damaged or worn.

"Nature of the deviation: During outgoing inspection a breaker went trip free during the operational phase of the testing procedure. The inspector found that the cam attached to the top of the secondary close latch, 716610K01, was not properly riveted in place. The head of the rivet was not pushed down flush against the side of the cam. Since the rivet was not seated properly, the other end of the rivet did not project through the other side of the latch and therefore the bradded end of the rivet was not deformed in a manner to sufficiently apply the required holding force to keep the cam in its proper and secure operating position.

"Corrective actions include:
a. Perform 100% inspection all part number 716610K01 secondary close latches in inventory to identify the nonconforming latches. (Action complete)
b. Trained inspectors and breaker assemblers on identifying this condition (Action Complete)
c. Contact primary vendor to investigate cause and correct on future orders. (Action Complete)
d. Verified that this is the only assembly with bradding that this vendor provides. (Action complete)
e. Notification of the potential existence of this deviation to affected customers (Action to be completed by 18 August 2014)

"Affected Customers: Constellation Energy, DTEEnergy, Entergy Operations, Exelon Corporation

"Recommendations: It is recommended that affected Licensees that have received latches that were identified as having been provided from parts that fall under this notification take the following actions:

"If the latch is in their inventory as a component, in a kit or in a breaker that is not currently in use it is suggested that the secondary trip latch be inspected for this condition. Inspection should include visual inspection of the rivets to confirm they are properly seated and bradded and physical manipulation of the cam to determine that it is securely held in place in the assembly.

"If a suspect latch is installed in a breaker that is currently installed and energized we recommend that at their next maintenance cycle, the secondary close latch in the breaker be inspected for this condition.

"We currently cycle Kline breakers that are refurbished approximately 55 close/open operations before they ship from the Florence facility. New breakers get at least that many operations or more. If a breaker has shipped out of the Florence facility during this period it is unlikely that the breaker would get through inspection without failing with a latch that is improperly riveted. ABB cannot guarantee that no latch on a breaker that shipped is affected but we do not see it as a likely occurrence with the testing that the breaker is subjected to prior to shipment. There have been no field failures reported that were attributed to this manufacturing issue."

* * * UPDATE FROM DAVID BROWN TO JOHN SHOEMAKER ON AT 1654 EDT ON 9/12/14 * * *

The following information was received from ABB Inc. via email;

"This amendment is being issued to correct 2 errors in the original notification:

1. This 'secondary close latch' was mistakenly referred to as a 'secondary trip latch' in Section 7 [of the report].

2. The manner in which the problem was detected was described improperly as a breaker 'went trip free' when in fact, the breaker 'failed to close'. This is from Section 5 [of the report].

"This [amendment] letter is being submitted to ensure accurate information has been reported. There have been no reported field failures and affected customers have been notified."

For questions, contact;
David Brown
QA Engineer, ABB Inc.
Ph: (843) 413-4782

Notified R1DO (Jackson), R2DO (Shaeffer), R3DO (Riemer), R4DO (Azua), and Part 21 Group via email.

AGREEMENT STATE REPORT - IODINE-125 SEEDS POSITIONED INCORRECTLY DURING IMPLANTATION

The following information was received via E-mail:

"On August 18, 2014, the licensee notified the Agency [Texas Department of State Health Services] that on August 15, 2014, it discovered that a medical event had occurred. One of the licensee's patients had iodine-125 seed implantation in July 2014 and on August 7, 2014, a post-plan computed tomography scan was performed. During the post-plan evaluation, the licensee discovered that the seeds had not been positioned in the target tissue as prescribed during implantation. The licensee believes that approximately 30 percent of the prescribed dose was delivered to the target tissue. The licensee is evaluating the data to determine actual dosimetrics and will report its calculated dose to the intended and other tissue to the Agency upon completion. The Agency will provide further information in accordance with SA-300."

This event occurred at the Baylor All Saints Medical Center in Fort Worth, Texas.

Texas Incident #: I-9221

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.

* * * UPDATE FROM KAREN BLANCHARD TO CHARLES TEAL AT 1706 EDT ON 8/25/14 * * *

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

"The licensee for this event was initially reported as Texas Oncology, license L-05545. It has been determined that Baylor All Saints Medical Center Radiology Department, license L-02212, is the actual licensee the implantation procedure in this event was licensed under. The licensees are continuing their investigation and will submit a written report within the required 15 days."

Notified R4DO (Pick) and FSME Events Resource via email.

AGREEMENT STATE REPORT - STUCK SHUTTER ON BERTHOLD MLT300 FIXED GAUGE

The following information was received from the Commonwealth of Kentucky:

"On 8/15/14, Gallatin Steel discovered a problem with the source holder (serial number 6596) on a Berthold MLT300 fixed gauge. The gauging device contained 27 mCi of Co-60, serial# 165-02-13. The source holder was closed and locked, removed from service, placed in storage, and service was scheduled with Berthold service group. On 8/20/14 Radiametrics Technologies shutter-checked, surveyed and leak tested the device. The shutter was found to be stuck in the closed position which was caused by the lifting mechanism. Excessive wear on the lifting mechanism caused it to indent the edge of the shutter and the top plate causing an inoperable condition. The shutter was repaired and rechecked for proper operation and no problems were found. On 2/13/14 Gallatin Steel sent the KY RHB [Kentucky Radiological Health Branch] notification of the event. Corrective actions include repair of the gauge, and service/inspection of the lifting device every 6 months. Gallatin Steel informed all personnel involved, including Berthold Service Group, of the incident and the notification requirements to the KY RHB."

Kentucky Event ID: KY150001

AGREEMENT STATE REPORT - STOLEN TRITIUM EXIT SIGN

The following information was obtained from the State of California via facsimile:

"On 01/22/15, RHB [California Radiologic Health Branch] was notified of a stolen tritium exit sign from an AMC Theatre in San Jose, CA. The police report No. 142273216 filed by the AMC theatres on 08/15/14 stated the following: 'The management was doing a walkthrough of the building on 08/15/14 at AMC Saratoga 14. In theatre No. 13, the manager noticed one of the exit signs missing.'

"The model, S/N or the activity of the exit sign is unknown. RHB will be contacting AMC theatres and the Ultimate Lighting Source (vendor) to get further details."

California Report Number: 5010-012215

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