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Event Notification Report for September 17, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/16/2014 - 09/17/2014

** EVENT NUMBERS **


49967 50375 50433 50435 50436 50437 50438 50462 50463

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Part 21 Event Number: 49967
Rep Org: C&D TECHNOLOGIES INC
Licensee: C&D TECHNOLOGIES INC
Region: 1
City: BLUE BELL State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHRISTIAN RHEAULT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/28/2014
Notification Time: 13:02 [ET]
Event Date: 02/14/2012
Event Time: [EDT]
Last Update Date: 09/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MEL GRAY (R1DO)
MARVIN SYKES (R2DO)
BILLY DICKSON (R3DO)
NRR PART 21 GROUP (EMAI)

Event Text

INTERIM PART 21 REPORT - MISALIGNED SEPARATORS IN LCR-25 STANDBY BATTERIES

The following is the summary portion of the report submitted by fax:

"Subject Interim Report - Inability to Complete 10CFR Part 21 Evaluation Regarding Misaligned Separators in LCR-25 Standby Batteries

"The purpose of this letter is to provide the NRC a report in general conformity to the requirements of 10CFR Part 21.21 (a)(2). On February 14, 2012 C&D Technologies, Inc. ('C&D') was informed by Entergy Operations that an LCR-25 battery installed at the Palisades Nuclear Power Plant had shown signs of misaligned separators (also known as shifted separators) of between 1/8 to1/4 [inch]. This was identified by the Palisades plant on or about November 4, 2011. On January 16, 2012, three additional cells were identified as experiencing separator misalignment.

"C&D requested that Palisades return the affected batteries for evaluation of this anomaly and issued a Return Material Authorization for that purpose. But since voltage readings were acceptable for all units involved, Palisades determined that an operability issue did not exist and opted to keep the batteries in service until their refuel outage scheduled for Fall, 2013. C&D inadvertently closed the internal corrective action without providing an Interim Report as required by 10CFR, Part 21.

"C&D has not performed a root cause technical evaluation to determine if there is any defect in the component or manufacturing process or whether the reported condition may have been due to user abuse of product, improper maintenance or other negligence or error.

"Thus, C&D is submitting this interim report to the NRC and notifying C&D's customers that use C&D LCR-25 batteries of this interim report, and is initiating an action plan to evaluate the reported potential defect and determine whether it could pose a substantial safety hazard for any U.S. licensee using such batteries.

"If you have any questions or wish to discuss this matter or this report, please contact:

Robert Malley
VP Quality and Process Engineering
bmalley@cdtechno.com
(215) 619-7830"

The sites affected are:
Palisades - 65 x LCR-25 NUC Batteries and,
Crystal River - 4 x LCR-25 NUC Batteries

* * * UPDATE FROM LARRY CARSON TO JOHN SHOEMAKER AT 1122 EDT ON 09/16/14 * * *

The following was excerpted from the final report received from C&D Technologies, Inc. via facsimile:

"Conclusion: The conclusion drawn from the return and analysis is that the misaligned separator was present from the time of assembly in the C&D facility through installation and initial operation.

"Recommendations: C&D recommends that operators of nuclear batteries perform an inspection of their batteries to detect misaligned separators. Inspection may be performed visually, and with the aid of mirrors as necessary.

"Corrective Actions: C&D has enhanced both in process and final battery inspection processes to detect and eliminate misaligned separators from shipment. C&D is also preparing an enhanced incoming inspection work form for nuclear battery operators that will better enable the operators to detect and segregate batteries with misaligned separators from use.

"Further Reporting: No further reporting is anticipated.

"C&D Contacts: Further information on this issue can be obtained from:

"Larry Carson- Nuclear Product Manager
Office Phone 215-775-1314
Email: lcarson@cdtechno.com

"Robert Malley-VP Quality and Process Engineering
Office Phone 215-619-7830
Email bmalley@cdtechno.com"

Notified R1DO (Lilliendahl), R2DO (Sykes), R3DO (Dickenson), and NRR Part 21 Group via email.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50375
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARK GILBERT
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/15/2014
Notification Time: 18:02 [ET]
Event Date: 08/15/2014
Event Time: 12:18 [CDT]
Last Update Date: 09/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
CHRISTINE LIPA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation

Event Text

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)

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Agreement State Event Number: 50433
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNIVERSITY OF VIRGINIA
Region: 1
City: CHARLOTTESVILLE State: VA
County: ALBERMARLE
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/08/2014
Notification Time: 16:37 [ET]
Event Date: 09/04/2014
Event Time: [EDT]
Last Update Date: 09/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MISADMINISTRATION OF Y-90 THERASPHERES

The following information was received via email:

"A Y-90 TheraSphere liver therapy procedure resulted in delivered doses to the liver and lungs that differed from the prescribed dose. The revised Lung Shunt Fraction (LSF) value was used to recalculate the actual radiation dose to lungs and LT liver lobe. The results are that the lungs received 34.5 Gy (instead of 3.7 Gy) and the LT liver lobe received 67 Gy (instead of 117 Gy). Also, it is calculated that the LT liver lobe was implanted with a Y-90 activity dose of 0.82 GBq (22.2 mCi) while the lungs received a Y-90 activity dose of 0.69 GBq (18.64 mCi) since the patient was implanted with 1.50 GBq (40.53 mCi) of Y-90. The patient's family was notified. UVA staff are meeting to analyze the root cause of the event. RMP [Virginia Radioactive Materials Program] staff will review UVA's findings and determine what further actions are necessary."

Virginia Event Report ID No.: VA-2014-16

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: 50435
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: THERMO SCIENTIFIC PORTABLE ANALYTICAL INSTRUMENTS, INC.
Region: 1
City: TEWKSBURY State: MA
County:
License #: 55-0238
Agreement: Y
Docket:
NRC Notified By: ED SALOMON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/08/2014
Notification Time: 18:27 [ET]
Event Date: 09/08/2014
Event Time: 16:00 [EDT]
Last Update Date: 09/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED CD-109 SEALED SOURCE

The following information was obtained from the Commonwealth of Massachusetts via email:

"The Agency (Massachusetts Radiation Control Program) was notified on 9/8/2014, by Thermo Scientific Portable Analytical Instruments, Inc. (MA RAM License # 55-0238), that a leak test result for a Cd -109 sealed source was above the leak test limits of 185 Bq (0.005 microCi). The wipe test showed that the removable activity was 486 Bq (0.0131 microCi), which is above the regulatory limit.

"The licensee provided the following information about the sealed source: The source manufacturer is Eckert and Ziegler (formerly/aka Isotope Products Laboratories). The model number is FXB-3 and intended for use in a handheld XRF analyzer. Total activity on the source is 40 mCi. The wipe test was done in a controlled environment in their production source room as they were taking the source out of its original packing material. The licensee did survey the area after discovering the wipe test and did not find any signs of contamination elsewhere. The package (not the sources within) was received on August 21, 2014 and wipe tested clean at that time, so there is no indication that contamination has spread anywhere beyond the source itself.

"There were no personnel contaminations or area contamination from this contaminated sealed source. The licensee will file a report to our agency within 5 days of this leak test.

"The Agency considers this matter to still be OPEN pending further review of this event."

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Agreement State Event Number: 50436
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALWEST GEOTECHNICAL
Region: 4
City: THOUSAND OAKS State: CA
County:
License #: 5539-56
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/08/2014
Notification Time: 18:28 [ET]
Event Date: 09/08/2014
Event Time: 11:30 [PDT]
Last Update Date: 09/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE/DENSITY GAUGE

The following information was received via E-mail:

"On September 8, 2014, at approximately 1130 to 1245 PDT, an authorized user of radioactive gauges who is the ARSO [assistant radiation safety officer] of Calwest Geotechnical, RML #5539-56, contacted RHB [Radiation Health Branch] Brea concerning a moisture/density gauge, Troxler model 3440, serial number 15195 (Cs-137, 0.333 GBq, Am-241, 1.63 GBq) that had been stolen from a transport vehicle in front of a restaurant in Santa Monica during the lunch break period of 1130 to 1245 PDT. The ARSO has contacted the local law enforcement officials in his area and has filled out a theft report which will be copied and sent to RHB Brea as part of this report. The ARSO will utilize local papers to attempt to retrieve the stolen gauge. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been stolen and it cannot be determined what condition the sources are currently in."

California Report No.: 5010-090814

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: 50437
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EARTH ENGINEERING, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: 05206
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/09/2014
Notification Time: 17:52 [ET]
Event Date: 09/09/2014
Event Time: [CDT]
Last Update Date: 09/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - HUMBOLDT MOISTURE DENSITY GAUGE IN VEHICLE INVOLVED IN A TRAFFIC ACCIDENT

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

"On September 9, 2014, the Agency [Texas Department of State Health Services] was notified by the Woodlands Fire Department that they were at the scene of a traffic accident [on roadway FM 2978 near Magnolia, TX] involving a vehicle transporting a gauge containing radioactive material. The gauge was a Humboldt 5001 EZ moisture/density gauge containing a 10 millicurie Cesium-137 source and a 40 millicurie Americium-241 source. The licensee contacted the Agency and stated one of their trucks was stopped behind a tractor trailer when it was struck from behind by a truck. Neither the gauge nor the transportation package was damaged in the event. No injuries to individuals involved in the event were reported. Traffic on the road the vehicles were traveling on was closed for more than 1.5 hours. The licensee stated the dose rate on contact with the transportation container was 0.5 millirem per hour, which is normal. The Transport Index for the container was 0.2. The licensee stated the gauge would be taken back to their facility and inspected. No individual received any significant exposure to radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9230

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Agreement State Event Number: 50438
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL COMPANY LP
Region: 4
City: PASADENA State: TX
County:
License #: 00230
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/09/2014
Notification Time: 18:10 [ET]
Event Date: 09/09/2014
Event Time: [CDT]
Last Update Date: 09/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTERS ON TWO PROCESS GAUGES

The following information was received via E-mail:

"On September 9, 2014, the Agency [Texas Department of State Health Services] was notified by the licensee that while taking a tank out of service for repairs, it was unable to close the shutters on two Ohmart Vega model SH-F2 level gauges, each containing 500 milliCuries of Cesium-137. The shutters are stuck in the open position, which is the normal operating position for the gauges. The licensee has contacted a service provider who will be on site on September 10, 2014 to make repairs to the gauges. The gauges do not create an exposure hazard to any individual. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9231

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Power Reactor Event Number: 50462
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/16/2014
Notification Time: 16:34 [ET]
Event Date: 09/16/2014
Event Time: 15:19 [EDT]
Last Update Date: 09/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BILLY DICKSON (R3DO)
LOUISE LUND (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATIONS AND PRESS RELEASE REGARDING ONSITE FATALITY

"At approximately 1420 [EDT] on September 16, 2014, a worker collapsed in an office building inside the protected area. Initial response by on-site responders found the person unresponsive. Subsequent response by off-site medical responders determined the person had died. Licensee was notified of fatality at 1519 [EDT]. The fatality was due to an apparent personal medical issue and not work related. The individual was not contaminated.

"The individual was transported off-site via Medic One, a local ambulance.

"The NRC Senior Resident Inspector was notified. Plant operation was not impacted by the event.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies. The Licensee plans to make a press release."

The licensee also notified Michigan OSHA, and other local authorities.

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Power Reactor Event Number: 50463
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: LUKE ECHOLS
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/16/2014
Notification Time: 23:20 [ET]
Event Date: 09/16/2014
Event Time: 19:05 [CDT]
Last Update Date: 09/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation

Event Text

LOSS OF DIVISION 3 OF SHUTDOWN SERVICE WATER REQUIRES HPCS TO BE DECLARED INOPERABLE

"At 1905 hours (CDT), during surveillance testing of the Division 3 Shutdown Service Water (SX) system, the Division 3 SX pump tripped for unknown reasons. The Division 3 SX system was declared inoperable and in accordance with Technical Specification 3.7.2, Action A, the High Pressure Core Spray (HPCS) system was declared inoperable. Since the HPCS system is a single train safety system, this event is reportable under 10CFR50.72(b)(3)(v)(D). An investigation is underway to determine the cause of SX pump to trip.

"The NRC Resident [Inspector] has been notified."

Page Last Reviewed/Updated Wednesday, September 17, 2014
Wednesday, September 17, 2014