Event Notification Report for September 29, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/26/2014 - 09/29/2014

** EVENT NUMBERS **


50466 50469 50471 50472 50473 50477 50496 50497 50498

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Agreement State Event Number: 50466
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: PDV MIDWEST REFINING
Region: 3
City: LEMONT State: IL
County:
License #: IL-01603-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/18/2014
Notification Time: 10:35 [ET]
Event Date: 09/16/2014
Event Time: [CDT]
Last Update Date: 09/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE WITH A STUCK OPEN SHUTTER

The following was received via email:

"The licensee's radiation safety officer called the Agency [Illinois Emergency Management Agency] to advise that on 9/16/14, an Ohmart Vega, m/n SH-F1-45 fixed gauge containing 15 milliCi of Cs-137 (as of April 2002) had a shutter which could not be closed. They became aware of the situation during the performance of routine 6 month operability checks. The manufacturer was immediately contacted to schedule an evaluation in the coming weeks and for advice. The licensee was advised to lubricate the shutter pinion and allow it to sit overnight before attempting to close the shutter again the next day. The licensee intends to have the manufacturer's field engineer come on site to inspect the device.

"The gauge is located on a vessel which is still in active use for sulfur production and is exposed to ambient weather conditions. The gauge is located approximately 15 feet overhead on a platform which is not a routine work location for day to day operations. A lock out/tag out procedure is actively in use at the site should any work on/in the vessel be necessary before repairs can be affected. Notifications to the acting RSO are part of that procedure. The licensee is aware of the 30 [day] written reporting requirement."

This is the second time that the shutter has stuck open recently.

Illinois Event #: IL14019

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Agreement State Event Number: 50469
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ANALYTICAL INSTRUMENT RECYCLE, INC.
Region: 4
City: GOLDEN State: CO
County:
License #: 974-01
Agreement: Y
Docket:
NRC Notified By: JAMES JARVIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/18/2014
Notification Time: 14:24 [ET]
Event Date: 02/01/2014
Event Time: [MDT]
Last Update Date: 09/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DISCOVERY OF THREE LEAKING SOURCES

The following information was received from the state of Colorado via email:

"The following is a notification not previously identified to NRC.

"On or about April 24, 2014, during licensing renewal activities, the [Colorado Radiation Control Program] Agency licensing staff received information that Colorado specific licensee Analytical Instrument Recycle, Inc. (AIR, 15860 West 6th Ave., Golden, CO 80401; CO License #974-01) had reportedly discovered that three generally licensed (GL) electron capture devices (ECDs) in their possession that had failed a leak test approximately two months prior (in ~February 2014). (The licensee refurbishes and resells analytical instruments containing ECDs, although the licensee performs leak tests, it is not authorized to work on or open ECDs or the sources contained within them.)

"The licensee's Radiation Safety Officer (RSO) indicated that he had previously sent notification regarding the leaking sources to the Agency (Colorado Department of Public Health and Environment) in early February, 2014 and provided a copy of an undated letter during the investigation.

"The licensee reported the leak test results/analysis data as follows:
1) Hewlett-Packard/Agilent model 19233 serial number L4716 (Contamination level of 0.064uCi)
2) Hewlett-Packard/Agilent model G1533A serial number K3545 (Contamination level of 0.013uCi)
3) Hewlett-Packard/Agilent model G1223A serial number F1219 (Contamination level of 0.008uCi)

"Each of the leaking devices contains a nominal activity of 15 mCi of Ni63, although the devices are authorized to contain up to 18 mCi of Ni63.

"The licensee reported that areas where the devices were handled had been surveyed and indicated that no contamination above background present in the work area or facility. The licensee reported to the Agency that the leaking ECDs were returned to the manufacturer on March 7, 2014.

"No further action is required and the Agency considers this matter closed."

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Agreement State Event Number: 50471
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: FRENCH & PARRELLO
Region: 1
City: WALL TOWNSHIP State: NJ
County:
License #: 507834-RAD110
Agreement: Y
Docket:
NRC Notified By: JACK TWAY
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/19/2014
Notification Time: 10:09 [ET]
Event Date: 09/19/2014
Event Time: [EDT]
Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The state of New Jersey provided notification that a licensee (French and Parrello) reported a Troxler moisture density gauge (Model 3430, Serial #38931) stolen. The gauge was in the possession of a contractor (employed by Aerotek staffing agency) who has not shown up for work for several days. Attempts have been made to contact the contractor. New Jersey instructed the licensee to contact local law enforcement. The gauge contains 40mCi Am-241 and 8mCi Cs-137.

NJ EVENT: 14-09-19-1107-54

* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 9/19/14 AT 1231 EDT * * *

The gauge operator contacted the Wall Township Police Department to inform them that he was in possession of the gauge and would be returning it to the licensee today.

Notified R1DO (Lilliendahl), FSME Events Resource (email), and ILTAB (email).


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: 50472
Rep Org: MONONGALIA GENERAL HOSPITAL
Licensee: MONONGALIA GENERAL HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 13:56 [ET]
Event Date: 09/19/2014
Event Time: [EDT]
Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

BRACHYTHERAPY PATIENT RECEIVED 54% OF PRESCRIBED DOSE

The authorized user determined that, due to scar tissue from a previous procedure , the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.

The investigation into the event is ongoing.

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: 50473
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT NDT, LLC
Region: 4
City: ABILENE State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 14:12 [ET]
Event Date: 09/17/2014
Event Time: [CDT]
Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
FSME EVENTS NOTIFICA (EMAI)
ANGELA MCINTOSH (FSME)
PATRICIA MILLIGAN (NSIR)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURES TO TWO RADIOGRAPHERS

The following information was obtained from the State of Texas via email:

"On September 18, 2014, the Agency [Texas Department of Health] was notified by the Licensee's Radiation Safety Officer (RSO) that two radiographers working at a field location may have received exposures in excess of the annual whole body exposure limit. The RSO stated two qualified radiographers were working at a temporary field site using an INC IR-100 exposure device containing a 55 curie iridium-192 source. One radiographer (RA) was performing the exposures and the other (RB) was developing the film. The RSO stated RA walked out of the darkroom and saw the camera setting on the truck's tailgate. The radiographer also observed the dose rate meter sitting on the truck's tailgate was reading pegged high. The radiographers picked up the crankout device and cranked the handle approximately one-half turn which locked the source in the fully shielded position. The RSO stated RA read their self-reading dosimeter (SRD) and it was off scale. The RSO stated RB was not wearing a SRD or OSL [optically stimulated luminescence] dosimeter. The RSO stated RB was wearing an alarming rate meter, but they are hard to hear and with the background noise of the generator they did not hear it alarming.

"The RSO stated RB was five feet from the exposure device for about 20 minutes. The RSO stated the calculated dose to RB is 12.8 rem based on their current information. The RSO stated RA was near the camera for about 30 seconds and his dose was calculated to be 10.8 rem. Both radiographers' dosimeters have been sent to the licensee's processor for reading. The RSO stated they have not calculated the dose to RA's hand yet. The RSO stated they are reenacting the event on September 19, 2014, to help calculate the dose to both workers. The licensee has contracted a consultant (Bruce Bristow) to aid in the dose calculations. The RSO stated the cause for the high exposures was failure of RA to fully retract the source. The RSO stated the exposure device was working properly. No other individuals received any exposure due to this event.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-9235

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Agreement State Event Number: 50477
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES OILFIELD OPERATIONS INC
Region: 4
City: HOUSTON State: TX
County: DIMMIT
License #: 06453
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/21/2014
Notification Time: 09:09 [ET]
Event Date: 09/20/2014
Event Time: [CDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
FSME EVENTS RESOURCE (E-MA)
PAM HENDERSON (FSME)

Event Text

AGREEMENT STATE REPORT - VEHICLE FIRE INVOLVING TWO DENSITY GAUGES

The following report was received via e-mail:

"On September 20, 2014, the licensee notified the Agency [Texas Department of State Health Services] that two nuclear gauges, Thermo Fisher Scientific Model 5190 density gauges containing a 200 milliCurie cesium (Cs) - 137 source, were inside a large fire that occurred in the early morning hours. The fire at an oil field temporary job site in Dimmit County, Texas burned over twenty vehicles and the two gauges stored in Type A containers were in the fire. Status of the gauges is unknown. An additional two similar gauges were at the site but not in the area of the fire. An investigation is ongoing and additional information in accordance with SA-300 will be reported. There was no public or worker exposures due to the incident as no one was on site at the time of the fire.

"Gauge Serial Numbers are B6610 and B7600."

Texas Incident #I-9236

* * * UPDATE FROM KAREN BLANCHARD TO JOHN SHOEMAKER AT 1247 EDT ON 9/22/14 * * *

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

"[The State was informed by the licensee at 1345 CDT on 9/22/14, that] the licensee surveyed and inspected the two Thermo Fisher Scientific Model 5190 gauges that were in a fire on September 20, 2014. Radiation measurement of 7 R/hr on contact with the outer surface of one of the gauges was detected, indicating that the lead shielding had been compromised (gauge SN: B7500). There were no elevated radiation levels detected on the second gauge. The licensee has secured all four gauges that were at the site and set up appropriate barrier while it awaits permission to remove them from the site. The cause of the fire is still under investigation. The manufacturer is sending a transport container. The licensee reported it will add external lead around the compromised gauge for transport. Upon receipt, the manufacturer will inspect/evaluate all four gauges."

Notified R4DO (Drake), FSME Events Resource via email.

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Power Reactor Event Number: 50496
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KIRK DUEA
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/26/2014
Notification Time: 02:53 [ET]
Event Date: 09/25/2014
Event Time: 22:00 [CDT]
Last Update Date: 09/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 69 Power Operation 69 Power Operation

Event Text

CONTAINMENT ISOLATION DECLARED INOPERABLE DUE TO RELAY AGE

"At 2200 CDT on September 25, 2014, the Duty Shift Manager was notified that Agastat relays associated with Primary Containment Isolation valves on the Hydrogen-Oxygen Analyzing System are beyond the analyzed shelf life for relays that are in the normally energized state and are considered INOPERABLE. This affected both primary containment isolation valves for a containment penetration on multiple flow paths. This issue was determined to be reportable under [10 CFR] 50.72 (b)(3)(v)(C) & (D) for an 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 control the release of radioactive material and mitigate the consequences of an accident.

"Additionally, the required actions involved isolating six flow paths via manual isolation valves. This action rendered the Hydrogen-Oxygen Analyzers non-functional for both trains and constitutes a loss of Emergency Preparedness and Accident Assessment Capability. This is reportable under [10 CFR] 50. 72(b)(3)(xiii).

"The Primary Containment Isolation Valves have been, and remain, in their closed position to satisfy their Primary Containment Function and protect the health and safety of the public.

"The NRC Senior Resident Inspector has been notified."

The licensee will notify the State of Minnesota.

The relays of concern were manufactured 19 years ago and have been in operation for 11 years, versus a manufacturer assumption of a 10 year operational lifespan.

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Power Reactor Event Number: 50497
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: REGGIE PICKENS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/27/2014
Notification Time: 20:09 [ET]
Event Date: 09/27/2014
Event Time: 16:16 [EDT]
Last Update Date: 09/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MALCOLM WIDMANN (R2DO)

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

Event Text

REACTOR COOLANT SYSTEM SAFETY INJECTION LINE ULTRASONIC TEST INDICATION

"On Friday, September 26, 2014, while performing planned inspections of Reactor Coolant System piping welds, one flaw indication was identified on each of two 1.5 inch Safety Injection Line connections to the Reactor Coolant System piping. On Saturday, September 27, 2014, after confirmatory inspections and evaluation, both of the flaw indications were determined to not meet the acceptance criteria specified in ASME Code Section XI. As such, these indications are reportable under 10 CFR 50.72(b)(3)(ii) as a Degraded Condition. A repair plan is being developed. There is no impact on current Unit 1 refueling operations while defueled and in No Mode. This condition and repair have no impact to the health and safety of the public or employees.

"The NRC Resident Inspector was notified."

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Power Reactor Event Number: 50498
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: DONALD NORWOOD
Notification Date: 09/28/2014
Notification Time: 10:55 [ET]
Event Date: 09/28/2014
Event Time: 08:30 [EDT]
Last Update Date: 09/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT ACTIVATION OF AN EMERGENCY SIREN

"On 9/28/14 at approximately 0830 EDT, the Operations Shift Manager was made aware that the Berrien County Sheriff's Department (BCSD) had been notified of an Emergency Siren that had actuated. BCSD was notified by local residents. BCSD reset the emergency siren and a local police officer verified the siren was no longer actuating.

"The cause of the actuation is under investigation at this time. The siren remains in service pending further investigation. There are a total of 70 sirens and all remain functional.

"This notification is being made under 10 CFR 50.72(b)(2)(xi), Offsite Notification, as a four (4) hour report.

"The licensee notified the NRC Resident Inspector."

Page Last Reviewed/Updated Thursday, March 25, 2021