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Event Notification Report for October 27, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/24/2014 - 10/27/2014

** EVENT NUMBERS **


50541 50543 50544 50547 50548 50565 50567 50568 50569

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Agreement State Event Number: 50541
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ELG METALS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 02275
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/16/2014
Notification Time: 12:12 [ET]
Event Date: 10/15/2014
Event Time: [CDT]
Last Update Date: 10/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
MEXICO (FAX)
JAMES RUBENSTONE (NMSS)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN X-RAY FLUORESCENCE DEVICE

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

"On October 15, 2014, the Agency [State of Texas] received a call from the licensee reporting that a Thermo Niton device model number XLP-818 containing 30 millicuries of americium-241 had been stolen. The device and a portable x-ray device were discovered missing from a locked cabinet on October 13, 2014. After initiating an investigation and searching for the devices, the licensee is confident that both devices were locked up in a cabinet on Friday, October 10, 2014 and went missing the following Monday morning. The licensee stated they did not believe any individual would receive any exposure due to this event. The licensee investigation is in progress. Additional information will be provided as it is received in accordance with SA 300."

Texas Incident #: I-9244

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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Non-Agreement State Event Number: 50543
Rep Org: MUNSON MEDICAL CENTER
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #: 21-08317-01
Agreement: N
Docket:
NRC Notified By: DENNIS AURAND
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/16/2014
Notification Time: 13:46 [ET]
Event Date: 10/16/2014
Event Time: 09:45 [EDT]
Last Update Date: 10/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
LAURA KOZAK (R3DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

PALLADIUM-103 BRACHYTHERAPY SEED BROKEN

"A Palladium-103 (Pd-103) brachytherapy seed (Theragenics Model 200 nominal activity 1.5 mCi) broke when the Mick shielded magazine was removed from the applicator. An activity of [approximately] 0.5 mCi for the lost portion of the seed was calculated by measuring the remaining portion of the seed. It was not recovered and presumed to have washed down a sink drain. The seed was broken and lost October 15, 2014 around 0945 [EDT]. The incident was discovered around 1645. Surveys of the area for the lost portion returned no radiation above background. Contamination from the seed is remote because the Pd-103 is coated on (adhered to) a graphite pellet. No personnel radiation exposure data available. It is unlikely the person involved received measurable dose.

"The process for removing the cartridge at the end of a procedure will be reviewed to reduce the chance of this happening again."

The licensee contacted NRC Region 3 DNMS personnel.

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Agreement State Event Number: 50544
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: O'SULLIVAN FILMS
Region: 1
City: WINCHESTER State: VA
County:
License #: 1655
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/16/2014
Notification Time: 13:47 [ET]
Event Date: 09/25/2014
Event Time: [EDT]
Last Update Date: 10/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST GENERAL LICENSED MATERIAL: AM-241 STATIC ELIMINATOR BARS

The following was provided by the Commonwealth of Virginia via email:

"On September 25, 2014, the Virginia Radioactive Materials Program (RMP) received a phone call from NRC Region 1 that one static eliminator bar, NRD A2003 serial number SA772 containing Am-241, Activity 19.6 mCi as of 4/16/1973 was found in Hedgesville, West Virginia and picked by the NRC inspectors. Record from NRD LLC indicated that this static eliminator bar was sold to O'Sullivan Films, which is located in Winchester, Virginia. In addition, the record from NRD LLC indicated that two other static eliminator bars, NRD A2003, Serial numbers 1229 and 1230, each containing 21 mCi of Am-241 as of 4/18/1975, were also sold to this company. Virginia RMP contacted O'Sullivan Films to investigate this case. O'Sullivan Films investigated the case and reported to RMP by the letter dated October 15, 2014 stating that O'Sullivan Films has not possessed these static eliminator bars and found no documentation that supports O'Sullivan Films having possessed, disposed of or returned these devices.

"Currently, no information is available regarding the whereabouts of these static eliminator bars."

VA Event Report ID No.: VA-14-18

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: 50547
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: PROJECT ENGINEERING CONSULTANTS
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800498
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/17/2014
Notification Time: 11:54 [ET]
Event Date: 10/16/2014
Event Time: 13:45 [MDT]
Last Update Date: 10/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENTS RESOURCE (EMAI)
JAMES RUBENSTONE (NMSS)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

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

"Event Description: The licensee failed to properly secure a moisture density gauge in a locked transportation case before leaving a temporary jobsite in a pickup truck. The device fell out of the truck onto the road. The licensee has not been able to locate the device. The local law enforcement agency has been notified."

The event location was 900 East and 5200 South, Murray, Utah. The device is a Troxler Model 3440, Serial number - 69079. This device contains 8 mCi of Cs-137 and 40 mCi of Am-241.

UT Event Report ID No.: UT140004

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: 50548
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY ASSOCIATES
Region: 4
City: GLENDALE State: AZ
County:
License #: AZ 07-639
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/17/2014
Notification Time: 12:16 [ET]
Event Date: 10/15/2014
Event Time: 10:30 [MST]
Last Update Date: 10/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MOVEMENT OF TREATMENT CYLINDER

"At approximately 1030 [MST] on October 15, 2014, the Agency [Arizona Radiation Regulatory Agency] was informed that the licensee had a medical event involving a High Dose Rate afterloader containing a 4.641 curie Iridium-192 source. A patient was receiving the third of three fractions involving a vaginal cylinder. When the Physicist entered the room after the treatment had concluded, he noticed that the cylinder had fallen out of the vaginal canal and was lying on the treatment table. The patient was unaware of the cylinders' position, but remembers feeling an 'oozing sensation' at the beginning of the treatment. The treatment time was for 431.3 seconds and the total prescribed dose for the fraction was 600 centigray and the total dose for all three fractions was 1800 centigray. The patient was also receiving external beam therapy at a rate of 200 centigray for 26 fractions, for a total dose of 5200 centigray. The patient received the last fraction on October 16th.

"The Agency is investigating the event.

"The Governor's office is being notified of this event."

Arizona First Notice Event No.: 14-025


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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Power Reactor Event Number: 50565
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: EMILY COLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/24/2014
Notification Time: 14:49 [ET]
Event Date: 08/27/2014
Event Time: 11:09 [CDT]
Last Update Date: 10/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES HICKEY (R2DO)

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

Event Text

INVALID ACTUATION OF GENERAL CONTAINMENT ISOLATION SIGNALS

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of general containment isolation signals affecting containment isolation valves in more than one system.

"On August 27, 2014, at 1109 hours Central Daylight Savings Time (CDT), while in a forced unit outage with the reactor noncritical (Mode 3) and with all control rods fully inserted, instrument mechanics were attempting to backfill reactor water level transmitter (LT) 3-53 sensing lines following performance of LT replacement. During this effort, water levels in both the variable and reference legs of the LT were disturbed resulting in a Browns Ferry Nuclear Plant (BFN) Unit 1 full scram and Primary Containment Isolation System (PCIS) Groups 2, 3, 6, and 8 isolation signals due to receipt of an invalid low reactor water level signal. The PCIS Groups 2, 3, 6, and 8 isolations caused the initiation of Trains B and C of the Standby Gas Treatment (SBGT) System and Control Room Emergency Ventilation (CREV) Subsystem 'A'. The Reactor and Refuel Zone ventilation fans tripped and the secondary containment dampers isolated. Train A of the SBGT System was tagged out of service during the event.

"Operations personnel responded to the PCIS initiation, ensured all equipment operated as designed, and placed affected systems back in service.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Problem Evaluation Report 928777.

"The NRC Resident Inspector has been notified of this event."

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Power Reactor Event Number: 50567
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHEL CICCONE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/24/2014
Notification Time: 20:59 [ET]
Event Date: 10/24/2014
Event Time: 19:03 [EDT]
Last Update Date: 10/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAN SCHROEDER (R1DO)

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

Event Text

NORMAL RANGE RADIATION MONITOR OUT OF SERVICE FOR UNPLANNED MAINTENANCE

The normal range Supplemental Leakage Collection and Release System (SLCRS) was removed from service due to a sample pump failure. Compensatory sampling and monitoring is being established per the Radiological Effluent Monitoring and Offsite Dose Calculation Manual. Following the sample pump repairs and restoration, the Radiation Monitor will be returned to service.

The licensee notified the NRC Resident Inspector, the State of Connecticut and Waterford township.

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Power Reactor Event Number: 50568
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: GERALD BAKER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/25/2014
Notification Time: 13:42 [ET]
Event Date: 10/25/2014
Event Time: 11:30 [EDT]
Last Update Date: 10/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAN SCHROEDER (R1DO)

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

Event Text

VENTILATION PROCESS RADIATION MONITORS OUT OF SERVICE FOR PLANNED MAINTENANCE

The normal and high range ventilation process radiation monitors (3HVR*RE 10 A/B) were removed from service for preplanned maintenance for greater than 72 hours. The radiation monitors will be returned to service following maintenance and completion of operational testing.

The licensee has notified the NRC Resident Inspector, the State of Connecticut and Waterford township..

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Power Reactor Event Number: 50569
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: DUANE SALISBURY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/25/2014
Notification Time: 23:41 [ET]
Event Date: 10/23/2014
Event Time: 10:46 [PDT]
Last Update Date: 10/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
WAYNE WALKER (R4DO)

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

Event Text

TURBINE BUILDING EXHAUST SAMPLE RACK DECLARED NON-FUNCTIONAL

"A planned outage for the Turbine Building Exhaust Air Radiation Indicating Switch (TEA-RIS-13) and the Turbine Building Process Radiation Monitoring Sample Rack (TEA-SR-26) for health inspection was initiated at 1046 PDT on 10/23/14. Due to maintenance retests taking longer than expected and in anticipation of possibly exceeding 72 hours for the planned outage, this event is being reported as a major loss of assessment capability under regulation 10 CFR 50.72(b)(3)(xiii). Compensatory measures have been implemented to obtain radiation readings from the associated effluent release pathway during the outage. Field team assessment function was unaffected and remains available.

"The Resident Inspector will be notified."

Page Last Reviewed/Updated Monday, October 27, 2014
Monday, October 27, 2014