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Event Notification Report for December 4, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/03/2014 - 12/04/2014

** EVENT NUMBERS **


50637 50638 50643 50649 50650 50652

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Agreement State Event Number: 50637
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/25/2014
Notification Time: 15:07 [ET]
Event Date: 11/24/2014
Event Time: [CST]
Last Update Date: 11/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS EVENT NOTIFICAT (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA STUCK SOURCE

The following was received via email:

"On November 25, 2014, the Agency [State of Texas] was notified by the licensee that on November 24, 2014, an INC IR100 radiography camera, Serial # 4374 with an Iridium-192 source, Model 32, Serial #W951, Activity - 1887 GBq (51 Ci) failed to operate properly at a field site. While the source was being cranked out, the drive cable went too far when the stopper in the pistol grip failed, resulting in the inability to reengage the drive cable and retrieve the source back into the camera. The licensee's RSO responded to the scene to inspect and retrieve the source. No individual received any significant additional exposure due to this event. The RSO received the highest dose of 23 mrem. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9256

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 50638
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: CARILLION CLINIC
Region: 1
City: ROANOKE State: VA
County:
License #: 770-051-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/25/2014
Notification Time: 15:31 [ET]
Event Date: 11/24/2014
Event Time: [EST]
Last Update Date: 11/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS EVENT NOTIFICAT (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received via email:

"A patient arrived for a rest/stress imaging procedure on 11/24/14. The rest dose was written to be 8 mCi Tc-99m, and the stress dose was written to be 24 mCi Tc-99m. The patient received the rest dose as written and the scan was performed. The patient was then to receive the 24 mCi stress dose, but instead received a 5 mCi stress dose (same drug, but only 21% of the intended activity) that was intended as the rest dose for another patient. Once the error was discovered, the patient was informed of the error and sent home with the intention of rescheduling the procedure at a later date. The licensee will submit the 15 day report to VRMP [Virginia Radioactive Materials Program] at which time the corrective actions will be reviewed and verified during their next inspection. "

Virginia Incident #: VA-14-23

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.

* * * RETRACTION ON 11/25/14 AT 1637 EST FROM MIKE WELLING TO DONG PARK * * *

This report is being retracted, because it does not meet 10CFR35.3045 criteria.

Notified R1DO (Noggle) and NMSS Events Notification via email.

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Non-Agreement State Event Number: 50643
Rep Org: VETERANS HEALTH ADMINISTRATION
Licensee: VETERANS HEALTH ADMINISTRATION
Region: 4
City: FRESNO State: CA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/26/2014
Notification Time: 14:54 [ET]
Event Date: 11/26/2014
Event Time: 08:00 [PST]
Last Update Date: 11/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS EVENT NOTIFICAT (EMAI)

Event Text

RECEIPT OF A PACKAGE WITH REMOVABLE SURFACE CONTAMINATION

"Per 10 CFR 20.1906(d), [licensee is] reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received today (November 26, 2014) at around 0800 PST by VA Central California Health Care System. This facility holds permit number 04-01935-03 under the VHA [Veterans Health Administration] master materials license. The package was checked-in and surveyed around 0830 PST. Wipe tests performed on the external surface of the package indicated a removable contamination level of 7155 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. The package contained seven unit dosages of radiopharmaceuticals ranging between 10 and 40 millicuries each of Technetium-99m and was shipped from Cardinal Health in Fresno, California. The specific radionuclide that resulted in the contamination was not identified but does not appear to be Technetium-99m. The wipe counting statistics were based on Ba-133. The inner packaging materials were not contaminated. The facility immediately notified the vendor/shipper, who serves as the final delivery carrier, about the contaminated package at about 0835 PST. VHA National Health Physics Program was notified around 0845 PST with initial information. As corrective actions, the packaging materials were bagged and set aside in a restricted area at the facility for further evaluation."

The licensee notified the NRC Region III Project Manager (Null).

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Power Reactor Event Number: 50649
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DENNY SMITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/03/2014
Notification Time: 01:10 [ET]
Event Date: 12/02/2014
Event Time: 20:50 [CST]
Last Update Date: 12/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 62 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO FAILURE OF CONDENSATE PUMP

"Initiated a manual Unit 1 reactor trip due to imminent failure of 1P-25B Condensate Pump. Unit 1 had commenced a rapid down power due to the degradation of the pump. The event is reportable under 10CFR50.72(b)(2)(iv)(B) for a manual actuation of the reactor protection system when the reactor is critical and 10CFR50.72(b)(3)(iv)(A) for an actuation of specified system (6) PWR auxiliary feedwater system. Auxiliary feedwater system actuation was due to low steam generator water levels in both 'A' and 'B' Steam Generators, an expected system response during a reactor trip. Decay heat removal is by forced circulation and is being controlled by auxiliary feedwater system and condenser steam dumps.

"After the trip, both main steam generator feedwater pumps were secured due to feed pump suction pressure remaining low post trip.

"All other plant systems functioned as required. All control rods fully inserted in the core due to the manual trip. There was no ECCS actuation. Off-site power has been maintained throughout the event."

No primary or secondary safety relief valves lifted during the reactor trip. Unit 1 is in a normal shutdown electrical lineup. There was no effect on Unit 2.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 50650
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID HURT
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/03/2014
Notification Time: 05:05 [ET]
Event Date: 12/03/2014
Event Time: 00:22 [CST]
Last Update Date: 12/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY KELLAR (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

"An unexpected main turbine trip causing a reactor trip occurred on 12/03/2014 [at 0022 CST] with the plant operating in Mode 1 at 100 percent power. As part of the plant design, an expected, valid actuation of the Auxiliary Feedwater System occurred in response to the reactor trip. As part of the Auxiliary Feedwater actuation, the 'B' Motor Driven Auxiliary Feedwater Pump to 'D' Steam Generator throttle valve did not throttle as expected and was manually isolated. All other systems functioned normally in response to the plant conditions. The plant is currently stable in Mode 3 at 0 percent power. Safety related buses are receiving normal off-site power and the grid is currently stable.

"The NRC Resident Inspector was notified."

All control rods fully inserted on the reactor trip. Steam generator levels are being maintained by the AFW system and decay heat is being removed by the main condenser. No primary or secondary safety relief valves lifted during the transient.

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Power Reactor Event Number: 50652
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: NATHAN BIBUS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/03/2014
Notification Time: 16:02 [ET]
Event Date: 12/03/2014
Event Time: 09:50 [CST]
Last Update Date: 12/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)

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

CONTROL ROOM AREA RADIATION MONITOR FAILED LOW

"At 0950 CST on December 3, 2014, R-1 Control Room Area Radiation Monitor failed low and was taken out of service. This monitor has no redundant monitor that will allow timely classification of two Emergency Action Levels (EALs) - NUE (Notification of Unusual Event) and Alert classifications - when out of service. This results in a Loss of Emergency Assessment Capability while R-1 is out of service. This is a reportable condition in accordance with 10 CFR 50.72(b)(3)(xiii).

"Control Room readings were normal as evidenced on R-1 prior to its failure. Compensatory measures have been established with a Portable Area Monitor installed in the Control Room adjacent to R-1. Corrective maintenance is in progress and will continue until the monitor is returned to service.

"The health and safety of the public was not affected by this issue.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Thursday, December 04, 2014
Thursday, December 04, 2014