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Event Notification Report for March 13, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/12/2015 - 03/13/2015

** EVENT NUMBERS **


50800 50861 50862 50865 50867 50868 50881

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50800
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: SCOTT MOECK
HQ OPS Officer: VINCE KLCO
Notification Date: 02/10/2015
Notification Time: 01:25 [ET]
Event Date: 02/09/2015
Event Time: 17:30 [CST]
Last Update Date: 03/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DON ALLEN (R4DO)

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

Event Text

SAFETY INJECTION TANK LEVEL RESULTS IN AN UNANALYZED CONDITION

"On October 14, 2013 a calculation for the containment internal structural analysis was revised and accepted by the station. This calculation limited the Safety injection tank level to 74%. On October 16, 2013 Safety injection tank level was raised to 100% for approximately 13 hours in preparations for plant start-up. While the plant was safely in a cold shutdown condition, this represents a reportable unanalyzed condition. This issue is of a historical nature and does not question the current operability of any plant systems or structures. This was self identified during a Fort Calhoun calculation review."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM MICHAEL PEAK TO DANIEL MILLS AT 2335 EDT ON 3/12/15 * * *

"Following review of the reported event, attendant calculations and associated documentation, engineering personnel determined that the condition described in event notification EN50800 did not place the plant in an unanalyzed condition.

"Revision 1 of a calculation for the containment internal structural analysis demonstrated that when the safety injection tanks 'B' and 'D' are 100% filled in an outage condition, approximately a 10% safety margin is maintained. This revision was the calculation of record at the time the safety injection tank levels were raised above 74%, in October, 2013.

"Revision 2 of the calculation was completed to remove excess conservatism and to provide a closer representation of available margin. In addition, margin was also improved by limiting tank level to 74%. However, improving margin by limiting tank level to 74% does not result in an unanalyzed condition when tank level is 100%, as adequate margin remains.

"Therefore this event is being retracted."

The licensee will notify the NRC Resident Inspector.

Notified the R4DO (Okeefe).

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Non-Agreement State Event Number: 50861
Rep Org: UNIVERSITY OF MISSOURI
Licensee: UNIVERSITY OF MISSOURI
Region: 3
City: COLUMBIA State: MO
County:
License #: 24-00513-32
Agreement: N
Docket:
NRC Notified By: JACK CRAWFORD
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/04/2015
Notification Time: 10:50 [ET]
Event Date: 03/04/2015
Event Time: [CST]
Last Update Date: 03/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

MISSING TRITIUM EXIT SIGN

A tritium exit sign was discovered missing during a December 2014 inventory. The missing tritium exit sign is an Isolite Model 2000 containing two (2) 10 Ci sources, S/N 11-38620 and 11-38621. It was originally scheduled for installation in December 2012 at the University of Missouri Power Station but not installed due to other extensive renovations. The licensee conducted an investigation contacting both the contractor who was to perform the install and the manufacturer before concluding that the sign was missing.

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: 50862
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: 00466
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/04/2015
Notification Time: 11:52 [ET]
Event Date: 03/03/2015
Event Time: 16:01 [CST]
Last Update Date: 03/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR SOURCE WOULD NOT FULLY LOWER TO SHIELDED POSITION

The following report was received from the Texas Department of State Health Services via email:

"On March 4, 2015, the licensee reported that a malfunction had occurred involving its J.L. Shepherd Mark I, Model 30, self-contained irradiator. [The] irradiator contains a J. L. Shepard Type 6810, 10,000 curie, Cs-137 source with serial number 85CS26. The source would not fully raise nor would it lower into the fully shielded position. The interlock system functioned as designed and the irradiator door remained locked. No one received any exposures and there is no risk for exposure as a result of this event. The licensee has contacted the manufacturer and scheduled repair. An investigation into this event is ongoing. An update will be forwarded in accordance with SA-300."

Texas Incident #: I-9282

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Agreement State Event Number: 50865
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EXXON MOBIL OIL CORPORTATION
Region: 4
City: TORRANCE State: CA
County:
License #: CA-0113-19
Agreement: Y
Docket:
NRC Notified By: TANYA RIDGLE
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/04/2015
Notification Time: 19:31 [ET]
Event Date: 03/04/2015
Event Time: 09:00 [PST]
Last Update Date: 03/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER NOT OPERATING PROPERLY ON NUCLEAR PROCESS GAUGE

The following information was received from the Los Angeles Radiation Management Department via facsimile:

"On March 4, 2015, the Radiation Safety Officer (RSO), Exxon Mobil Oil Corporation (License #0113-19) reported to LA County Radiation Management that the shutter on one of their Thermo Nuclear gauges was not operating such that it could be completely closed per the manufacturer's design/specifications. This issue was discovered while Exxon Mobil was testing the integrity of all sources and source holders located in the area affected by the explosion that took place on February 18, 2015 (5010 #021815).

"At approximately 0900 [PST], [the RSO], along with a licensed Thermo Nuclear technician discovered that the Thermo Nuclear source holder, would not close completely, despite multiple attempts by the Thermo Nuclear technician. A radiation survey was performed around the source holder and the surrounding area was taped off with caution tape. The radiation level surrounding the source holder was found to be approximately 4 mR/hr. Exxon Mobil identified the source holder as Thermo Nuclear Model 5197, S/N CN-2435, with a 100 mCi Cs-137 source (S/N B8849).

"Upon discovery, [the RSO] immediately contacted LA County Radiation Management to report the findings. In addition to taping off the area, [the RSO] stated that the source is still in its normal position, approximately 10 feet from the ground and away from any routine traffic. Exxon Mobil has 24 gauges in the area that [were] impacted by the explosion on February 18, 2014. [The RSO] stated that only 11 gauges have been inspected thus far for leakage and damage. The remaining gauges will be inspected by the end of the week. Should Exxon Mobil discover another damaged source or source holder, they have been instructed to report the findings to LA County Radiation Management immediately."

California 5010 Number: 030415

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Agreement State Event Number: 50867
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: DESERT NDT
Region: 4
City: ELK CITY State: OK
County:
License #: OK-32101.01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/05/2015
Notification Time: 15:42 [ET]
Event Date: 03/05/2015
Event Time: [CST]
Last Update Date: 03/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO ASSISTANT RADIOGRAPHER

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

"We [Oklahoma Department of Environmental Quality] have been notified by Desert NDT (OK-32104-01) located in Elk City, OK, that the dosimetry report for the February 2015 monitoring period showed a dose of 5780 mR for one of their assistant radiographers. They also report that the individual's daily pocket dosimetry readings for this period do not correlate with this result. The investigation is ongoing."

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Agreement State Event Number: 50868
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: LEGACY GOOD SAMARITAN MEDICAL CENTER
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-91155
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/05/2015
Notification Time: 17:38 [ET]
Event Date: 03/04/2015
Event Time: [PST]
Last Update Date: 03/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENTS DUE TO A MISALIGNED GAMMA KNIFE

On March 4, 2015, the licensee notified the State of Oregon that they discovered that their Elekta Leksell Gamma Knife was off target by approximately 1.87mm. This was allegedly due to maintenance performed in early January 2015, that resulted in a misaligned couch. Since the misalignment, eight patients have undergone gamma knife surgery. The licensee Medical Physicist is currently evaluating each case to determine whether an underdose/overdose occurred to any of the patients.

The Elekta Leksell Gamma Knife is licensed for up to 6.6 kCi of Co-60.

The State of Oregon will update this report as more information becomes available.

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: 50881
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SHANE HARVEY
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/12/2015
Notification Time: 16:06 [ET]
Event Date: 03/12/2015
Event Time: 09:00 [CDT]
Last Update Date: 03/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (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

Event Text

LOSS OF THE SEISMIC MONITORING COMPUTER

"In accordance with 10 CFR 50.72(b)(3)(xiii), this notification reports a loss of Emergency Preparedness assessment capability with the unplanned inoperable condition for the Byron seismic monitor. Specifically, the seismic monitor was declared non-functional at 0345 CST on March 7, 2015 following an unplanned loss of the seismic monitoring central computer. This condition adversely impacted the capability to perform an ALERT EAL (HA4) assessment in accordance with the Radiological Emergency Plan Annex. The loss of assessment capability is reportable to the NRC within 8 hours of the discovery in accordance with 10 CFR 50.72(b)(3)(xiii)

"The seismic recorder was reset by Plant Engineering at 0440 CST on March 8 2015, which restored the seismic monitoring system to full capability.

"The unplanned non-functional condition of the seismic monitor was entered into the Byron CAP [Corrective Action] Program when the condition was discovered. Initially it was determined that the condition did not meet the requirements for an ENS notification as it was concluded that it did not substantially impair Byron station's emergency assessment capability in the event of an earthquake. Upon further review, at 0900 CDT on March 12, 2015, it was concluded that an ENS notification was warranted because the monitor was specifically Cited in the Emergency Action Level (EAL) HA4 threshold for identifying an ALERT due to an OBE (Reference procedure EP-AA-1002, Addendum 3, 'Emergency Action Levels for Byron Station').

"A follow-up written notification is not required for this notification under 10 CFR 50.73. The NRC Resident Inspector has been notified."

The State of Illinois Resident Inspector has been notified.

Page Last Reviewed/Updated Friday, March 13, 2015
Friday, March 13, 2015