Event Notification Report for June 05, 2015

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

The following report was received via e-mail:

"A Troxler 3450 moisture density gauge was run over by a soft tire roller. The gauge housing was cracked open with no apparent damage to the source or shielding. The gauge was placed in its case and transported to the CTL lab in Tacoma."

The sources are: 10 mCi Cs-137 and 50 mCi Am-241

Washington Incident: WA-15-017

* * * UPDATE AT 1704 EDT ON 6/10/2015 FROM STEVE MATTHEWS TO MARK ABRAMOVITZ * * *

"A Troxler 3450 moisture density gauge was damaged by a soft tire roller at 2140 [PDT] Friday night, June 5th. The location was 15433 West Snoqualmie Valley Road, between Woodinville and Duvall near Carnation. The gauge housing was cracked open but there was no apparent damage to sources or shielding. The gauge was placed in its Type A package and transported to the licensee's facility in Puyallup. From there, the gauge was picked up by a gauge manufacture representative for repair and leak test. The incident occurred because the portable gauge operator turned away momentarily to speak with another construction worker and didn't see the roller getting close and making contact with the gauge. The licensee will be conducting additional training on constant control. There will be a citation for lack of constant surveillance and not notifying our office [Washington Office of Radiation Protection]. The actual notification we received was from the licensees customer, King County Materials Lab."

Notified the R4DO (Werner) and NMSS Events Notification (via e-mail).

PART 21 - INCORRECT PART NUMBER RELAY SHIPPED TO BRUNSWICK NUCLEAR PLANT

The following is an excerpt of communication received via fax:

"Summary:
Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 04/13/15 upon discovery that governor control panels shipped to Brunswick Nuclear Plant contained an incorrect part number relay. The evaluation was concluded on 06/05/15 and it was determined that this issue is a reportable defect as defined by 10CFR Part 21. Under certain adverse conditions, a panel with the incorrect part number relay may lose power thereby resulting in inoperability of the electronic control portion of the control system. This could prevent the emergency diesel generator set from performing its safety-related function during an emergency event.

"Discussion:
The relay in question is the Governor Control At Setpoint (GCASP) relay installed in the governor control panel assembly P/N 8002096-PANEL. The panel provides speed control functions for the emergency diesel generator (EDG). In the original panel design the part number specified was 219XBX282NE. During the course of EMC testing, it was determined that the EMI suppression diode within in the GCASP relay must be removed in order for the EUT to comply with the requirements of [International Electrotechnical Commission] IEC 61000-4-5. When the diode was installed and the negative polarity portion of surge testing forward biased the diode, this resulted in a short circuit connection between the supply and return conductors of the control panel's power. This caused the fuses designed to protect the panel from overcurrent conditions to fail open; resulting in a loss of power to the control panel.

"In place of the EMI suppression diode, a [Metal Oxide Varistor] MOV (P/N V150LA10AP) was added across terminals 6 & 7 of the GCASP relay socket. The MOV provides similar EMI suppression to the removed diode and responds appropriately to either polarity of surge waveform. The MOV is external to the relay and is considered a separate component. The MOV is not affected by this notification.

"Removal of the internal EMI suppression diode for the GCASP relay resulted in a part number change. The relay part number that should have been installed is P/N 219XBX283NE. The part number of the relay actually installed was P/N 219XBX282NE. The difference between the two relays is that P/N 219XBX282NE contains an internal suppression diode whereas 219XBX283NE does not.

"Impact on Operability:
During normal operating conditions, the EDG will perform its safety related function with the incorrect GCASP relay installed in the governor control panel. Both relays provide the same switching function.

"However, if a negative polarity surge similar to the requirements of IEC 61000-4-5 were to occur on the 125 VDC bus with the incorrect relay installed, the control panel may lose power. The 27GP relay would de-energize, alerting plant personnel of an under-voltage condition within the governor control panel. The EDG would remain operable on the mechanical governor though the electronic control portion would be inoperable.

"Root cause evaluation:
An error by a technician in conjunction with a lapse in oversight allowed this problem to occur. Contributing to the issue was that only one digit differentiates the two part number relays and both have the same overall appearance (size, shape, case style, etc).

"Evaluation of previous shipments:
This issue only affects one part number (qty 4) supplied on one customer purchase order.

"Corrective Action:
The customer was advised of the situation via letter 'Notice of GCASP Relay Discrepancy - Governor Control Panel' sent on 04/15/15. The correct relays were then supplied to the customer as dedicated, safety-related replacements on ESI IWO 8002474 (Brunswick PO 00786240) for installation in the panels. There are four panels affected, each containing one of these relays. ESI supplied four replacement relays which were [Certificate of Conformance] C-of-C'd and shipped on 04/17/15. These are plug-in style relays and to replace the relay only requires pulling out the old relay and plugging in the new relay. No special tools or instructions are necessary."

LOSS OF DECAY HEAT REMOVAL TO THE 'A' STEAM GENERATOR

"Fort Calhoun Station is currently completing a scheduled refueling outage. On June 5, 2015 at 1330 during performance of surveillance testing on the auxiliary feed water system, [Hydraulic Control Valve] HCV-1107A, Steam Generator RC-2A Auxiliary Feedwater Inlet Valve, did not open when given an open signal. HCV-1107A has been declared inoperable. HCV-1107A is required to open to meet the decay heat removal safety function for Steam Generator A. Fort Calhoun Station is in Mode 3 (Reactor Coolant System temperature is greater than 515 degrees Fahrenheit and not critical). With HCV-1107A inoperable and unable to feed the A steam generator both auxiliary feedwater trains are considered inoperable. HCV-1107A is inside the Containment Building.

"Fort Calhoun Station Technical Specifications 2.5(1)D. requires:
With both AFW trains inoperable, then initiate actions to restore one AFW train to OPERABLE status immediately. Technical Specification (TS) 2.0.1 and all TS actions requiring MODE changes are suspended until one AFW train is restored to OPERABLE status.

"Fort Calhoun Station is evaluating the best approach to repairing HCV-1107A.

"The Resident Inspector has been notified."

* * * UPDATE PROVIDED BY CHARLIES SMITH TO RICHARD SMITH AT 2300 EDT ON 06/05/2015 * * *

"Fort Calhoun Station has determined plant cooldown required to perform repairs. Plant cooldown in progress."

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Whitten)

AGREEMENT STATE REPORT - RADIOACTIVE SOURCE FOUND IN SCRAP METAL

The following report was received via e-mail:

"Scrap alarm was received at Gerdau Ameristeel, Jacksonville. Scrap bales were from KAS Metals (1912 Elman St. Orlando). Radiation surveys conducted with a Radcomm read 500 mR/hr at the front of trailer and 300 mR/hr at 2 meters. Readings in the cab were 10 mR/hr. All reading and units were confirmed. Due to the reading exceeding DOT levels the load was not granted an exemption and was left in a secure area until Bureau [Florida Bureau of Radiation Control] personnel arrive. The driver left Orlando at 1030 EDT and arrived in Jacksonville at 1430 EDT. The driver [works for] for CPG Enterprises."

Florida event number: FL15-057

* * * UPDATE ON 6/16/15 AT 1208 EDT * * *

The following was received via e-mail:

"The source was found to be a broken Troxler handle assembly, [containing] 8 mCi of Cs-137, Dated April 1999, Serial# 50-5034, (ALT 60-5034) 1.5 R/hr [on contact] Issued Sample Tag # Z-011"

Notified R1DO (Bickett) and NMSS Events Notification (email).

AGREEMENT STATE REPORT - LOSS OF I-125 SEED

The following report was provided by the Maine Radiation Control Program via email:

"Maine Medical Center (MMC) reported the loss of an I-125 localization seed (39209B-5-12) that contained an activity of 3.4 MBq (92 æCi). The seed was discovered lost during an inventory performed on 6/5/2015. The seed was still in the inventory log, but was not physically present. A nuclear medicine technologist searched the hot laboratory, mammography, and ultrasound areas, but the seed was not found. MMC continued to search for the seed for several weeks. There is no evidence that the seed was implanted into a patient. MMC believes that the seed was inadvertently placed into the trash in the hot laboratory. Corrective actions included providing additional training to personnel."

Maine Event Report: ME150003

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

RADIOACTIVE SURFACE CONTAMINATION EXCEEDS LIMITS

The licensee nuclear medicine technologist ordered a package containing radioisotopesTc-99m and Xenon for a patient. The package was delivered by an offsite nuclear pharmacy to the Indiana University Health- Ball Memorial Hospital. When the technician surveyed the package, the surface contamination exceeded specified limits and nominally measured about 14,000 dpm. The package was quarantined and the vendor/shipper was notified concerning the surface contamination. The package was placed in a gamma camera and the indicated camera spectrum indicates Xenon package contamination. The Radiation Safety Officer has ordered the package to remain quarantined. No personnel contamination resulted from this event.

PART 21 REPORT - FERRAZ SHAWMUT/MERSEN FUSES P/N: AJT25 AND AJT60

The following information was excerpted from the email provided by the reporting organization:

"On April 2015, United Controls International (UCI) performed dedication testing on time delay fuses AJT25 and AJT60 for First Energy - Perry Nuclear Power Plant under purchase orders 45469886 and 45469450, respectively. The subject fuses were being tested per United Controls Standard dedication testing which excludes seismic and environmental testing requirements. Both fuses, AJT25 and AJT60 opened during their current clearing tests at times that are within their respective clearing time tolerance ranges but their Smartspot labels did not change color, as required, to indicate the fuses cleared.

"For fuse AJT25, eight fuses have been tested, including one (1) fuse from the first lot which comprises 30 fuses (with manufacture date 09/15 [9th week of 2015]) and seven (7) fuses from the second lot which comprises 32 fuses (with manufacture date 10/15). Five (5) fuses were tested for current clearing at 135% of the fuse rated current, two (2) fuses were tested for current clearing at 200% of the fuse rated current and one (1) fuse was tested for current clearing at 500% of the fuse rated current.

"For fuse AJT60 with manufacture date 06/15, only one (1) fuse was tested from the received lot of fuses which comprises 24 fuses for current clearing time at 135% of the fuse rated current. Further testing of the AJT60 fuses was not performed since a trend was already observed in regard to the fuses AJT25 failure.

"UCI has returned all received fuses in the three (3) received lots. Mersen [Ferraz/Shawmut/Mersen] has then performed evaluation on the 30 AJT25 fuses with manufacture date of 9/15 (9th week of 2015), confirmed that the seven (7) fuses that UCI has tested were open and conducted testing on six (6) among the remaining 23 fuses. Testing by Mersen revealed that only two out of the six fuses had their Smartspot indicator that went off to indicate that the fuses cleared. Upon further examination by Mersen; it is believed that over tightening of the crimping jars during installation and crimping of the ferrule endcaps is the cause of the Smartspot indicator's malfunction.

"The fuses are Ferraz Shawmut/Mersen part numbers AJT25 and AJT60. UCI recommends the purchaser to include a requirement for suppliers to provide fuse with manufacture date after 6/30/15 where the manufacturer has performed corrective action to prevent this issue from recurring."

Point of Contact: Divya Paidy, Engineering Manager, dpaidy@unitedcontrols.com, (770) 496-1406, ext. 106,