United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2015 > August 21

Event Notification Report for August 21, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/20/2015 - 08/21/2015

** EVENT NUMBERS **


51311 51312 51314 51315 51316 51317 51333 51334 51335

To top of page
Agreement State Event Number: 51311
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CALFRAC WELL SERVICES CORP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 06710
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2015
Notification Time: 08:43 [ET]
Event Date: 08/11/2015
Event Time: [CDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE INLINE DENSITY GAUGE

The following report was received via e-mail:

"On August 11, 2015, the licensee notified the Agency [Texas Department of State Health Services] that during a routine inspection of one of its Berthold model 8010 portable inline density gauges (SN: 10182), that contained a 20 millicurie Cesium-137 source, it found that the shutter handle was bent and the shutter could not be fully operated. The shutter was in the closed position. The gauge was secured at the licensee's facility. The licensee's radiation safety officer (RSO) is investigating the cause of the damage. The RSO has contacted the gauge manufacturer and arrangements are being made for repairs. There have been no exposures to any individual as a result of this event. Further information will be provided as it is obtained in accordance with SA-300."

Texas Incident #I-9333

To top of page
Agreement State Event Number: 51312
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NEWELL RECYCLING SOUTHEAST
Region: 1
City: PHENIX CITY State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2015
Notification Time: 09:09 [ET]
Event Date: 08/05/2015
Event Time: [CDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - Sr-90 SOURCE FOUND AT RECYCLING FACILITY

The following report was received via fax:

"On August 5, 2015, while investigating a collection of naturally occurring radioactive material (NORM) at Newell Recycling Southeast facility in Phenix City, AL, representatives from the Alabama Office of Radiation Control identified what appeared to be a very old gauge containing radioactive material. Initial field analysis measurements identified the isotope as Sr-90.

"A follow-up visit on August 7, 2015 by Alabama Office of Radiation Control personnel confirmed the source of radiation to be a very old device containing a sealed Sr-90 source. Maximum radiation levels of 1500 mR/hr (beta + gamma) and 300 mR/hr (gamma only) at the port opening were measured. The device was secured and placed in storage at the facility. A leak test was performed and the results are pending.

"The origin of the device is unknown. There are no identifying marks on the device. The Alabama Office of Radiation Control continues to investigate to determine the make, model and serial number. It is assumed that the device is a very old, generally licensed device that was abandoned, lost or stolen in the past."

Alabama Incident 15-36

To top of page
Agreement State Event Number: 51314
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CLEARWATER PAPER CORPORATION
Region: 4
City: MCGEHEE State: AR
County:
License #: ARK-0530-0312
Agreement: Y
Docket:
NRC Notified By: SUSAN ELLIOT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2015
Notification Time: 16:30 [ET]
Event Date: 08/11/2015
Event Time: 13:00 [CDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED KAY-RAY FIXED GAUGES REPAIRED WITH SHUTTER OPEN

The following report was received from the State of Arkansas via email:

"[The licensee] discovered two fixed gauges, manufactured by Kay-Ray, model #GRP-6082, serial #6124 (digester 2) and #6125 (digester 3) with a 5 Curie Cs-137 source were damaged sometime in May 2014.

"The Department [Arkansas Department of Health] became aware of the repair during a routine inspection of the plant. According to the field service report, repairs were performed on June 5, 2014. The repairs were to the lead shielding around source holders which was separated from the original fabrication and needed to be refastened. The field service report indicated the shutter was not closed during the repairs.

"Basic evaluations at the time of inspection, by [licensee] Radiation Control Health Physicists, indicated there were no public exposure levels above the regulatory requirement. The gauges are mounted on a steel metal box. The gauges are located on the 3rd floor 10 feet above the floor. Gauges are in cages inaccessible without a ladder. It is believed a small field of radiation was present but there were no significant exposures to the public.

"The State [Arkansas] is awaiting a written report from the licensee and will continue to investigate this event. The State will update this event as more information becomes available.

"Louisiana Department of Environmental Quality Office was notified."

Arkansas Event Number: ARK-2015-011

To top of page
Agreement State Event Number: 51315
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: UNKNOWN
Region: 1
City: MURFREESBORO State: TN
County:
License #: NON LICENSE
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2015
Notification Time: 17:14 [ET]
Event Date: 07/13/2015
Event Time: 09:45 [EDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - NDC GAUGE RECOVERED FROM LANDFILL

"On July 13, 2015, a load of residential waste set off the radiation alarm at Middlepoint Landfill, in Murfreesboro, TN. The load, originally thought to be personnel medical waste, was set aside to decay. [Tennessee Radiological Health] Division staff returned on July 16, 2015, with a Canberra Inspector 1000 [detector], for identification and to obtain a spectrum for analysis. After review, the material was determined to be Am-241. [Tennessee Radiological Health] Division staff returned to landfill on July 17, to search for item. Separated from residential waste, the item was found to be a NDC Model 100 series backscatter gauge, SN #11755. The activity on the label was 0.93 GBq (25 mCi). The gauge was transported to the [Tennessee Radiological Health] Division field office in a probe down position surrounded by lead bricks; this resulted in dose rate readings to nearest occupant at approximately background levels. The [Tennessee Radiological Health] Division staff monitored the gauge in route to the field office. Upon arrival, the gauge was surrounded by lead bricks and stored in an isolated area with a pre-arrival background level of 6 microR/hr dose rate. The post-arrival dose rate readings were 8 microR/hr.

"Under reciprocity, NDC Technologies personnel are scheduled to pack and remove the gauge on 8/13/2015, for return to the manufacturer."

Tennessee State Event Report ID NO: TN-15-102

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

To top of page
Agreement State Event Number: 51316
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONNECTEC, INC.
Region: 4
City: IRVINE State: CA
County:
License #: 7972-30
Agreement: Y
Docket:
NRC Notified By: ANDREW TAYLOR
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2015
Notification Time: 20:20 [ET]
Event Date: 08/06/2015
Event Time: [PDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM TARGET SIGHTS

The following report was received by the State of California via email:

"On August 12, 2015, [the licensee's], Alternate Radiation Safety Officer, contacted the [State of California Radiologic Health Branch] Brea Radioactive Materials office to report lost Tritium [target sight] sources. After receipt at the [licensee] facility, 18 sources were no longer accountable in the inventory process. [The licensee] noted that, sometime between August 6 and August 10, the loss was discovered by one of the [licensee's] authorized users while performing an inventory of sources in the shipment to ensure that the proper number of sources were received. The lost sources were SRB Technologies, Inc. model AR Tritium [target sights] generally licensed sealed sources (these sources do not have serial numbers) with 0.8 Curies of tritium, for a total of 14.4 Curies.

"After the missing sources were discovered, SRB Technologies was contacted to determine the number of sources that were supposed to be contained in the package. When SRB Technologies personnel notified [licensee] that the package contained 36 sources, as listed in the included packing slip, [licensee] personnel conducted a search of the facility to find the sources. When the search did not find the missing sources, it was determined that the missing sources were likely to have been thrown away with the packaging in their trash bin, which had already been emptied on the morning of August 7, 2015. The Irvine facility of Waste Management was contacted to determine if it was possible to search the trash bin, but they were told that was not possible and the trash was most likely to have been dumped in a landfill. Once the investigation into the loss of sources was completed on August 12, 2015, the licensee determined the sources to be lost, most likely in a landfill. After the determination that the source were lost was made, [the licensee] then contacted the [State of California] Brea Office to make the official report."

California 5010 Number: 081215

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

To top of page
Non-Agreement State Event Number: 51317
Rep Org: MIDDLESEX HOSPITAL
Licensee: MIDDLESEX HOSPITAL
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 06-00649-03
Agreement: N
Docket:
NRC Notified By: JOAN MERTIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/13/2015
Notification Time: 12:03 [ET]
Event Date: 08/11/2015
Event Time: 12:00 [EDT]
Last Update Date: 08/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - PATIENT RECEIVED UNDERDOSE OF YTTRIUM 90

During a treatment of the left lobe of the liver, the dose delivered to the patient was discovered to differ greater than 20 percent than the intended dose. 120 Gray was prescribed by the physician and 72 Gray was delivered. During the procedure the Radose meter did not appear to be operating properly. Subsequent investigation determined that there was some radioactivity that remained in the vial. The technologist called the manufacturer who advised to perform several flushes and the Radose meter still did not change. The procedure was ended at that point. After ending the procedure when the survey was performed on the waste jar, it was discovered that only 60% of the dose was delivered. The activity appeared to be concentrated in the plunger attached to the vial. A new Radose detector will be obtained prior to the next procedure.

The patient will be informed of the issue by the physician.

Source Material: Yttrium 90, 7.03 GBq.

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.

To top of page
Power Reactor Event Number: 51333
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOE BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/20/2015
Notification Time: 18:51 [ET]
Event Date: 08/20/2015
Event Time: 10:32 [CDT]
Last Update Date: 08/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMIE HEISSERER (R2DO)

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

Event Text

AUTOMATIC START OF AN EMERGENCY DIESEL GENERATOR ON LOW BUS VOLTAGE

"On August 20, 2015, at approximately 1032 CDT, during the Residual Heat Removal flow rate test, the 3ED 4kV Shutdown Board received a degraded voltage signal, which automatically started the 3D Emergency Diesel Generator (EDG). The EDG performed its safety function by automatically supplying power to the Shutdown Board. Troubleshooting on the degraded voltage signal is in progress. The remaining 4kV Shutdown Boards and EDGs were unaffected and remain operable.

"This constitutes an automatic actuation of the EDG and requires an 8-hour ENS notification in accordance with 10 CFR 50.72(b)(3)(iv)(A), due to the valid actuation of the EDG, and a 60-day report in accordance with 10 CFR 50.73(a)(2)(iv)(A).

"The licensee has notified the NRC Resident Inspector."

To top of page
Power Reactor Event Number: 51334
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN LOGAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/20/2015
Notification Time: 22:28 [ET]
Event Date: 08/20/2015
Event Time: 17:10 [CDT]
Last Update Date: 08/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
KENNETH RIEMER (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

CONDITION THAT COULD PREVENT PRESSURIZER PORV BLOCK VALVES FROM OPERATING

"On 8/20/2015 at 1710 CDT, a design flaw was discovered with the pressurizer power operated relief valve (PZR PORV) block valve control circuitry. Specifically, the circuit deficiency for which a design basis fire in the Main Control Room (MCR) or cable spreading room could prevent the PZR PORV block valves from being closed from the local control switch at their associated motor control center (MCC). Engineering has reviewed this issue and determined that a potential fire induced ground in the MCR or cable spreading room could clear the associated control power fuses which would prevent the block valves from operating at the local control switch.

"These valves are considered to form a High/Low pressure interface which requires postulating a proper polarity DC cable to cable fault. Engineering has reviewed the circuit design and cable routing associated with PORVs 1(2)RY455A and 1(2)RY456 and determined that their associated cables are routed with other DC circuit cables in the MCR control board and cable spreading room raceways, such that this postulated fault could potentially cause spurious opening of one of the PORVs even after the control power fuses have been removed as directed by the station abnormal operating procedures for control room inaccessibility.

"This identified block valve circuit deficiency prevents the credited safe shutdown action of locally closing the block valves to mitigate the spurious operation of a PORV.

"Hourly fire watches of the affected MCR and cable spreading room fire zones have been implemented. In addition, the MCR is continuously staffed and the affected cable spreading room fire zones are equipped with detection and automatic suppression.

"This event is being reported under 10CFR50.72(b)(3)(ii)(B) for 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'

"The licensee has notified the NRC Resident Inspector."

To top of page
Power Reactor Event Number: 51335
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ALAN SHEPHARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2015
Notification Time: 23:08 [ET]
Event Date: 08/20/2015
Event Time: 17:55 [CDT]
Last Update Date: 08/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
KENNETH RIEMER (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

CONDITION THAT COULD PREVENT PRESSURIZER PORV BLOCK VALVES FROM OPERATING

"On 8/20/2015 at 1755 [CDT], a design flaw was discovered with the pressurizer power operated relief valve (PZR PORV) block valve control circuitry. Specifically, the circuit deficiency for which a design basis fire in the Main Control Room (MCR) or cable spreading room could prevent the PZR PORV block valves from being closed from the local control switch at their associated motor control center (MCC). Engineering has reviewed this issue and determined that a potential fire induced ground in the MCR or cable spreading room could clear the associated control power fuses which would prevent the block valves from operating at the local control switch.

"These valves are considered to form a High/Low pressure interface which requires postulating a proper polarity DC cable to cable fault. Engineering has reviewed the circuit design and cable routing associated with PORVs 1(2)RY455A and 1(2)RY456 and determined that their associated cables are routed with other DC circuit cables in the MCR control board and cable spreading room raceways, such that this postulated fault could potentially cause spurious opening of one of the PORVs even after the control power fuses have been removed as directed by the station abnormal operating procedures for control room inaccessibility.

"This identified block valve circuit deficiency prevents the credited safe shutdown action of locally closing the block valves to mitigate the spurious operation of a PORV.

"Hourly fire watches of the affected MCR and cable spreading room fire zones have been implemented. In addition, the MCR is continuously staffed and the affected cable spreading room fire zones are equipped with detection and automatic suppression.

"This event is being reported under 10CFR50.72(b)(3)(ii)(B) for 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Friday, August 21, 2015
Friday, August 21, 2015