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Event Notification Report for December 21, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/18/2015 - 12/21/2015

** EVENT NUMBERS **


51510 51596 51597 51598 51611 51612 51613 51614

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Power Reactor Event Number: 51510
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: THOMAS JONES
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/02/2015
Notification Time: 09:20 [ET]
Event Date: 11/02/2015
Event Time: 09:20 [EST]
Last Update Date: 12/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)

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

LOSS OF RADIATION MONITORING EQUIPMENT DUE TO PLANNED MAINTENANCE

"A planned modification at Calvert Cliffs Nuclear Power Plant will remove the Spent Fuel Pool Area Radiation Monitoring system from service. The planned out of service window is expected to be 7 weeks, beginning 11/02/15 and ending 12/18/2015. During this time portable radiation monitors will be installed as compensatory measures to monitor and support timely and accurate EAL declarations. Affected Emergency Response Organization personnel have been made aware of the compensatory measures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a planned event that affects Emergency Preparedness Assessment Capability for greater than 72 hours. An update will be provided once the Spent Fuel Pool Area Radiation Monitoring system is restored to normal operation."

The licensee has notified the NRC Resident Inspector.


* * * UPDATE AT 1616 EST ON 12/18/2015 FROM BRIAN HAYDEN TO MARK ABRAMOVITZ * * *

"This is concerning the planned modification to Calvert Cliffs Nuclear Power Plant Spent Fuel Area Radiation Monitoring System. The modification window is extended to January 8, 2016. Compensatory measures that were put in place on November 2, 2015 will continue to be in effect until the completion of the modification testing and the new equipment is fully in service."

The licensee notified the NRC Resident Inspector.

Notified R1DO (Ferdas).

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Non-Agreement State Event Number: 51596
Rep Org: DEPARTMENT OF THE ARMY
Licensee: BROOKE ARMY MEDICAL CENTER
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 42-01368-01
Agreement: Y
Docket:
NRC Notified By: MAJ. DAVID BYRD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 11:48 [ET]
Event Date: 11/17/2015
Event Time: [CST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GLENN DENTEL (R1DO)

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

Event Text

LOST IODINE-125 SEED

"One 180 microCi I-125 seed for breast radioactive seed localization (I-125 RSL) was lost at Brooke Army Medical Center (BAMC) on 17 November 2015.

"Loss of the I-125 seed occurred in BAMC Pathology on 17 November 2015 due to lack of training and supervision of new Residents during the removal of the seed while grossing the specimen. Health Physics Service (HPS) was notified and responded to Anatomic Pathology/Histology at approximately 1130 on 20 November.

"According to events leading up to the loss, the I-125 seed was not removed from the specimen prior to being submitted for sectioning. Typically, RSL seeds are tracked on a BAMC I-125 Seed Tracking Form, which indicates when the seed is removed from the specimen. In this case, the tracking form was completed only to the point of Pathology receiving the specimen with the seed still within. A radiograph illustrating the seed within the specimen was taken on 16 November 2015 in Mammography and delivered with the specimen to Pathology. Due to a lack of supervision and training, [the Pathology Resident] did not verify on the tracking form that the seed had been removed. The I-125 Seed Tracking Form was found incomplete on 20 November 2015 by the RSO [Radiation Safety Officer], who then contacted [the Pathology Resident] and informed the Health Physics personnel. Health Physics personnel immediately responded and performed a survey of the entire Histology suite focusing on all work stations and processing equipment used in the preparation of this specimen; the seed was not located within the Histology suite. According to [the Pathology Resident], the step to verify seed removal was overlooked, and confirmation of the seed's absence with a radiation probe was skipped. Furthermore, the tissue was grossed and submitted entirely for sectioning. Most likely, the seed stuck to the grid and was disposed of as biohazard waste. The biohazard disposal route from Pathology on the 4th floor to the hospital exit passes through radiation monitors located on the fourth floor and in basement utility rooms and the biohazard waste room, but due to the low activity of one I-125 seed in biohazard bag with unknown amount of material the monitors would not alarm.

"Initial activity of the I-125 RSL seed was 300 microCi on 7 October 2015, and had decayed to 180 microCi on 20 November 2015. Assuming no shielding, an exposure rate of 0.03 mR/hr at 1 meter is to be expected. Personnel are not likely to handle the waste for an extended period of time and the waste was likely incinerated at Stericycle.

"Steps have been taken since the incident to prevent recurrence.
A. Procedure: The grossing staff pathologist will ensure seed disposal via inspection of appropriate paperwork and scanning with appropriate probe rather than verbal assurance.
B. Additional training sessions on the use of the NeoProbe and I-125 RSL seed procedure.

"Based on accounts above, the I-125 seed was left with the specimen during grossing and was then submitted to sectioning and the seed was lost. In addition to ensuring the proper training and SOPs [Standard Operating Procedures] are in place and followed, we will continue to have radiation monitors in place on each floor and the back loading docks of the facility to make certain there is full accountability of the I-125 seeds."

The licensee notified NRC Region 4 (Torres).

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: 51597
Rep Org: TERRACON CONSULTANTS, INC
Licensee: TERRACON CONSULTANTS, INC.
Region: 4
City: GREAT FALLS State: MT
County:
License #: 030-32176
Agreement: N
Docket:
NRC Notified By: KATIE GILCHRIST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 17:40 [ET]
Event Date: 12/10/2015
Event Time: 12:40 [MST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

While in use at a remote job site, a Troxler moisture density gauge (Model 3440, Serial Number 37384) was damaged when it was struck by a bulldozer. The source rod was out at the time of the incident but the source was able to be retracted into the shielded position.

The licensee surveyed the meter and found no abnormal radiation readings. The gauge was transported back to the licensee facility for storage awaiting results of the swipe test. Once the swipe test results are returned, the licensee intends to ship the gauge to the vendor for repair or replacement.

The licensee will provide the model and source information for the gauge once is it obtained. No personnel overexposures occurred during this incident.

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Agreement State Event Number: 51598
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: AMERICAN TESTING SERVICES, INC.
Region: 4
City: COTTONWOOD HEIGHTS State: UT
County:
License #: UT1800062
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/10/2015
Notification Time: 19:43 [ET]
Event Date: 12/10/2015
Event Time: 08:30 [MST]
Last Update Date: 12/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was received from the State of Utah via email:

"The licensee stopped and parked their truck in Cottonwood Heights, Utah. Licensee personnel stepped away from the truck but left it unlocked and running. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Troxler Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case with the source rod locked (gauge and source information listed below). The licensee notified the police and has begun actions to recover the gauge (Cottonwood Police Department, Case Number 15x7206).

"Troxler Moisture Density Gauge:
Gauge Serial Number: 12386
Source Information: CS-137 (8.7 mCi) S/N: 50-0529
Source Information: Am241: BE (40.0 mCi) S/N: 47-7684

"This incident is still being investigated [by the State of Utah]."

Utah Event Report ID No.: UT150009

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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Part 21 Event Number: 51611
Rep Org: QUALTECH NP
Licensee: QUALTECH NP
Region: 3
City: CINCINNATI State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MARGIE HOVER
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2015
Notification Time: 15:50 [ET]
Event Date: 10/06/2015
Event Time: [EST]
Last Update Date: 12/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
LADONNA SUGGS (R2DO)
RAY AZUA (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

POTENTIAL PART 21 INVOLVING A200 SERIES STARTERS

The following is excerpted from a report submitted by QualTech NP, Nuclear Division, Curtiss-Wright Corporation:

"Pacific Gas and Electric (PG&E) reported to QTNP [QualTech NP] that they have had eight Cutler Hammer A200 series starter failures since September 15, 2008. The failures would remain in the operated/energized contact state with power removed for some period of time. All starters impacted with this failure were continuously energized. The concern was that if tripped, that the main contacts would not open to protect the motor.

"Testing was performed by Eaton Industrial Controls Division after receiving defective samples from PG&E. The test report from Eaton was received by QTNP for further review and evaluation. On October 6, 2015 QTNP determined that the Cutler Hammer A200 series starter failures may be reportable and an extent of condition review needed to be done.

"The root cause was a silicon based mold release that remained on the molded parts and would come between the moving (magnet) & fixed armatures. When heated for an extended period of time, this material would become sticky causing anywhere from a minor delay in opening, up to a frozen closed condition.

"Cutler Hammer has determined that the silicone mold release was first introduced into the manufacturing facility in May, 2008, due to a shortage of the Zinc Stearate Mold release that was traditionally used. The silicon based mold release was periodically used until October 2012. According to Cutler Hammer, anything made after January 1, 2013 should definitely be silicon mold release free.

"Thus any starters/contactors of the CH A200 series manufactured between May 2008 & December 31 , 2012 could have this concern. This failure has only been reported for continuously energized applications. The end user should evaluate their applications for this potential failure mechanism."

QTNP has notified North Anna, H. B. Robinson, Diablo Canyon, and Hatch.

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Part 21 Event Number: 51612
Rep Org: NUTHERM INTERNATIONAL, INC
Licensee: NUTHERM INTERNATIONAL, INC
Region: 3
City: MOUNT VERNON State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ADRIENNE SMITH
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2015
Notification Time: 16:41 [ET]
Event Date: 12/18/2015
Event Time: [CST]
Last Update Date: 12/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARC FERDAS (R1DO)
PART 21/50.55 REACTO (EMAI)

Event Text

POTENTIAL PART 21 INVOLVING RTD TRANSMITTER

The following is excerpted from a report submitted by Nutherm International, Inc.:

"The wire insulation in T2 transformer on the Moores Industry RTD transmitter, Part Number: RBT/3W20-40/4-20MA/117AC/-EZ84.06-LNP-VTD [EX] was damaged during assembly. This damage reduced the insulation resistance and dielectric breakdown between the windings of the transformer. This resulted in early, catastrophic failure of the RTD transmitter.

"It has been determined that no visual inspection of the transformer or testing after the transformer is installed will discover this defect. This defect can only be found by performing testing on the transformer prior to installation."

Two of these transmitters were sent to Entergy Operations - Fitzpatrick.

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Power Reactor Event Number: 51613
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: HENDRIK VERWEY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/19/2015
Notification Time: 00:44 [ET]
Event Date: 12/18/2015
Event Time: 17:22 [EST]
Last Update Date: 12/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARC FERDAS (R1DO)

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

BOTH TRAINS OF CONTAINMENT ATMOSPHERE DILUTION SYSTEM INOPERABLE

"On December 18, 2015 at 1722 EST, with James A. FitzPatrick Nuclear Power Plant (JAF) operating at 100 percent power, JAF received a notification pursuit to 10 CFR 21.21(d)(3)(ii) related to Moore Industries RTD temperature transmitters. Specifically, wire insulation in T2 transformer was damaged during assembly which reduced the insulation resistance and dielectric breakdown between the windings of the transformer. This equipment is in both redundant trains (A and B) of the Containment Atmosphere Dilution (CAD) System.

"Preliminary review by Operations and Engineering, which was completed on 12/18/15 at 2100 EST, determined the Part 21 results in both trains of CAD being inoperable and the applicable Technical Specification (TS) for both redundant trains of CAD being inoperable was entered.

"Per TS 3.6.3.2 Condition B, this places the unit in a 7-day shutdown LCO, provided the hydrogen control function is maintained. Per the TS Bases, the alternate hydrogen control capabilities are provided by the Primary Containment lnerting System, which is unaffected.

"The event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could prevent fulfillment of a safety function."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51614
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KRIS STRAUSSER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/19/2015
Notification Time: 10:38 [ET]
Event Date: 12/19/2015
Event Time: 07:02 [EST]
Last Update Date: 12/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARC FERDAS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 6 Startup 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO LOW REACTOR WATER LEVEL

"At 0702 EST on 12/19/2015, the Unit 2 reactor automatically scrammed on a valid reactor low level signal (12.5 inches). The reactor low level signal was caused by the trip of the in-service 2A Reactor Feedwater Pump, causing reactor level to lower, exceeding the low reactor level setpoint of 12.5 inches.

"The shutdown was normal. The plant is stable in Hot Shutdown with normal reactor level, pressure control via the Main Steam Bypass Valves to the Main Condenser and normal level control using the Condensate System.

"High level trip of the 2A Reactor Feedwater Pump was caused by high reactor level of +54 inches following opening of bypass valves during reactor start-up and pressurization. The cause is still being investigated."

All systems functioned as expected following the reactor scram. The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, December 21, 2015
Monday, December 21, 2015