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Event Notification Report for February 5, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/04/2016 - 02/05/2016

** EVENT NUMBERS **


51688 51689 51690 51691 51692 51693 51708 51711 51712

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Agreement State Event Number: 51688
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CARDINAL HEALTH NUCLEAR PHARMACY
Region: 1
City: TAMPA State: FL
County:
License #: 3453-13
Agreement: Y
Docket:
NRC Notified By: KELLIE ANDERSON
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/27/2016
Notification Time: 10:18 [ET]
Event Date: 01/27/2016
Event Time: [EST]
Last Update Date: 01/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT: RADIATION OVEREXPOSURE TO EXTERNAL WHOLE BODY

The following was received from the State of Florida via email:

"Tampa inspection office [State of Florida Bureau of Radiation Control] conducted a routine inspection on January 22, 2016. Searching their records [the inspector] found that [one] employee had exceed the annual limit of 5 Rem per year (not including the month of December). [The employee] had nine high exposure investigative reports recorded in the last year. The report also noted that the RSO [Radiation Safety Officer] failed to take any action to mitigate more exposure to ionizing radiation.

"The RSO will be required to submit a report. The BRC [State of Florida Bureau of Radiation Control] will request a safety inspection of the facility paying particular attention to [the employee] daily duties and make recommendations to reduce exposure. The BRC would also suggest additional unannounced inspections to insure improvement to their adherence to regulations.

"Isotope: F-18
Activity: 16.5 MeV Cyclotron
Material Form: Particle Accelerator
External Whole Body exposure
Maximum Dose Received: 5.2 Rem/year (excluding December)
Florida Incident Number FL16-016."

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Agreement State Event Number: 51689
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 201-031-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2016
Notification Time: 12:36 [ET]
Event Date: 01/18/2016
Event Time: [CST]
Last Update Date: 01/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 MEDICAL SEED

The following report was received from the Commonwealth of Kentucky via email:

"[The licensee] reported the loss of a I-125 localization seed (lsoAid Advantage, Model IAI-125A). On 1/19/16, the licensee discovered the number of seeds in storage did not match the number recorded. After the licensee conducted an investigation, they believe the seed was lost when it was transferred from the vial, pathology puts them in, to the Cidex storage/decontamination vial. The seeds in the vial had been placed there between 12/21/15 and 1/18/16. As part of the investigation the licensee verified that all seeds were removed from patients during that time and the hot lab was thoroughly searched.

"They [the licensee] believe the I-125 seed was most likely disposed of in the trash and taken to landfill with other waste from the hospital. The licensee reported the missing seed came from one of the three orders, lot #39858, 0.147 mCi as of 1/19/16, lot #39809, 0.128 mCi as of 1/19/16, or lot #39111, 0.075 mCi as of 1/19/16. Corrective actions include retraining Nuclear Medicine Techs in the handling of radioactive breast seeds, including stressing the importance of surveying all material to verify that the seed was placed in the Cidex vial and not lost in the surrounding area.

Kentucky Event Report ID No.: KY160001

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: 51690
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: CHEVRON USA PRODUCTS COMPANY
Region: 4
City: PASCAGOULA State: MS
County:
License #: MS-413-01
Agreement: Y
Docket:
NRC Notified By: ROBERT SIMS
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/28/2016
Notification Time: 09:33 [ET]
Event Date: 09/18/2015
Event Time: [CST]
Last Update Date: 01/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE OPEN/STUCK SHUTTER

The following was received from the State of Mississippi via email:

"During Fall shutter checks and inventory, on 9/18/2015, an Ohmart-Vega fixed gauge, DEA-2102, device model no. SHLM-BR1, (housing serial no. 13530993) (source serial no. 8533CN), was discovered to have an open/stuck shutter, the source disconnected, and was unable to be moved into the closed position. The RSO [Radiation Safety Officer] contacted the manufacturer and arrangements for repair are in motion. DRH [Mississippi Division of Radiological Health] was notified on 1/15/2016 and recommended that RSO take surveys with a survey measurement of the source. On 1/22/2016, [the] RSO provided readings that did not exceed 0.02 mR/hr at the surface of the steel drum that encloses the gauge and the source. The gauge and source is sealed in the steel drum and is only accessible by the manufacturer. The source is not in a designated work area, and is not causing exposure limits beyond the limits for radiation control to the general public and occupational workers."

Isotope: Cs-137
Activity: 40mCi
Mississippi report # MS-16001

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Agreement State Event Number: 51691
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CJAMS INC & HIGH COUNTRY AUTO ACCESSORIES
Region: 4
City: YAMPA/STEAMBOAT SPRINGS State: CO
County:
License #: CO GENERAL LI
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/28/2016
Notification Time: 13:09 [ET]
Event Date: 01/21/2016
Event Time: [MST]
Last Update Date: 01/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST/ABANDONED TRITIUM EXIT SIGN

The following Agreement State Report was received by the State of Colorado via email:

"[The licensee reported that,] according to the maintenance specialist for the property [located in Steamboat Springs, CO], an inspection of the property was conducted to complete the Radioactive Materials Unit annual report for 2015. They reported on 6/24/15, the exit sign was still in the space. Upon completing an audit of the general license files, contact was made to the current tenant who reported the building had been remodeled. A call was made to the reporting maintenance staff who completed the forms. During the discussion regarding the lost/abandoned exit sign, a request for further information would need to be submitted along with a corrective action should the sign not be found. [The maintenance specialist] conducted a site inspection and found the sign to be missing on 1/21/16. A detailed report was submitted with a corrective action letter received on 1/27/16.

"Tritium Exit Sign:
Model: SLX 60
Source Serial: #412078
Isotope: H-3, Activity
Activity: 7500 mCi
Date Shipped from Isolite Corporation: 6-18-2007

"The property management company is reviewing all properties to verify if a Tritium exit signs are still in use and providing the current tenants of regulatory requirements to correct and prevent any future displacement or loss of exit signs containing Tritium."

Colorado Event Report ID No.: CO16-I16-02

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: 51692
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: JL SHEPHERD & ASSOCIATES
Region: 4
City: SAN FERNANDO State: CA
County:
License #: 1777
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/28/2016
Notification Time: 13:19 [ET]
Event Date: 01/14/2016
Event Time: [PST]
Last Update Date: 01/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHIPMENT EXCEEDED RADIATION LIMIT

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

"On January 14, 2016, the Southwest Research Institute (SRWI) notified the Texas radiation control program (TxRCP) of the receipt of an exclusive use shipment with package contact dose rates up to 1900 mrem/hr, which exceed the 1000 mrem/hr limit for exclusive use shipments in closed vehicles. The package contained a nominal 8.4 Ci Co-60 source. SWRI personnel verified that the dose rate limits in the cab of the vehicle and at other shipment locations did not exceed regulatory limits.

"On 1/27/16 CDPH/RHB [California Department of Public Health/Radiologic Health Branch] was notified by NRC (R. Erickson) by email of the event being investigated by TxRCP inasmuch as a California licensee (JL Shepherd & Associates) had prepared the package for shipment from a Maryland licensee to SWRI. On 1/27/16, TxRCP requested that CDPH/RHB (CaRCP) take the lead in investigation of the event inasmuch as JL Shepherd & Associates had prepared the package for shipment, including performing the radiation surveys. CDPH/RHB agreed to take the investigation lead. At the request of NRC, the TxRCP retracted their event report to NRC HOO, and NRC requested that CDPH/RHB submit an event report to NRC."

California 5010 number: 012716

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Agreement State Event Number: 51693
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: MEMC PASADENA INC
Region: 4
City: PASADENA State: TX
County:
License #: 05129
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/28/2016
Notification Time: 17:30 [ET]
Event Date: 01/28/2016
Event Time: [CST]
Last Update Date: 01/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

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

"On January 28, 2015, the licensee notified the Agency [Texas Department of State Health Services] that during routine leak test and shutter checks, it had discovered that the shutters on two Ohmart-Vega SH-F1 gauges were stuck in the open position. Open is the normal operating position for these two level gauges that are mounted on the sides of tanks. Each gauge contains a 120 millicurie cesium-137 source. Due to the location of the gauges, there is no risk of exposure to any individual. The licensee has contacted the manufacturer and is scheduling repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I 9376

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Power Reactor Event Number: 51708
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ERIC POWELL
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/04/2016
Notification Time: 13:33 [ET]
Event Date: 02/04/2016
Event Time: 11:21 [EST]
Last Update Date: 02/04/2016
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):
JOHN ROGGE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 74 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO MAIN TURBINE TRIP

"This 4 and 8 hour notification is being made to report that Salem Unit 2 suffered an unplanned automatic reactor trip and subsequent automatic Auxiliary Feedwater system actuation. The trip was initiated due to a Main Turbine trip above P-9 (49% power). The Main Turbine trip was caused by a Main Generator Protection signal.

"Salem Unit 2 is currently stable in Mode 3. Reactor Coolant system pressure is 2235 PSIG and Reactor Coolant system temperature is 547 F with decay heat removal via the Main Steam Dump and Auxiliary Feedwater Systems. Unit 2 has no active shutdown tech spec action statements in effect. All control rods inserted on the reactor trip. All ECCS and ESF systems functioned as expected.

"No major secondary equipment was tagged for maintenance prior to this event. The 24 Service Water pump is tagged for scheduled preventive maintenance and did not affect post trip plant response. No personnel were injured during this event."

The licensee has notified the NRC Resident Inspector and will notify the Lower Alloway Creek Township.

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Power Reactor Event Number: 51711
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: STEVEN KIRSHBERGER
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/04/2016
Notification Time: 18:50 [ET]
Event Date: 02/04/2016
Event Time: 15:06 [CST]
Last Update Date: 02/04/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GREG PICK (R4DO)
FFD GROUP (EMAI)

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

NON LICENSED SUPERVISOR IN VIOLATION OF THE FITNESS FOR DUTY POLICY

A non-licensed supervisor tested positive for a drugs during a random Fitness for Duty test. The individual's access to the plant has been suspended. The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 51712
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JAMES SCHWER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/05/2016
Notification Time: 03:49 [ET]
Event Date: 02/05/2016
Event Time: 01:09 [EST]
Last Update Date: 02/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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 N 0 Hot Standby 0 Hot Standby

Event Text

EXCESSIVE CONTROL ROOM IN-LEAKAGE IDENTIFIED

"On February 5, 2015 at 0109 EST, the Control Room Emergency Ventilation System (CREVS) was declared inoperable due to a higher than allowed identified in-leakage rate for the Control Room Envelope (CRE) when in the Normal Operating Mode. Unit 1 remains at 100 percent power and Unit 2 remains in Mode 3 for an unrelated planned maintenance outage. Unit 1 and Unit 2 share a common CRE.

"This in-leakage was detected during additional testing following the event documented in EN #51584.

"At the time of discovery, there is a reasonable expectation this condition could prevent the fulfillment of the safety function of a system that is required to mitigate the consequences of an accident, thus satisfying the reporting criteria for 10CFR50.72(b)(3)(v)(D).

"Actions to implement mitigating actions were immediately initiated in accordance with Technical Specification 3.7.10. CREVS has been placed in Recirculation Ventilation Mode, isolating the control room from outside air.

"The NRC Senior Resident Inspector has been notified of the condition."

Page Last Reviewed/Updated Friday, February 05, 2016
Friday, February 05, 2016