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Event Notification Report for April 8, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/07/2016 - 04/08/2016

** EVENT NUMBERS **


51832 51833 51834 51835 51839 51841 51842 51850 51853 51854 51856

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Agreement State Event Number: 51832
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: UNSPECIFIED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: J. KRISHNAMOORTHY
HQ OPS Officer: RICHARD SMITH
Notification Date: 03/30/2016
Notification Time: 15:35 [ET]
Event Date: 03/29/2016
Event Time: [EDT]
Last Update Date: 03/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the State of New York via facsimile:

"The Licensee's Radiation Safety Officer called on March 29, 2016 to report that during the administration of Y90 to the liver of patient in the Interventional Radiology suite earlier in the day, only 3.9 mCi of the intended 11.7 mCi was administered due to a clogged catheter. [NY State Department of Health] will update after receiving report from the licensee."

NY State Incident No.:1136

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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Agreement State Event Number: 51833
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ATC GROUP SERVICES, INC
Region: 1
City: TAMPA State: FL
County:
License #: 2962-2
Agreement: Y
Docket:
NRC Notified By: PAUL NORMAN
HQ OPS Officer: RICHARD SMITH
Notification Date: 03/30/2016
Notification Time: 16:05 [ET]
Event Date: 03/30/2016
Event Time: [EDT]
Last Update Date: 03/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

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

"A Troxler Gauge was run over by heavy equipment at a construction site. The Type B container case was broken open exposing the source. [A Florida State] Inspector was sent to the scene to investigate."

State of Florida Incident Number: FL16-047

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Agreement State Event Number: 51834
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TORRANCE UNIFIED SCHOOL DISTRICT
Region: 4
City: TORRANCE State: CA
County: LOS ANGELES
License #: N/A
Agreement: Y
Docket:
NRC Notified By: JEFF DAY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/30/2016
Notification Time: 16:12 [ET]
Event Date: 03/29/2016
Event Time: [PDT]
Last Update Date: 03/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"Torrance Unified School District (TUSD) reported to the RHB [Radiation Health Branch] via email on March 29. 2016 regarding nine tritium exit signs the school district is unable to account for after construction at two of their sites (5 signs at South High School located at 4801 Pacific Coast Highway, Torrance, CA 90505 and 4 signs at North High School located at 3620 W 182nd St, Torrance, CA 90504). TUSD has notified the contracted construction company, Balfour Beatty Construction, regarding the incident and requested removal documentation for the 9 exit signs, which to date has not been provided.

"The four Tritium Exit Signs from North High School located at 3620 W. 182nd St Torrance, CA 90504:
ISOLITE 2040-50G-20-BK Expiration date 1/1/23 received around 2/27/02 11.5 Curies Tritium
ISOLITE 2040-50G-20-BK Expiration date 1/1/23 received around 2/27/02 11.5 Curies Tritium
ISOLITE 2040-50G-20-BK Expiration date 1/1/23 received around 2/27/02 11.5 Curies Tritium
ISOLITE 2040-50G-20-BK Expiration date 1/1/23 received around 2/27/02 11.5 Curies Tritium

"The five Tritium Exit Signs from South High School located at 4801 Pacific Coast Hwy Torrance, CA 90505:
ISOLITE 2040-70G-20-BA Expiration date 4/20/22 Received around 1/15/02 11.5 Curies Tritium
ISOLITE 2040-70G-20-BA Expiration date 4/20/22 Received around 1/15/02 11.5 Curies Tritium
ISOLITE 2040-70G-20-BA Expiration date 4/01/22 Received around 1/15/02 11.5 Curies Tritium
ISOLITE SLX-60-S-G-20-B Expiration date 4/01/25 Received around 3/22/05 Est. 11.5 Curies Tritium
ISOLITE SLX-60-S-G-20-B Expiration date 4/01/25 Received around 3/22/05 Est. 11.5 Curies Tritium"

California 5010 Number: 032916 / TUSD

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: 51835
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KLEINFELDER, INC.
Region: 4
City: FRESNO State: CA
County:
License #: 6728-10
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/30/2016
Notification Time: 17:18 [ET]
Event Date: 03/29/2016
Event Time: [PDT]
Last Update Date: 03/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

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

"On 03/29/16, the California Office of Emergency Services (OES) contacted the RHB [Radiation Health Branch] via an email to notify them of a damaged moisture/density gauge. The gauge was a Troxler gauge, Model 3440, S/N 38618 containing 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge had been run over by an excavator while the operator was taking a reading along the side of the road where the incident occurred. Per the licensee, the Cs-137 source was in the shielded position (at the time of the incident readings were taken over a standard block for counts) when the gauge was damaged. The licensee stated that a 20 foot area was cordoned off until the gauge was removed. Fire Department personnel were at the scene.

"Per the licensee, a Pacific Nuclear Technology (PNT) RSO arrived at the site, and confirmed a survey meter reading of 0.5 mRems at one meter from the gauge, which is considered normal for this type of gauge. It was also noted that the Cs-137 and Am-241 sources were intact. Survey of the area after removal of the gauge indicated background readings. The gauge was placed inside the transit cage and returned to the licensee's storage location. A leak test will be performed and the gauge will be disposed of in the near future. RHB will be following up on this incident."

California 5010 Number: 032916 / Kleinfelder

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Agreement State Event Number: 51839
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ACUREN INSPECTION, INC.
Region: 3
City: DAYTON State: OH
County:
License #: 03320 99 0006
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 14:07 [ET]
Event Date: 03/30/2016
Event Time: [EDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA STUCK SOURCE

The following information was received from the State of Ohio by email:

"On March 30, 2016 at approximately [1250 EDT] the Bureau of Environmental Health and Radiation Protection (BEHRP) received a phone call from licensee's RSO that an industrial radiography crew working on a water tank construction job in Groveport, Ohio had a source stuck in the guide tube of a QSA Model 880D camera and were unable to retrieve the back into the camera. The source in use was 75 Curies of Iridium-192. The incident occurred at approximately [1225 EDT]. The stuck source was discovered after a shot time had ended and the radiography crew attempted to crank the source back in to the camera. The radiography crew conducted surveys of the area and moved boundaries out 2 mR/hr or less. The cause of the stuck source was due to a magnetic stand becoming dislodged during radiography operations, which fell onto the guide tube, crimping it, and preventing retraction of the source."

* * * UPDATE:FROM STEPHEN JAMES TO VINCE KLCO ON 3/31/2016 AT 1631 EDT VIA EMAIL * * *

"A BEHRP inspector was immediately dispatched to the job-site and arrived there at approximately [1320 EDT]. The inspector met with the licensee's customer and reviewed the actions taken by the radiography crew to establish new barriers and prevent access to the site. The licensee's trained retrieval personnel dispatched to the site arrived a short time later. After a thorough review of the incident and work area, the licensee's response team was able to retrieve the source, which was completed at approximately [1600 EDT] that afternoon. The maximum dose received by any individual involved in the recovery effort was 50 mR. The camera and guide tube will be returned to manufacturer for repair.

"QSA Global Camera,Serial Number-D8042; Source Serial Number-29222G.

"Ohio Event- OH160002"

Notified the R3DO (Pelke) and the NMSS Events Notification via email.

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Agreement State Event Number: 51841
Rep Org: COLORADO DEPT OF HEALTH
Licensee: PRESBYTERIAN ST. LUKE'S MEDICAL CENTER
Region: 4
City: DENVER State: CO
County: DENVER
License #: CO 632-06
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 17:58 [ET]
Event Date: 03/24/2016
Event Time: [MDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - DOSE MISADMINISTRATION

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

"The Colorado Department of Public Health and Environment - Radioactive Materials Unit was notified on March 25, at [1041 MDT] of a misadministration that occurred on the evening of March 24, 2016. The licensee is Presbyterian St. Luke's Medical Center. A patient was given approximately 70% of the prescribed SIR-Spheres dose due to a clogged catheter.

"The investigation is ongoing and a corrective action has not yet been determined."

Colorado Report: CO16-M16-02

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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Agreement State Event Number: 51842
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: O'NEILL SERVICE GROUP
Region: 4
City: REDMOND State: WA
County:
License #: WN-I0609-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 20:03 [ET]
Event Date: 03/31/2016
Event Time: [PDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CANADA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN PORTABLE NUCLEAR GAUGE

The following excerpted information was received from the State of Washington by email:

"Event Narrative: The Washington Department of Health received a call today (3/31/2016) at noon from the RSO of the licensee, to report a stolen gauge from their conex unit at their SeaTac location. The RSO first noticed the missing gauge (the only one stored at this facility) when he went to check it out at 1030 PDT this morning. There was no indication of it being checked out by other users, and the RSO called the other users to make sure. The RSO also noticed the broken lock on the conex door. The licensee's contractor called police for this incident as well as other containers that had been broken into. More information to come.

"Make/Model/Serial Number- Troxler 3440, SN 31182.
Isotopes/Activity - Cesium 137/0.37 GBq and Americium 241 Beryllium/1.85 GBq"

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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Power Reactor Event Number: 51850
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/06/2016
Notification Time: 17:07 [ET]
Event Date: 04/06/2016
Event Time: 15:45 [CDT]
Last Update Date: 04/07/2016
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
REBECCA NEASE (R2DO)
BERNARD STAPLETON (IRD)
BILL DEAN (NRR)
CATHY HANEY (R2RA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 91 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO MAIN STEAMLINE HIGH HIGH RADIATION CONDITION

At 1545 CDT on 04/06/16 Browns Ferry Unit 3 declared and exited the declaration of an unusual event due to a main steam line high high radiation condition. Power to Unit 3 was reduced to 91 percent power. The high radiation condition alarm cleared at 1526 CDT. Browns Ferry Unit 3 reported that the high radiation conditions were due to resin intrusion from the condensate demineralizers into the reactor and hydrogen water chemistry was a potential contributor to the event. The cause is still under investigation.

The NRC Resident Inspector has been notified.

State and Local notifications were made.

Notified DHS SWO, FEMA Ops Center, NICC Watch Officer, FEMA NWC and Nuclear SSA (email).

* * * UPDATE FROM BILL BALL TO DANIEL MILLS AT 0034 EDT ON 04/07/2016 * * *

"At 1941 [CDT] BFN [Brown's Ferry] determined this notification to be potentially newsworthy due to receiving notification that counties [surrounding the plant] were alerted of this event. No plant conditions changed."

The licensee may issue a press release.

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Nease).

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Fuel Cycle Facility Event Number: 51853
Facility: B&W NUCLEAR OPERATING GROUP, INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU FABRICATION & SCRAP
Region: 2
City: LYNCHBURG State: VA
County: CAMPBELL
License #: SNM-42
Agreement: N
Docket: 070-27
NRC Notified By: CHRIS TERRY
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/07/2016
Notification Time: 08:00 [ET]
Event Date: 04/06/2016
Event Time: 14:15 [EDT]
Last Update Date: 04/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAI)
CRAIG ERLANGER (FCSE)

Event Text

FITNESS FOR DUTY

An employee was reported to the Fitness for Duty Coordinator due to improper prescription medicine handling. The employee's site access has been suspended pending outcome of a drug test and investigation.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 51854
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: XAVIER DECAMBRA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/07/2016
Notification Time: 18:01 [ET]
Event Date: 04/07/2016
Event Time: 15:07 [EDT]
Last Update Date: 04/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
REBECCA NEASE (R2DO)

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

UNANALYZED CONDITION - HIGH PRESSURE FIRE SUPPRESSION ISOLATED FROM CONTAINMENT

"This notification is being made as the result of the review of an occurrence on March 30, 2016 at 2220 [EDT] that resulted when a major portion of the site high pressure fire protection (HPFP) system, including fire suppression capabilities for the Main Turbine Building, Auxiliary Building, Control Building, Diesel Generator Buildings, and both Unit 1 and Unit 2 Containments were isolated without having the required compensatory suppression systems established. Upon discovery of the non-functional HPFP system, compensatory fire watches were established and an alternate means to provide water to the HPFP system was aligned.

"A review of the Sequoyah Nuclear Plant (SQN) Safe Shutdown Analysis identified this loss of fire suppression may not have ensured the required equipment remained available under certain postulated fire scenarios. The analysis determined that the effects of a postulated fire in specific fire areas could have prevented critical systems or components from performing their intended functions, potentially resulting in the inability to achieve and maintain safe shutdown.

"Analysis identified areas which credit the availability of fire suppression to assure that the safe shutdown capability could have been achieved, the site did not have fire suppression for approximately 45 hours.

"No actual fire occurred or existed during the time the fire suppression system was not functional. Installed fire detection equipment and communication to the Main Control Room remained available.

"The condition has been corrected and the HPFP system is functional.

"At the time of the non-functional HPFP system, it was not recognized that an unanalyzed condition that could have significantly degraded plant safety existed. The condition placed both Unit 1 and Unit 2 in an unanalyzed condition that significantly degraded plant safety and is reportable under 10 CFR 50.72(b)(3)(ii)(B). This 8-hour non emergency notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(B). The condition has been entered into the licensee's corrective action program (CR 1155763) and a License Event Report will be submitted.

"The NRC Resident Inspector has been notified of this condition."

The original clearance that created this event was satisfactory as written, however, one of the valves was leaking and the clearance boundaries were expanded. The clearance was issued at 1411 EDT on 3/29/2016.

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Power Reactor Event Number: 51856
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL JONES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/07/2016
Notification Time: 22:32 [ET]
Event Date: 04/07/2016
Event Time: 17:30 [EDT]
Last Update Date: 04/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
DON JACKSON (R1DO)

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

Event Text

BOTH DOORS OF SECONDARY CONTAINMENT OPEN SIMULTANEOUSLY

"Nine Mile Point Unit 2 (NMP2) experienced a momentary loss of Secondary Containment due to both Reactor Building (RB) airlock doors being opened at the same time.

"At 1730 [EDT] on 04/07/16, both RB airlock doors were opened simultaneously for less than 5 seconds. This resulted in Secondary Containment being declared Inoperable (TS 3.6.4.1). Secondary Containment was restored to Operable when the doors were closed.

"The event is reportable in accordance with 10 CFR 50.72(b)(3)(v)(C), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'

"The condition has been entered into the station's corrective action program and the NRC Resident Inspector has been notified."

There is no interlock on these doors, just lights to verify the opposite door is open or shut. An Operator was entering secondary containment as another Operator was leaving.

Page Last Reviewed/Updated Friday, April 08, 2016
Friday, April 08, 2016