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Event Notification Report for April 11, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/08/2016 - 04/11/2016

** EVENT NUMBERS **


51030 51761 51839 51841 51842 51843 51859 51860

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Part 21 Event Number: 51030
Rep Org: AZZ/NLI NUCLEAR LOGISTICS, INC
Licensee: ALLEN BRADLEY
Region: 4
City: Fort Worth State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/01/2015
Notification Time: 13:32 [ET]
Event Date: 04/30/2015
Event Time: [CDT]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MEL GRAY (R1DO)
FRANK EHRHARDT (R2DO)
ROBERT ORLIKOWSKI (R3DO)
GEOFFREY MILLER (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

POTENTIALLY UNQUALIFIED COMPONENT IN CERTAIN ALLEN BRADLEY TIMING RELAYS

The following is an excerpt from a document received from the licensee via email:

"Report of potential 10 CFR Part 21, Allen Bradley Timing Relay Model 700RTC

"Pursuant to 10 CFR 21.21(d)(3)(ii), AZZ/NLI is providing written notification of the identification of a potential failure to comply.

"On the basis of our evaluation, it is determined that AZZ/NLI does not have sufficient information to determine if the subject condition would, or has, created a Substantial Safety Hazard or would have created a Technical Specification Safety Limit violation as it relates to the subject plant applications.

"The specific part which fails to comply or contains a defect:

"As of 2009-2010, Allen Bradley relays base model 700RTC, contain an unevaluated CPLD (Complex Programmable Logic Device). This was an unpublished design change that was implemented to replace an obsolete integrated circuit chip. The undocumented design change did not result in a part number change from Allen-Bradley. There was no change to the appearance of the relay that would identify any design changes were made to the relay configuration. Therefore, NLI qualification/dedication of the relays after 2009 have not included additional testing for the new CPLD component.

"The timing relay model 700RTC has been dedicated/qualified for multiple applications for various plants.

"Between 2009-2010 Allen Bradley made a design change without changing the part number of the commercial relay or providing any documented evidence of a design change. The manufacturer specification data sheets maintain the classification that the relays are 'solid state', which would imply that there are no digital devices installed in the relay. However, after inspection of the internals of the timing relay (Figure 2), it has been identified that the unit does contain a CPLD which meets the definition of a digital device under the guidance of NEI 01-01."

Potentially affected plants include Browns Ferry, Ginna, Millstone, Nine Mile Point, North Anna, Ft. Calhoun, Perry, River Bend, South Texas Project, and St. Lucie.

* * * UPDATE FROM TRACY BOLT TO JOHN SHOEMAKER AT 1744 EDT ON 4/8/16 * * *

AZZ/NLI Nuclear Logistics provided additional information regarding Part 21 Report No: P21-04302015, Rev. 1.

Notified R1DO (Rogge), R2DO (Nease), R3DO(Skokowski), R4DO (Kellar), and PART 21/50.55 REACTORS via email.

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Agreement State Event Number: 51761
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TICONA POLYMERS INC
Region: 4
City: BISHOP State: TX
County:
License #: 02441
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/01/2016
Notification Time: 13:22 [ET]
Event Date: 02/29/2016
Event Time: [CST]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - STUCK SHUTTER IN THE NORMALLY OPEN POSITION

The following Agreement State Report was received from the State of Texas via email:

"On March 1, 2016, the Agency [Texas Department of State Health Services] received notice that on February 29, 2016, the licensee had discovered that a Berthold fixed gauge model MB7442D containing 30 milliCuries of cesium-137 had malfunctioned. The shutter was stuck in the open position. The gauge is normally left in the open position, and no exposure to the public is likely. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9383

* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1746 EDT ON 4/8/16 * * *

The following updated report was received from the State of Texas via facsimile:

"The following information was provided by the manufacturer: Celanese of Bishop, TX contacted Berthold in early March [2016], to come out and repair a LB 7442 device with a broke shutter. This device was one of many that was sold by BSI until they went out of business in [approximately] 2003. The cause of the broke shutter was corrosion that had built up on the brass shutter shaft making it hard to turn.

"When the Berthold service engineer was replacing the shaft he noticed that the source holder did not have a lock washer between the source holder and the source. The missing lock washer was not the cause of the broke shutter but has been an issue in the past with a plant in Wyoming that had some of the older BSI devices. Vibration caused the source to come lose from the source holder, the source dropped down into a position that prevented the shutter mechanism from cutting off the radiation beam when rotated which resulted in continuous high readings. Berthold worked with the NRC and the Wyoming plant to inspect the remaining shields to see if there were others that were missing the lock washer. It was noted that some did in fact have the lock washer in place but some did not. The sources that did not have lock washers on them were disassembled from their source holder and lock washers were added.

"[The manufacturer has] not seen any other records of this happening except for the FMC Corp plant in Wyoming in 2010. At Celanese, the Berthold service engineer removed the source from the source holder and added a lock washer before placing it back into the shield. It was noted by the Berthold service engineer that Celanese appeared to have more of the same devices from that era. The issue in Wyoming could have been an isolated incident but definitely worth noting."

Notified R4DO (Kellar) and NMSS Events Notification.

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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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Non-Agreement State Event Number: 51843
Rep Org: CHRISTIANA CARE HEALTH SYSTEM
Licensee: CHRISTIANA CARE HEALTH SYSTEM
Region: 1
City: NEWARK State: DE
County:
License #: 07-12153-02
Agreement: N
Docket:
NRC Notified By: CAROL WEN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/01/2016
Notification Time: 13:57 [ET]
Event Date: 04/01/2016
Event Time: 10:30 [EDT]
Last Update Date: 04/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - DOSE 75% OF PRESCRIBED DOSE

A patient was receiving a Y-90 Therasphere treatment to the cancer patient's liver. During the infusion, there was resistance in the tubing. The tubing was disconnected, flushed with a saline solution, and then reattached to the transfer system. The company representative was present during the procedure. After the procedure, the residual activity in the waste was determined to be approximately 25 percent of the total activity. The intended dose to the treatment area was 125 Gy with the actual dose being 94.8 Gy. The prescribing physician and the patient will be notified.

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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Power Reactor Event Number: 51859
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/08/2016
Notification Time: 20:50 [ET]
Event Date: 04/08/2016
Event Time: 18:20 [EDT]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO OIL LEAK IN A SWITCHYARD TRANSFORMER OIL SYSTEM

"At 1657 EDT on April 8, 2016, an oil leak developed from the station's switchyard transformer no. 4. Approximately 25,000 gallons of oil has leaked within the transformer's containment berm. At 1820 EDT on April 8, 2016, DC Cook environmental personnel determined that approximately 2000 gallons of oil had leaked outside of the containment berm onto the ground. None of the oil has made it to any nearby drains. Leak has stopped and cleanup is ongoing. D.C. Cook has notified the State of Michigan and local authorities. The NRC Resident Inspector was notified.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies."

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Power Reactor Event Number: 51860
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHAEL GAGNON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/09/2016
Notification Time: 23:14 [ET]
Event Date: 04/09/2016
Event Time: 15:23 [EDT]
Last Update Date: 04/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
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
3 N Y 52 Power Operation 20 Power Operation

Event Text

SECONDARY CONTAINMENT DETERMINED TO BE INOPERABLE DURING SURVEILLANCE TESTING

"During pre-planned surveillance testing of the Supplementary Leak Collection and Release System (SLCRS), an issue was found affecting the Secondary Containment boundary. Millstone Unit 3 is being moved to Mode 5 for a refuel outage where investigation and repairs will be made. This is reportable under 10CFR50.72(b)(3)(v)(C), a condition that could have prevented the fulfillment of a safety function for systems or structures to control the release of radioactive material, and 10CFR50.72(b)(3)(v)(D) to mitigate the consequences of an accident."

The surveillance testing was being performed while Millstone 3 was being removed from service for an upcoming Refueling Outage.

The licensee has notified the NRC Resident Inspector and State and Local authorities.

Page Last Reviewed/Updated Monday, April 11, 2016
Monday, April 11, 2016