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Event Notification Report for May 11, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/10/2016 - 05/11/2016

** EVENT NUMBERS **


51898 51903 51904 51905 51915 51917

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Agreement State Event Number: 51898
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ARIAS & ASSOCIATES INC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 04964
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2016
Notification Time: 17:07 [ET]
Event Date: 05/02/2016
Event Time: 05:30 [CDT]
Last Update Date: 05/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (FAX)

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 obtained from the State of Texas via email:

"On May 2, 2016, the licensee notified the Agency [State of Texas] that one of its technicians had discovered at approximately 0530 CDT, that a Troxler Model 3430 moisture/density gauge had been stolen out of the back of the licensee's pickup while it was parked at the technician's residence. The licensee's radiation safety officer (RSO) reported the technician had checked out the gauge on Saturday, April 30, 2016, to do a job in another town. After traveling to the job site, the job was cancelled. The technician failed to follow the licensee's procedures and went home instead of returning the gauge to the facility. The gauge was left chained inside the back of the company pickup. The technician told the RSO that the trigger lock was on the device. The technician told the RSO he heard noise outside his house at approximately 0300-0400 CDT this morning and suspects that was when it was being stolen. He found the chains had been cut and the transport case and gauge were gone along with another concrete testing device. Local law enforcement was notified and the technician drove around searching the area. The RSO contacted multiple pawn shops in the area.

"Device: Troxler Model 3430 moisture/density gauge Serial #: 31528
Sources: Cesium-137 - 8 millicuries; Americium-241 - 40 millicuries

"More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: I-9395


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: 51903
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: HONEYWELL INTERNATIONAL, INC.
Region: 1
City: SOUTH CHESTERFIELD State: VA
County: CHESTERFIELD
License #:
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2016
Notification Time: 15:41 [ET]
Event Date: 05/03/2016
Event Time: [EDT]
Last Update Date: 05/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

The following was received from the Commonwealth of Virginia via email:

"Honeywell International is authorized by general licenses to possess a number of tritium exit signs. It was discovered during an internal physical inventory that eight tritium signs were unaccounted. All were distributed by Safety Shield, Inc., and included one Model L3, s/n T8543, 11.5 curies; one Model XT, s/n S1075, 7.5 curies; and six Model 2040's, s/n 207011 through 207016, 7.5 curies each. The signs were received several years ago. Honeywell was unable to locate the signs despite a search of the facility and additional record review. Honeywell has submitted a procedural change in an effort to better track the remaining tritium signs at the facility. The licensee will keep the agency informed of any additional information.

"Event Report ID No.: VA-16-002"

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: 51904
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: NEW YORK PRESBYTERIAN HOSPITAL
Region: 1
City: New York State: NY
County:
License #: 75-2960-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/03/2016
Notification Time: 15:45 [ET]
Event Date: 11/11/2015
Event Time: [EDT]
Last Update Date: 05/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL RADIATION WORKER OVEREXPOSURE

The following was received from New York via email:

"Possible [overexposure] event occurred when a radiochemist employed by Weill Cornell Medical College recorded an exposure of 1675 mRem during the October 1-October 31 monitoring period. This caused his year to date exposure for the year 2015 to exceed the annual maximum permissible personnel exposure of 5000 mRem per year. His year to date dose equivalent through October 31, 2015 is 5546 mRem. The radiochemist synthesizes radiopharmaceuticals for PET and PET/CT. He works primarily with Carbon-11 with a 511 keV gamma energy.
Investigation was performed by the licensee [New York Presbyterian Hospital]. They analyzed his workload, procedure methods and the quantities of the radiopharmaceuticals he worked with in October and confirmed that it did not vary from previous months in this year. Also other radiochemists working with him did not receive any elevated exposures nor were there any contaminations in the radiochemistry area. Since the radiochemist October exposure was 43 percent of what he had received in his previous 9 months, the licensee concluded that the dosimeter may have been accidentally contaminated. The investigation concluded that the radiochemist did not receive an overexposure of 1675 mRem."

New York Incident # NY150008

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Agreement State Event Number: 51905
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: TAYLOR REGIONAL HOSPITAL
Region: 1
City: CAMPBELLSVILLE State: KY
County:
License #: 202-160-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2016
Notification Time: 18:25 [ET]
Event Date: 02/23/2016
Event Time: [CDT]
Last Update Date: 05/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RECEIVED DOSE FROM BRACHYTHERAPY TREATMENT DIFFERENT THAN PRESCRIBED DOSE

The following was received from the Commonwealth of Kentucky via facsimile:

"KY RHB [Kentucky Department for Public Health & Safety, Radiation Health Branch] was notified by telephone on 5/3/16 at approximately 1600 [EDT] by a representative from Taylor Regional Hospital, of a medical event involving 2 separate patients that had permanent prostate implants using Pd-103. Both patients had implants on 2/23/16 and post implant CT's [computed tomography] on 3/22/16. Post implant dosimetry for one patient revealed the dose received to 90 percent of the prostate was 83.19 Gy and the prescribed dose was 125 Gy (66.55 percent of prescribed). The second patient received 89.06 Gy of the 125 Gy prescribed (71.25 percent of the prescribed). Additional information expected from the licensee.

"Event Report ID No.: KY160002"

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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Part 21 Event Number: 51915
Rep Org: ELECTROSWITCH
Licensee: ELECTROSWITCH
Region: 1
City: Weymouth State: MA
County:
License #:
Agreement: Y
Docket: 99900833
NRC Notified By: LARRY FRIEDMAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/10/2016
Notification Time: 15:59 [ET]
Event Date: 05/10/2016
Event Time: [EDT]
Last Update Date: 05/10/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ART BURRITT (R1DO)
JAMIE HEISSERER (R2DO)
ERIC DUNCAN (R3DO)
VIVIAN CAMPBELL (R4DO)

Event Text

PART 21 REPORTING OF DEFECTS AND NONCOMPLIANCE

The following is a synopsis of information received via fax:

"Various Electroswitch products - Series 24 Instrument & Control (Part #24XX, 24XXX, 243XX, 74XXX), Series 24 LOR (part #78XX), Series 24 LOR/ER (part #78XX), Series 24 CSR (part #88XX), Series 24 LSR (part #92XX), Series 31 Instrument & Control (part #31XXX, 65XXX, 75XXX), Series 31 TR/LSR (part #93XX), Series 20 Cam (part #20KB, 20KD, 20LB, 20LD, 20MB, 20MD, 20MF, 20MG, 20PF, 20PG, 20PH, 20PJ, 20PL, 20PY), Series 20 Module (part #10XXX, 17XXX, 18XXX, 19XXX, 29XXX, 30XXX, 32XXX,38XXX,40XXX, 60XXX, 61XXX, 62XXX, 63XXX) [have a potential deviation (departure from the technical requirements included in the procure document)]

"It was determined on May 10, 2016 that Electroswitch does not have the capability to perform the evaluation to determine if a defect, which could create a substantial safety hazard, exists.

"Any Electroswitch product that has a part number listed above and was sold as a Safety-Related Class IE product [may contain the deviation].

The two nonconformances issues are:

"Initial Product Qualification Tests for Dielectric Withstanding Voltage, Insulation Resistance and Contact Resistance as defined in Electroswitch's ESC-STD-1000 Rev. 3 dated 9/3/1984 General Specifications for Rotary Switches and Auxiliary Relays for Utility Applications including Class 1E Equipment for Nuclear Power Generating Stations was found to be in contradiction to IEEE C37.90-1978 Relays and Relay Systems Associated with Electric Power Apparatus.

"Electroswitch did not procure materials, parts, equipment and/or services from an Appendix B supplier nor were applicable Commercial Grade Surveys, Source Inspections and Material Analyses performed for the following materials:
Precious metal blade overlay material
Red metal blade material
Precious metal overlay thickness of switch blade material
Molding compound of switch insulators (terminal decks and barriers)
Carbon steel for securing rods
Solenoids
Relays
Services (test labs) pertaining to product qualification

Electroswitch is attempting to determine which NRC licensees are potentially affected.

"The following personnel may be contacted regarding this notification:

Larry Friedman
Quality Assurance Manager
781-607-3309

Ed Reszenski
Engineering Manager
781-607-3341"

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Power Reactor Event Number: 51917
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: JUSTIN WIEMER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/10/2016
Notification Time: 19:38 [ET]
Event Date: 05/10/2016
Event Time: 11:38 [CDT]
Last Update Date: 05/10/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
VIVIAN CAMPBELL (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation

Event Text

CONTAINMENT COOLING WATER SYSTEM INOPERABLE DUE TO UNANALYZED CONDITION

"During scheduled maintenance, at 1138 CDT, the Fort Calhoun Station Shift Manager was notified via phone call and condition report of an unanalyzed condition which was the result of the maintenance on Shutdown Cooling Heat Exchanger valves. This condition could have led to the inability of the Component Cooling Water (CCW) system to perform its design function of providing a cooling medium for the Containment atmosphere under Loss of Coolant Accident (LOCA) conditions. This was identified by OPPD [Omaha Public Power District] staff engaged in Design Basis Reconstitution.

"As part of the maintenance, HCV-484, Shutdown Cooling Heat Exchanger AC-4A CCW Outlet Valve, and HCV-481, Shutdown Cooling Heat Exchanger AC-4B CCW Inlet Valve, were opened. Under these conditions, with the assumed single failure loss of DC control power and accident conditions of a LOCA, CCW would be allowed to flow through both shutdown cooling heat exchangers, effectively bypassing flow to the Containment Cooling Units. These conditions are not assumed under plant design basis calculations, and therefore placed the plant in an unanalyzed condition.

"Following clearance removal at 1535 CDT, both HCV-484 and HCV-481 were returned to service and the condition described above no longer exists."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 11, 2016
Wednesday, May 11, 2016