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Event Notification Report for May 12, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/11/2016 - 05/12/2016

** EVENT NUMBERS **


51853 51903 51904 51905 51906 51915 51918

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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: 05/12/2016
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.

* * * UPDATE FROM CHRIS TERRY TO STEVE VITTO ON 05/11/2016 AT 0726 EDT * * *

The licensee has completed the investigation.

The licensee has notified the NRC Resident Inspector.

Notified Heisserer (R2DO), Erlanger (FCSE), FFD Group (email), NMSS Events Notification Group (email).

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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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Agreement State Event Number: 51906
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: JAMES HARDIE BUILDING PRODUCTS
Region: 1
City: PLANT CITY State: FL
County:
License #: G0663-1
Agreement: Y
Docket:
NRC Notified By: RENO FABII
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/04/2016
Notification Time: 09:27 [ET]
Event Date: 04/07/2016
Event Time: [EDT]
Last Update Date: 05/04/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

FLORIDA AGREEMENT STATE REPORT - LOST RADIOACTIVE THICKNESS GAUGE

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

"An audit conducted on James Hardie Building Products on April 4th, 2016 discovered a thickness gauge (NDC Model 102) was unaccounted for. The company was in the process of transferring equipment and under going an expansion. The auditor gave the company time to search for the device. As of 5/4/2016 all nine (9) of their facilities have been searched and the gauge has not been found. The last positive 'eyes on' sighting of device occurred in 2013 at the Plant City facility. The device was locked down to a wooden pallet. New policies and procedures are being implemented by James Hardie Building Products."

Although the audit was completed on April 4, 2016, the licensee did not conclude their search of all their facilities until April 7, 2016. The gauge was an NDC Systems Model 102, serial number 11838, containing 25 mCi of Am-241.

Florida Incident Number: FL16-059

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: 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: 05/11/2016
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)
PART 21/50.55 REACTO (EMAI)

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 1E product [may contain the deviation].

The two nonconformance 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"


* * * UPDATE FROM LARRY FRIEDMAN TO DONALD NORWOOD AT 1656 EDT ON 5/11/2016 * * *

The following information was received via fax:

Below is the list of utilities (and plants where specified) which were notified of Electroswitch's decision to end the Appendix B Quality Assurance Program:

Ameren Energy

Dominion Energy

Duke Energy

Energy Northwest

Entergy Nuclear (Waterford 3 Nuclear)

Entergy Nuclear (Pilgrim Power Plant)

Entergy Nuclear (Indian Point Energy)

Xcel Energy (Monticello Nuclear)

MPR Associates for FPL

Nebraska Public Power (Cooper Nuclear)

Nextera (Point Beach Nuclear)

Xcel Energy (Prairie Island Gen)

Southern Power (Hatch)

Southern Power (Vogtle)

TVA

TVA (Watts Bar Nuclear)

Wolf Creek Nuclear

Notified R1DO (Burritt), R2DO (Heisserer), R3DO (Duncan) and R4 DO (Campbell) and via E-mail Part 21/50.55 Reactors Group.

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Power Reactor Event Number: 51918
Facility: FARLEY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROBERT NORRIS
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/11/2016
Notification Time: 10:56 [ET]
Event Date: 05/11/2016
Event Time: 06:53 [CDT]
Last Update Date: 05/11/2016
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):
JAMIE HEISSERER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 29 Power Operation 0 Hot Standby

Event Text

FARLEY UNIT 2 TRIP ON HI HI STEAM GENERATOR LEVEL

"At 0653 [CDT] on 5/11/16, Farley Unit 2 reactor was manually tripped from 29 [percent] power. The initiating event was hi-hi Steam Generator level. Steam Generator levels began to rise following the start of a second condensate pump. The hi-hi steam generator level setpoint was reached causing the only running main feedwater pump to trip, a main feedwater isolation, and an automatic turbine trip. Auxiliary feedwater automatically started as expected. The reactor was manually tripped per procedure. All other systems responded properly for the event and there were no complications.

"The plant is currently stable in Mode 3.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, May 12, 2016
Thursday, May 12, 2016