United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > May 31

Event Notification Report for May 31, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/27/2016 - 05/31/2016

** EVENT NUMBERS **


51030 51942 51943 51945 51946 51947 51962 51964 51965

To top of page
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: 05/27/2016
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 This was an unpublished design change that was implemented to replace an obsolete integrated circuit chip.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.

* * * UPDATE FROM LES TAGGART TO BETHANY CECERE AT 0951 EDT ON 5/26/16 * * *

AZZ/NLI Nuclear Logistics provided Revision 2 to Part 21 Report No: P21-04302015 to correct the referenced EPRI TR-102323 Rev. 3 to Rev. 4 and change 'timing' contacts to 'instantaneous' contacts as shown below:

"(vii) The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.

"The relays that are currently in stock at NLI have been placed on hold until after the units have been determined to be qualified for the specific application. NU has completed the EMC qualification testing per the requirements of EPRI TR-102323 Rev. 4 for the following tests, as applicable: CE101, CE102, RE101, RE102, RS101, RS103, CS101, CS114, CS115 and CS116.

"The results were satisfactory with exception of the following condition: During Conducted Susceptibility CS114 onto the power lines, with the timing circuit in operation, the instantaneous contacts exhibited chatter in the range of 2.6 MHz to 20.3 MHz. The unit requires a ferrite to be installed onto the input power lines of the relay with 3 turns through the ferrite core. In this modified configuration, the relay was not susceptible to Conducted Susceptibility and successfully passed the required test per CS114."

Notified R1DO (Lilliendahl), R2DO (Guthrie), R3DO(Kunowski), R4DO (Werner), and PART 21/50.55 REACTORS via email.

To top of page
Agreement State Event Number: 51942
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PETNET SOULTIONS INC.
Region: 1
City: NORTH WALES State: PA
County:
License #: PA-0830
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: RICHARD SMITH
Notification Date: 05/19/2016
Notification Time: 14:47 [ET]
Event Date: 05/18/2016
Event Time: [EDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE NOTIFICATION - TRANSPORTED PACKAGE EXCEEDS LIMITS

The following was received via FAX:

"The licensee notified the Department [Pennsylvania Bureau of Radiation Protection] by telephone on May 18, 2016, of an event that required reporting based on 10 CFR 20.1906(d)(2).

"Event Description: On May 18, 2016, a PETNET courier mistakenly picked up a white [shielded container] from a PA licensee which he assumed was empty because it was near other PET cases he was returning to the PETNET North Wales Pharmacy. As he was loading the cases into his trunk, the lid of the white [shielded container] opened and two rods fell out on the ground. He did not realize they were radioactive material. He placed them in his trunk using his hands, leaving the rods unshielded, and proceeded to return to the pharmacy. He placed the [shielded container] and 2 rods on top of the empty cases in PETNET's loading area. The PETNET Radiation Safety Officer (RSO) found the rods and surveyed them, noting the dose rate > [greater than] 200 mRem/hour on the surface. She immediately placed the sources in a shielded [container], and began her investigation. Survey/wipes were taken of the rods, the courier vehicle, the area in which the rods were discovered, and the courier's hands. No removable contamination was found. Dose modeling by the RSO determined there was enough interposed shielding with the large number of other [shielded containers] in his vehicle to reduce his exposure to below regulatory limits. Rods are going to be properly packaged and shipped back to the PA licensee.

"Cause of the Event: Human Error.

"Actions: A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt.

"Media Attention: None at this time.

"Event Report ID No: PA160015"

* * * UPDATE FROM JOSEPH MELNIC TO VINCE KLCO ON 5/24/16 AT 1217 EDT * * *

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

"EVENT DESCRIPTION: On May 18, 2016, a PETNET courier mistakenly picked up a white pig from a PA licensee which he assumed was empty because it was near other PET cases he was returning to the PETNET North Wales Pharmacy. As he was loading the cases into his trunk, the lid of the white pig opened and two rods fell out on the ground. He did not realize they were radioactive material. The rods were two Ge/Ga-68 calibration sources containing 2.16 mCi each. He placed them in his trunk using his hands, leaving the rods unshielded, and proceeded to return to the pharmacy. He placed the pig and 2 rods on top of the empty cases in PETNET's loading area. The PETNET Radiation Safety Officer found the rods and surveyed them, noting the dose rate >200 mr/hr on the surface, 1.4 mR/hr at one meter. She immediately placed the sources in a shielded pig, and began her investigation. Surveys/wipes were taken of the rods, the courier vehicle, the area in which rods were discovered and the courier's hands. results of the wipes were 0 dpm, all surveys were background. No removable contamination was found. A survey by the RSO has shown no overexposure to the courier's hands as a result of picking up the rods and the RSO determined there was enough interposed shielding with the large number of other pigs in his vehicle to reduce his exposure to below regulatory limits. The rods are going to be properly packaged and shipped back to the PA licensee. The courier's whole body badge was sent for analysis. No finger extremity badge was worn.

"ACTIONS: A reactive inspection has been performed by the Department [State of Pennsylvania]. Dose modeling of the courier's hands will be requested to determine dose to the hands More information will be provided upon receipt."

Notified R1DO (Lilliendahl) and NMSS Events via email.

To top of page
Agreement State Event Number: 51943
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: TAYLOR REGIONAL HOSPTIAL
Region: 1
City: CAMPBELLSVILLE State: KY
County:
License #: 202-099-27
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: RICHARD SMITH
Notification Date: 05/19/2016
Notification Time: 19:10 [ET]
Event Date: 05/19/2016
Event Time: [CDT]
Last Update Date: 05/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENTS - MISADMINISTRATION

The following was reported to the NRC via phone notification and email:

"As a result of a routine health and safety inspection, Taylor Regional Hospital has reported 13 medical events which occurred [from] 2006 [to] 2011. These medical events are the result of permanent prostate brachytherapy where post implant dosimetry for each of the 13 patients revealed the total dose delivered to the target organ differed from the prescribed dose by 50 REM and 20% or more. The Kentucky Cabinet for Health and Family Services is continuing to communicate with the licensee to ascertain all relevant information related to these events.

"Event report ID No: KY160004"


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.

To top of page
Agreement State Event Number: 51945
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: SEADRIFT State: TX
County: CALHOUN
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: KARL DIEDERICH
Notification Date: 05/19/2016
Notification Time: 22:08 [ET]
Event Date: 05/19/2016
Event Time: [CDT]
Last Update Date: 05/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR GAUGE STUCK SHUTTER

The following information was received via E-mail:

"Event Type: 30.50(b)(2), Events in which equipment is disabled or fails to function as designed.

"Event Narrative: On May 19, 2016 the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that while performing routine shutter checks, the shutter on an Ohmart model SHLM-BR4 could not be closed. The gauge contains a 5.0 curie cesium-137 source. Open is the normal operating position of the gauge. The source does not create any additional risk of exposure to the workers or members of the general public. The RSO stated they will call their service company to repair the gauge. The RSO stated the gauge is scheduled to be replaced during their next outage this fall. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9405.

To top of page
Non-Agreement State Event Number: 51946
Rep Org: UNITED STATES AIR FORCE
Licensee: UNITED STATES AIR FORCE
Region: 4
City: ANDERSEN AFB State: GU
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/20/2016
Notification Time: 15:25 [ET]
Event Date: 05/18/2016
Event Time: 08:30 [GST]
Last Update Date: 05/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST AM-241 SOURCE

"A B-52 bomber crashed shortly after take-off at Andersen AF base in Guam at 0830 local time (2230 GMT, Wednesday, 18 May 2016). The B-52 had a Sniper Pod which contained 12 microcuries of Am-241. So far the safety team could not locate the Sniper Pod at the incident spot.

"The value for Am-241 listed in Appendix C to [10 CFR] Part 20 is 0.001 microcuries. Each Sniper Pod carries 12 microcuries of Am-241. Hence, we [USAF] reported the incident to the NRC Operations Center in accordance with 10 CFR 20.2201. We will provide you [NRC with a written] incident report within 30 days."

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

To top of page
Agreement State Event Number: 51947
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GREEN BAY PACKAGING INC, ARKANSAS KRAFT DIVISION
Region: 4
City: MORRILTON State: AR
County:
License #: ARK-0197-0312
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/20/2016
Notification Time: 16:17 [ET]
Event Date: 05/20/2016
Event Time: [CDT]
Last Update Date: 05/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

FIXED NUCLEAR GAUGE READINGS HIGHER THAN EXPECTED

The following information was received via E-mail:

"While performing routine shutter tests of fixed gauges, the licensee noted higher than expected readings from a fixed gauge when the shutter was closed. The expected reading was 2 millirem per hour and the readings during the shutter check were found to be 6 millirem per hour. The licensee has contacted the manufacturer and a field engineer is expected on Monday, May 23, 2016.

"The gauge is identified as an Ohmart SR-2, Serial Number M-2688, containing 4500 milliCuries of Cesium-137.

"The State of Arkansas is awaiting a written report from the licensee with a report of the findings of the field engineer."

Arkansas Event Number: AR-2016-002

To top of page
Power Reactor Event Number: 51962
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: DAN DULLUM
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/27/2016
Notification Time: 09:22 [ET]
Event Date: 03/28/2016
Event Time: 13:20 [EDT]
Last Update Date: 05/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JON LILLIENDAHL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 80 Power Operation

Event Text

INVALID SPECIFIED SYSTEM ACTUATION

"This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made pursuant to 10 CFR 50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of containment isolation valves in more than one system.

"On 3/28/16, at approximately 1320 [EDT], a loss of power occurred on the Unit 2 E124 480 volt load center due to an equipment operator inadvertently opening the main feed breaker during the process of applying a clearance to de-energize the E124-P-A motor control center for planned maintenance. Loss of the E124 load center resulted in Group II and Group III primary containment isolations due to an invalid ESF actuation signal. Systems impacted by the containment isolations included containment instrument nitrogen, containment atmospheric monitoring, reactor water cleanup, and secondary containment.

"Balance of plant impacts included partial loss of feedwater heating and a reduced condenser vacuum. Reactor power lowered to 86% as a result of the event and further decreased to approximately 80 percent when re-establishing the 3A, 4A and 5A feedwater heaters.

"Following direction from the control room, the E124 main feed breaker was promptly re-closed by equipment operators. Affected equipment was restored to its normal or planned configuration and containment isolations were reset at 1406.

"The containment isolation signal was generated as a result of the loss of power to the E124 load center and was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered to be an invalid actuation."

The licensee has notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 51964
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM HERZOG
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/27/2016
Notification Time: 23:17 [ET]
Event Date: 05/27/2016
Event Time: 20:46 [CDT]
Last Update Date: 05/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG WERNER (R4DO)

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

OFFSITE NOTIFICATION DUE TO AN INADVERTENT ACTUATION OF ONE EMERGENCY SIREN

"A South Texas Project offsite emergency notification siren was inadvertently going off. The Matagorda County Sheriff's Office notified Site Security that a siren had actuated. At the time of the inadvertent siren actuation the area was experiencing lightning and rain. Suspect lightning caused the inadvertent siren actuation. Station Personnel are addressing the issue with the siren.

"The Matagorda County Sheriff's Office was the only offsite agency that was contacted during the event."

The licensee has notified the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 51965
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RUSS CRUZEN
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/30/2016
Notification Time: 19:11 [ET]
Event Date: 05/30/2016
Event Time: 09:30 [PDT]
Last Update Date: 05/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GREG WERNER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

MANUAL OPENING OF REACTOR TRIP BREAKERS DUE TO ROD POSITION ERROR GREATER THAN 12 STEPS

"On 5/30/2016 at 0930 [PDT], Unit 2 was in its 19th refueling outage in Mode 4 (hot shutdown, reactor subcritical). Routine post-maintenance testing of digital rod position indication (DRPI) was in progress in accordance with Surveillance Test Procedure (STP) R-1C. Rod Shutdown Bank A was being withdrawn. With Shutdown Bank A Group 1 demand indicating 14 steps, and Group 2 demand indicating 13 steps, Bank A DRPI indicated 12 steps but control rod B4 DRPI indication remained at Step 0. With the bank demand position exceeding rod B4's DRPI indication by greater than 12 steps, Operators manually opened the Reactor Trip Breakers, placing all the rods in a known position due to an inoperable DRPI system. All systems actuated as required and rods fully inserted.

"Manual initiation of a reactor trip where the actuation is not part of a pre-planned evolution is reportable under 10 CFR 50.72 (b)(3)(iv)(A). While the reactor trip was initiated in accordance with the STP's instructions, the manual actuation was not a preplanned outcome of the STP.

"Subsequently, it was determined that rod B4 had remained on the bottom at Step 0 as indicated by DRPI. A moveable gripper fuse was blown, preventing that rod from being withdrawn. The blown fuse was replaced and testing continued in accordance with the procedure.

"There was no impact to public, employee, or plant safety.

"The NRC Resident Inspector was notified."

Page Last Reviewed/Updated Wednesday, June 01, 2016
Wednesday, June 01, 2016