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Event Notification Report for June 16, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/15/2016 - 06/16/2016

** EVENT NUMBERS **


51917 51989 51990 51991 51992 51993 52007

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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: 06/15/2016
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.

* * * UPDATE ON 6/15/16 AT 1836 EDT FROM JOHN BLALOCK TO DONG PARK * * *

"Discovered 6/15/2016 at 1330 CDT: During the extent of condition review for the above ENS notification, it was discovered that the unanalyzed condition that occurred on 5/10/2016 also occurred five other times during the past 3 years. Details for these additional occurrences will be included in the 60-day Licensee Event Report associated with the original 5/10/2016 ENS notification."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Taylor).

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Agreement State Event Number: 51989
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EXXONMOBILE CORPORATION
Region: 4
City: BEAUMONT State: TX
County:
License #: 02316
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/08/2016
Notification Time: 10:03 [ET]
Event Date: 06/06/2016
Event Time: [CDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - CABLE ON BERTHOLD LB 300 MODEL FAILED

The following report was received from the Texas Department of State Health Services via facsimile:

"On June 7, 2016, the Agency [Texas Department of State Health Services] was notified by the Licensee's consultant that on June 6, 2016, the licensee found the cable on a Berthold LB 300 model gauge that connects the operating rod to a 500 milliCurie cobalt 60 source had failed. The source is currently inserted in the in source well in the normal operating position and cannot be removed. The failure does not create any additional exposure risk to the licensee's workers or members of the general public. The licensee stated there is no access to the vessel the source is located in during operation. The licensee intends to work with the manufacturer to repair the gauge during its next outage. Additional information on this event will be provided in accordance with SA-300."

Texas Incident Report No.: I-9410

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Non-Agreement State Event Number: 51990
Rep Org: PARAGON MEDICAL
Licensee: PARAGON MEDICAL
Region: 3
City: PIERCETON State: IN
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: DAMIEN SHRIVER
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/08/2016
Notification Time: 14:14 [ET]
Event Date: 06/01/2016
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

LOST GENERAL LICENSED MATERIAL

The licensee lost two general licensed devices containing Po-210 sources. These were lost between 2011 and 2014.

Manufacture: NRD Inc.
Model Number: P-2021-8101, P-2101-8101
Device Serial Number: A2HW030, A2JJ603
Original activity per device: 10.00 mCi, 10.00 mCi
Current activity: 0.0 mCI, 0.0 mCi
Original ship date: 10/4/2011, 1/7/2013

The licensee notified R3 (Sulaiman).

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: 51991
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2909-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 08/13/2015
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"Mount Sinai Medical Center (MSMC) reported that a patient only received 62 percent of their prescribed Y-90 microsphere (BTG International / Nordion model TheraSpheres) dose during treatment performed on 8/13/2015. The patient was prescribed to receive 1.81 GBq (48.92 mCi) of Y-90 microspheres for an exposure of 15,000 cGy (rad) to the liver. Access to the liver was gained through the femoral artery, with catheterization performed using a reverse curve catheter and coaxial micro-catheter. Following completion of the treatment procedure, radiation surveys using a Rados detector revealed 0 mR/hour. The microsphere delivery kit was then taken to the hot laboratory for further radiation surveys. At that time MSMC discovered a residual activity of approximately 33.7 percent of the microspheres in the vial. The cause was determined to be a procedure problem. Corrective actions included procedure modifications."

NMED: 150485

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: 51992
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN KETTERING CANCER CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2968-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 01/16/2015
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"Memorial Sloan-Kettering Cancer Center reported that a pediatric male patient only received 64.38 MBq (1.74 mCi) of I-124 labeled monoclonal 8H9 on 1/16/2015, instead of the prescribed 120.25 MBq (3.25 mCi). The patient had been diagnosed with pontine glioma. The incident occurred because the infusion process along the gauze at the site of the catheter connector leaked. The leak was not obvious on visual inspection. The cause was determined to be a procedure problem. Corrective actions included generating a new procedure and improvements to radioactive material labeling and handling."

NMED: 150094

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: 51993
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ANHEUSER-BUSCH, LLC
Region: 1
City: WILLIAMSBURG State: VA
County:
License #: GL 1385
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 16:11 [ET]
Event Date: 05/25/2016
Event Time: [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER WILL NOT FULLY OPEN

The following report was received via e-mail:

"On May 27, 2016 the Virginia Radioactive Material Program (VRMP) received a reciprocity notification from Heuft USA, Inc., to perform maintenance on a fixed gauge which was not properly functioning. The gauge is a Heuft Model 45US, serial number 1254AR containing 45 mCi of Am-241.

"On May 31, 2016 the Heuft service engineer arrived at the Anheuser-Busch facility to investigate the gauge not functioning. The shutter was able to be fully closed but would not fully open. The engineer determined this to be due to a thin piece of material present in the shutter assembly which is not normal, and which interfered with the shutter opening fully. The engineer reported that the root cause of the problem appears that a cylindrical portion of the liner has broken off, perhaps as a result of cyclical thermal stress.

"The shutter assembly was replaced and is working properly. There was no public health exposure or environmental release from this event."

Virginia report: VA-16-006

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Power Reactor Event Number: 52007
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILL MUFFLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/15/2016
Notification Time: 15:14 [ET]
Event Date: 04/17/2016
Event Time: 21:04 [EDT]
Last Update Date: 06/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
SILAS KENNEDY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

INVALID ACTUATION OF EMERGENCY DIESEL GENERATOR

"This is to report the Salem Unit 1, 1B Emergency Diesel Generator (EDG) actuation due to an invalid signal.

"This report is being made per paragraphs 10CFR50.73 (a)(1) and 10CFR50.73(a)(2)(iv)(A) to address the invalid actuation of the 1B EDG on April 17, 2016, during replacement of an indicating bulb.

"Plant conditions; Salem Unit 1 was in mode 6 at the time of the invalid actuation.

"On April 17, 2016, at approximately 2055 [EDT] while performing Solid State Protection System (SSPS) testing of the 1B Safeguards Equipment Cabinet (SEC), operators identified that an input test light was not lit as expected.

"At approximately 2104 [EDT] while attempting to replace the light bulb, the 1B EDG unexpectedly automatically started.

"The 1B EDG responded properly to the auto start signal and started in SEC Mode 1, accident only, and did not load.

"The cause of the inadvertent start was determined to be a loss of the block circuit which allowed an output to the logic module which then caused the EDG to auto start. Subsequent testing of the input block switches demonstrated that, due to switch degradation, slight pressure applied to the switch was enough to allow the block signal to be momentarily interrupted, even without repositioning of the switch. It was determined that the loss of the block was most likely due to the operators finger coming in contact with the switch during the bulb replacement."

The licensee has notified the NRC Resident Inspector. The licensee will notify the State of New Jersey and Delaware.

Page Last Reviewed/Updated Thursday, June 16, 2016
Thursday, June 16, 2016