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Event Notification Report for July 1, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/30/2016 - 07/01/2016

** EVENT NUMBERS **


52032 52034 52035 52036 52037 52038 52054 52055 52056 52057

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Agreement State Event Number: 52032
Rep Org: COLORADO DEPT OF HEALTH
Licensee: PORTER ADVENTIST HOSPITAL - ENCORE ELECTRIC
Region: 4
City: DENVER State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/22/2016
Notification Time: 11:00 [ET]
Event Date: 12/31/2005
Event Time: [MDT]
Last Update Date: 06/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Category 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the State of Colorado via email:

"Event Report ID No.: CO16-I16-08

"Detail: The facility hired a contractor to remodel space within the hospital. During the construction pedestrian traffic was routed around the area. According to the facility environmental health safety office the Tritium exit signs were only in use during the project.

"Event Description: It is unknown due to the extensive passage of time and the departure of employees who were involved with the project. No further information is available related to the use or the disposition of the 6 Tritium exit signs, Model # SLXTUIGW10, Serial # 162229 to 162234, H-3, 7.3 CI."

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 52034
Rep Org: COLORADO DEPT OF HEALTH
Licensee: VAIL MOUNTAIN SCHOOL
Region: 4
City: VAIL State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/22/2016
Notification Time: 13:28 [ET]
Event Date: 06/22/2016
Event Time: [MDT]
Last Update Date: 06/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from Colorado via email:

"The facility manager completed the documentation for the 2016 Annual General License reports. During his inspection, only 2 of the 4 Tritium exit signs were reported. It is unknown as to what may have occurred with the other two signs as staff has changed since the signs were designated to be used at the facility.

"Pictures were submitted showing the labels on the existing two signs located within the modern fold doors at the school. No serial number was provided on the label from the manufacture Shield Source. The distributor, Isolite, did report serial numbers on the quarterly report to the state."

Colorado Report # CO16-I16-09

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: 52035
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/22/2016
Notification Time: 17:46 [ET]
Event Date: 06/17/2016
Event Time: [CDT]
Last Update Date: 06/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION OF BRACHYTHERAPY PATIENT

The following was received from Wisconsin via email:

"On Friday, June 17, 2016, a licensee discovered contamination on a package that was used to ship I-125 prostate brachytherapy seeds. The post procedure survey of the packaging revealed elevated levels of radiation. After wipes were taken, the licensee determined that there was I-125 contamination on the inside of the packaging. There was no other contamination in the operating room. The licensee had the patient return to the facility to perform a urine bioassay. The bioassay revealed elevated levels of I-125 in the patient's urine. However further analysis will be required to determine activity concentrations. The licensee has also administered Lugols solution to the patient to block the thyroid. The department and the licensee are still collecting data to determine if this is a medical event. Site visits and updates will be performed as needed."

Wisconsin Report ID # WI160004

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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Non-Agreement State Event Number: 52036
Rep Org: U.S. AIR FORCE
Licensee: U.S. AIR FORCE
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: ANTHONY CAGLE
HQ OPS Officer: VINCE KLCO
Notification Date: 06/23/2016
Notification Time: 11:45 [ET]
Event Date: 06/20/2016
Event Time: [CDT]
Last Update Date: 06/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST/MISSING DETECTION SOURCE

The following was received by email:

"Per your request, I'm sending this email as a follow-up to my telephonic notification to your office that occurred earlier today (re: 10 CFR 20.2201).

"We're reporting the apparent loss (presently unknown whereabouts) of an aggregate quantity of approximately 95 mCi of Ni-63 housed in the following seven generally licensed devices (GLDs):

- 3 ea. x Smiths Detection SABRE 2000s (up to 15 mCi Ni-63 ea.)
- 2 ea. x Smiths Detection SABRE 4000s (up to 15 mCi Ni-63 ea.)
- 2 ea. x GE VaporTracers (up to 10 mCi Ni-63 ea.)

- 19 May 2016: Tinker AFB installation RSO attempted to schedule semiannual swipe sample collection for May 2016. The unit possessing/using GLDs indicated that the GLDs had been transferred. Installation RSO advised unit to present documentation.

- 23 May 2016: Unit reported to installation RSO that they were still looking for paperwork.

- 13 Jun 2016: After an exhaustive search of records and information management systems, neither the installation RSO or the unit found any documentation for GLD transfer.

- 16 Jun 2016: Installation RSO notified the unit commander; continues to investigate.

- 20 Jun 2016: Installation RSO notified the USAF Radioisotope Committee Secretariat by telephone and then by email to report situation."

The above report of a possible lost or missing source involves sources not specifically licensed under the MML (Master Material License).

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: 52037
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: VINCE KLCO
Notification Date: 06/23/2016
Notification Time: 17:13 [ET]
Event Date: 06/22/2016
Event Time: [CDT]
Last Update Date: 06/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA COMPONENT FAILURE

The following information was received from the State of Texas by email:

"On June 23, 2016, the licensee notified the Agency [Texas Department of State Health Services] that a radiography camera had failed to lock in position after retracting the source. The ball stop moved about 3/16 of an inch causing the camera to not lock in position after the source was retracted into position. The licensee's radiation safety officer (RSO) obtained the following information about this component failure. The camera was a delta 880 source serial number S7340 at an activity of 52.6 curies. No overexposures were reported to the RSO. An investigation into this event is being conducted by the RSO. The camera has been secured and is located at one of the licensee's sites. Updates will be provided as obtained in accordance with SA300."

Texas Incident: I-9415

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Agreement State Event Number: 52038
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: GLACIER SOILS TESTING LLC
Region: 4
City: EVERETT State: WA
County:
License #: WN-10562-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: VINCE KLCO
Notification Date: 06/23/2016
Notification Time: 19:46 [ET]
Event Date: 06/23/2016
Event Time: [PDT]
Last Update Date: 06/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED

The following information was received by the State of Washington via email:

"The operator of a portable moisture-density gauge temporarily left the gauge unattended at a construction site in Redmond, Washington, and the gauge was run over by the wheel of a roller. The top of the gauge handle was broken off, but both radioactive sources are in safe condition inside the body of the gauge. The gauge operator is maintaining security around the damaged gauge, and has called a nuclear gauge calibration and servicing company to come to the construction site to assess the scene, package the gauge for transport to a safe location, and conduct radiation surveys to verify that there is no radioactive contamination of the construction site and the roller equipment, and to verify that the radioactive sources are undamaged and inside the gauge case."

The portable gauge is a Campbell Pacific Nuclear; Model MC-1-DR; Serial Number MD51008063; Sources-Cs-137 (.010 Ci), Am/Be (.050 Ci).

Washington Item Number: WA160002

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Research Reactor Event Number: 52054
Facility: U. S. GEOLOGICAL SURVEY
RX Type: 1000 KW TRIGA MARK I
Comments:
Region: 0
City: DENVER State: CO
County: DENVER
License #: R-113
Agreement: Y
Docket: 05000274
NRC Notified By: TIM DEBEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/30/2016
Notification Time: 10:34 [ET]
Event Date: 06/30/2016
Event Time: 07:15 [MDT]
Last Update Date: 06/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
RESEARCH AND TEST REACTOR EVENT
Person (Organization):
GEOFFREY WERTZ (NRR)

Event Text

REACTOR SHUTDOWN AFTER TECHNICAL SPECIFICATION VIOLATION

"At 0712 [MDT] on 6/30/16 a routine GSTR [Geological Survey TRIGA Reactor] startup and ascent to 900 kW was initiated after successful completion of the daily prestart checks and an excess reactivity check. At 0715 [MDT], as power was passing through [approximately] 200 kW, it was clear to the operator that one of the three power instruments (the NP1000) was not functioning since it was still reading 0% when it should have been reading [approximately] 20%. The reactor was then shutdown, Reactor Supervisor notified, and troubleshooting commenced. Shortly after this, the NP1000 signal cable was found to have the coaxial cable pulled out of one of the connectors in the signal path. Repair, troubleshooting, and testing were performed to resolve the problem. At 0804 [MDT] the reactor was started up and all power instrumentation operated correctly and the daily power operation was performed without further problems.

"The NP1000 is a required safety instrument for operation of the reactor, so malfunction of the instrument is a violation of the facility's Technical Specifications.

"Specifically, specification E.7 states: 'The type and minimum number of safety systems which shall be operable for reactor operation are shown in Table I.' Table I requires the NP1000 to provide a high power scram at 110% power, but the cable problem would have prevented the high power scram from occurring in that instrument."

The licensee will notify the NRC Project Manager.

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Part 21 Event Number: 52055
Rep Org: CURTISS WRIGHT
Licensee: TARGET ROCK, CURTISS-WRIGHT FLOW CONTROL CORPORATION
Region: 1
City: FARMINGDALE State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN DEBONIS
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/30/2016
Notification Time: 16:52 [ET]
Event Date: 05/02/2016
Event Time: [EDT]
Last Update Date: 06/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
HAROLD GRAY (R1DO)
OMAR LOPEZ (R2DO)
MICHAEL KUNOWSKI (R3DO)
THOMAS HIPSCHMAN (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 - INADEQUATE SWAGING AND ADHERENCE OF SILICONE O-RING AND SILICONE PAD IN SOFT SEAT MAIN DISC AND PILOT DISC ASSEMBLIES

The following is a summary of the information from the email provided:

"[The] soft seat main disc and pilot disc assemblies are installed in certain process solenoid operated valves, some of which perform safety related functions such as containment isolation. These designs include a soft seat insert in the main and/or pilot disc that could loosen and potentially result in excessive leakage or failure of the valve to operate properly.

"Supplier:
Target Rock, Business Unit of Curtiss-Wright Flow Control Corporation
1966E Broadhollow Road, East Farmingdale, NY 11735

"Should you have any questions regarding this matter, please contact Michael Cinque, General Manager at (631) 293-3800.

"Plant Site Locations:
Arkansas Nuclear One, Grand Gulf, Peach Bottom, Sequoyah, Browns Ferry, Hatch, Perry, Shearon Harris, Brunswick, Limerick, Pilgrim, South Texas, Dresden, Millstone, Quad Cities, Susquehanna, Duane Arnold, Nine Mile Point, River Bend, Three Mile Island, Fermi, Palo Verde, Saint Lucie, Watts Bar."

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Power Reactor Event Number: 52056
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: PAUL GALLANT
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/30/2016
Notification Time: 18:19 [ET]
Event Date: 06/30/2016
Event Time: 14:30 [EDT]
Last Update Date: 06/30/2016
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):
HAROLD GRAY (R1DO)

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

Event Text

BOTH PRIMARY CONTAINMENT ISOLATION VALVES FOR A PENETRATION POTENTIALLY INOPERABLE

"On June 30, 2016 at 1430 [EDT], with the reactor at 100 [percent] and the mode switch in RUN, Pilgrim Station determined both Primary Containment Isolation Valves (PCIVs) CV-5065-91 and CV-5065-92 for Drywell Penetration X-32A were inoperable due to the potential failure of relays relied on to perform the primary containment isolation function.

"The valves have been closed and deactivated in the isolated condition in accordance with Technical Specification Limiting Condition For Operation Action Statement 3.7.A.2.b.

"Preparations are in progress to replace the relays to restore the valves to operable status.

"This 8-hour notification is being made in accordance with 10 CFR 50.72 (b)(3)(v)(C) and 10 CFR 50.72 (b)(3)(v)(D).

"The licensee has notified the NRC Senior Resident Inspector.

"The licensee will notify the Commonwealth of Massachusetts."

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Power Reactor Event Number: 52057
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JOE GRAHAM
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/30/2016
Notification Time: 22:54 [ET]
Event Date: 06/30/2016
Event Time: 17:15 [CDT]
Last Update Date: 06/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
THOMAS HIPSCHMAN (R4DO)

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

Event Text

MULTIPLE VALID SPECIFIED SYSTEM ACTUATIONS DUE TO LOSS OF SERVICE TRANSFORMER 21

"On June 30, 2016 at 1715 CDT, Grand Gulf Nuclear Station (GGNS) experienced an electrical power supply loss from Service Transformer 21 which resulted in power supply being lost to Division 2 (16AB Bus) and Division 3 (17AC Bus) ESF buses. This resulted in a valid actuation of Division 2 and Division 3 Diesel Generators on bus under voltage. They both automatically started and energized their respective ESF buses as designed.

"During this event, the loss of power to the Division 2 (16AB Bus) resulted in a Division 2 RPS bus power loss, which actuated a Div 2 RPS half SCRAM signal.

"The power loss also resulted in a loss of the Instrument Air pressure resulting in some Control Rod Scram Valves to drift open. This in turn caused the Scram Discharge Volume to fill to the point where a Div 1 RPS half SCRAM signal was initiated from Scram Discharge Volume level high on Channel 'A'. This resulted in a valid full RPS Reactor SCRAM while not critical. Instrument Air pressure was restored and the SCRAM signal was reset at 1733 CDT.

"Appropriate off normal event procedures were entered to mitigate the transient. No ECCS initiation signals were reached. All safety systems performed as expected.

"GGNS was in Mode 4, Cold Shutdown, with MSIVs closed at the time of the event. Reactor water level was maintained in the normal water level band by Control Rod Drive system throughout this event. RHR 'A' was maintained in Shutdown Cooling operation and it was not affected by this event."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, July 01, 2016
Friday, July 01, 2016