Event Notification Report for July 13, 2016

LOST/STOLEN U.S. ARMY RADIOACTIVE CHEMICAL ALARMS

On July 13, 2016, the U.S. Army TACOM Radiation Safety Program Manager in Warren, MI was notified of a misplaced U.S. Army chemical alarm containing 250 microcuries of Am-241 from a U.S. National Guard Unit in North Carolina. The chemical alarm was misplaced on April 21. Since the material has not been recovered, the U.S. Army considers the material lost/stolen.

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

SECONDARY CONTAINMENT TECHNICAL SPECIFICATION NOT MET

"On July 13, 2016, at 19:50 EDT a severe thunderstorm warning was issued for Monroe County. This severe thunderstorm warning included the Fermi 2 site.

"Due to high winds encountered during the thunderstorm, the Technical Specification (TS) for secondary containment pressure boundary was not met numerous times. The duration of time that the secondary containment Technical Specification was not met was approximately 1 second for each event.

"All plant equipment responded as required to the changing environmental conditions and Reactor Building HVAC returned secondary containment pressure within TS limits. At 20:40 EDT secondary containment vacuum was greater than the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) and steady, and the LCO was exited. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material.

"The licensee has notified the NRC Resident Inspector."

* * * RETRACTION AT 1922 EDT ON 3/17/2017 FROM DEREK ETUE TO BETHANY CECERE * * *

"In this event notification, DTE Electric Company (DTE) reported conditions whereby the Fermi 2 secondary containment was believed to have exceeded Technical Specification Surveillance Requirements due to high winds. DTE hereby retracts this event notification as the Fermi 2 secondary containment has been determined to have been operable during this event as described below.

"The Fermi 2 secondary containment pressure is maintained at a pressure less than the external pressure to contain, dilute, hold up, and reduce the activity level of fission products prior to release to the environment, and to isolate and contain fission products that are released during a Design Basis Accident or certain operations. Secondary containment pressure is monitored by a number of differential pressure (dP) sensors. High wind gusts have resulted in momentary negative pressure on the leeward side of the building, causing a more positive pressure indication from one or more dP sensors. The secondary containment building pressure remains relatively constant during these 'wind events.'

"In December 2016, DTE implemented a software design change to display a 120-second rolling average for secondary containment dP indication. A 120-second rolling average recorded every second provides the operator a more accurate report of actual secondary containment conditions, while mitigating the signal noise and wind gust effects. The conditions associated with the subject event notification were re-reviewed in light of the improved secondary containment dP indication and it was determined that the Fermi 2 secondary containment was operable during this event. Specifically, the secondary containment pressure did not exceed Technical Specification Surveillance Requirements during this event.

"In summary, the above event notification is retracted because the Fermi 2 secondary containment was determined to have been fully operable during the conditions identified in the subject report."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Stoedter)

AGREEMENT STATE REPORT - FAILURE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following was received via email:

"The lock on a radiography camera did not spring back into place when the radiographer retracted the cable and source into the shielded position. He [the radiographer] was able to crank the source back out and when he retracted it back into the camera the second time, the lock sprung closed and secured the source. There was no unexpected radiation exposure to the employee or to the general public. The entire incident lasted less than 10 seconds. Due to the apparent equipment failure it is reportable under 10 CFR 30.50(b)(2).

"The device is identified as:
Manufacturer: QSA Global
Model #: 880 Delta
Device Serial #: 1636
Isotope: lr-192
Activity: 34 Ci

"The licensee (System One) is going to conduct an internal investigation to determine the cause of the malfunction. The Department [Pennsylvania Bureau of Radiation Protection] will be scheduling a reactive inspection.

"Event Report ID: PA160018"

AGREEMENT STATE REPORT - UNDERDOSE MEDICAL EVENT

The following was received via email:

"Event Description: A patient was undergoing a Y-90 Therasphere procedure in two separate treatments (to different liver segments). The delivery kits for both administrations passed the standard pre-administration testing. The physician and team noted no other equipment related issues until the administering Interventional Radiologist Physician noted unusual resistance during the first actual administration. After unsuccessful attempts to 'clear the line,' the efforts to complete the administration were terminated. The team then attempted to treat a second site, with essentially the same sequence of events occurring. Both delivery sets came from the same manufacturing lot, and both dosages of Theraspheres came from the same drug lot. The licensee estimates approximately 25 percent of the written directive dose was delivered.

"Cause of the Event: Unknown at this time. It is worth noting, another Theraspheres administration on another patient was performed the following day without incident. The delivery system kits were again from the same lot as those used on the previous day, but the Therasphere dosage was from a different lot.

"Actions: Licensee notified Nordion of the occurrence. The Department [PA Department of Environmental Protection] will perform a reactive inspection next week.

"Event Report ID: PA160019"

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.

DEGRADED SAFETY ITEMS CAUSED BY URANIUM BUILDUP

"On July 13, 2016, it was determined by the Environment, Health and Safety (EH&S) department that scrubber clean-out material, found in the S-1030 scrubber transition section during the annual maintenance shutdown that occurred in late May, potentially exceeded the uranium mass limit for the scrubber transition.

"(IROFS [Items Relied on for Safety] VENT-S1030-110) requires annual inspection and removal of significant solids buildup in the transition section. Upon inspection, significant buildup was found, and the ductwork was opened to permit extensive cleanout. 36 containers of material with a total gross weight of 210.4 kg was removed from the inlet transition during the cleanout on May 28th to May 29th. Grab samples were subsequently taken from each container and analyzed for uranium concentration. On July 13th, the EH&S department was made aware that the grab sample results averaged 47.8% U. Although the exact uranium mass cannot be determined until the material is dissolved and representatively sampled, available evidence suggests that the mass limit of 29 kg U in the inlet transition was exceeded. The 29 kg U limit is based on an optimally moderated, fully reflected spherical geometry which very conservatively bounds the conditions in the inlet transition of the scrubber. IROFS remained to limit the quantity of uranium available to the scrubber (IROFS VENT-S1030-101, -102, -103 & -104), which are physical barriers designed to minimize uranium in the airflow entering the transition area. Continuous liquid spraying in the inlet transition section to limit solids accumulation (IROFS VENT-S1030-109) was also in place.

"The inlet transition and scrubber were thoroughly cleaned, and the uranium bearing solids were placed into favorable geometry containers. Also, the inspection and cleanout of the transition frequency was increased to monthly.

"Based on available but degraded IROFS, this accident sequence was unlikely. Therefore, this mass accident sequence does not meet the performance requirements of 10CFR70.61. The actual configuration remained safe at all times. Also, no external conditions affected the event.

"Immediate Corrective Actions:
NRC Region II personnel, who were onsite at the CFFF [Columbia Fuel Fabrication Facility], were made aware of the discovery.

"The Conversion area was shutdown to plan for a second extensive scrubber clean-out to validate that the accumulation of solids is a slow buildup over time. The last extensive cleanout was performed in 2009.

"An extent of condition was performed to determine if other scrubbers potentially had significant uranium buildup. Inspection data indicated that this material accumulation issue was limited to the S-1030 scrubber.

"This event has been entered into the facility Corrective Action Prevention And Learning system (CAPAL) #100397353."

* * * UPDATE PROVIDED BY NANCY PARR TO JEFF ROTTON AT 1025 EDT ON 07/26/2016 * * *

"Onsite chemical analysis confirmed that uranium mass limit for the scrubber transition piece was exceeded. The accumulated material contained 87 kgs of Uranium.

"The Criticality Safety Evaluation for this system was revised and implemented on July 20, 2016 to add Items Relied on For Safety to prevent recurrence of a mass exceedance while the causal analysis and additional corrective actions are completed."

Notified R2DO (Nease) and NMSS Events Notification Group via email.

* * * UPDATE PROVIDED BY NANCY PARR TO HOWIE CROUCH AT 1749 EDT ON 07/31/2016 * * *

"On July 31, 2016, it was determined by the Environment, Health and Safety (EH&S) department that clean-out material found in the S-1030 scrubber packing and floor also potentially exceeded the uranium mass limit for the scrubber criticality safety evaluation. Over years of operations, the same available but degraded mass prevention and inspection/clean-out IROFS did not prevent exceedance of the mass limit.

"This report is being upgraded to a 1 Hour Event Notification based on 10CFR70 Appendix A(a)(4).

"There was no consequence to the public, the workers or the environment.

"The scrubber process will remain in a safe shutdown mode until further investigation and corrective actions are completed."

Notified R2DO (Rose), IRD (Grant), NMSS EO (Kotzalas) and NMSS Events Notification via email.

* * * UPDATE FROM JOHN HOWELL TO VINCE KLCO AT 1620 EDT ON 8/7/2016 * * *

"On August 6, 2016 at 1700, it was reported to the Environment, Health and Safety (EH&S) department that residual material located within the abandoned S-1056 scrubber was sampled and confirmed to contain Uranium.

"24 Hour Event Notification based on 10CFR70 Appendix A(b)(1) 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10CFR70.61.'

"The S-1056 is an out-of-service scrubber. When operational, it scrubbed the acid fumes from the Conversion area. It currently is an unanalyzed system without IROFS or controls. The reported volume of approximately 15 kg is well within safety margins.

"It was taken out of service in 2002, when the S-1030 scrubber replaced it. The material in the S-1056 was discovered as an extent of condition for the S-1030 event.

"The discovery and sampling were documented in Redbook 71409. At no time was there any actual or potential health and safety consequence to the workers, the public, or the environment."

The licensee notified the NRC Regional Inspector (Lopez).

Notified the R2DO (Suggs), R2RA (Haney) and NMSS Events Notification Group via email.

* * * UPDATE AT 1546 EDT ON 8/23/16 FROM NANCY PARR TO JEFF HERRERA * * *

"On August 23, 2016, during the extent of condition for this S-1030 scrubber system event, a review of inspection video for the S-1030 ductwork in Conversion identified material accumulation in an elbow which potentially could exceed the uranium mass limit for the elbow section (36.5 kgU).

"This report is being updated based on a potential to meet the 10 CFR 70 Appendix A(a)(4) in the ductwork.

"There was no consequence to the public, the workers or the environment.

"The scrubber process will remain in a safe shutdown mode until further investigation and corrective actions are completed."

The Region IV Project Managers were notified.

Notified the R2DO (Michel), IRDMOC (Stapleton) and NMSS Events Notification Group (via email).

* * * UPDATE AT 1810 EDT ON 9/15/16 FROM NANCY PARR TO DANIEL MILLS * * *

"24-Hour Event Notification based on 10 CFR 70 Appendix A(b)(1) 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10 CFR 70.61.'

"On September 15, 2016 at 1204 EDT, it was reported to the Environment, Health and Safety (EH&S) department that residual material was located within the abandoned 3A/3B ventilation system. Based on gamma radiation surveys, the material contains Uranium.

"The 3A/3B system was taken out of service in 2002, when the S-1030 scrubber replaced it. When operational, it removed chemical fumes and particulate matter from the Conversion area. The material in the system was discovered as an extent of condition for the S-1030 event.

"When taken out of service, the system was isolated from the introduction of any additional material and/or moderator. However, because the system is out of service, it is considered an unanalyzed system without IROFS or controls. The reported depth of material in the duct appears well within analyzed safety margins for similar systems.

"At no time was there any actual or potential health and safety consequence to the workers, the public, or the environment.

"UPDATED INFORMATION FROM AUGUST 23, 2016 NOTIFICATION:
This notification also serves to update previously reported information provided on August 23, 2016 where a review of inspection video for the S-1030 ductwork in Conversion identified material accumulation in an elbow which potentially could exceed the uranium mass limit for the elbow section (36.5 kg U). This report was made based on a potential to meet the 10 CFR 70 Appendix A(a)(4) in the ductwork. The material was removed from the ductwork and weighed. The total weight of the material removed was 5.5 kgs in the elbow and 3.0 kgs in a horizontal section of the duct, which is well below the mass limit in the safety basis. Therefore, the information from the August 23, 2016 potential report is retracted."

Notified the R2DO (Walker) and NMSS Events Notification Group (via email).

* * * UPDATE AT 1701 EDT ON 10/05/16 FROM NANCY PARR TO JEFF HERRERA * * *

"On October 4, 2016 at approximately 1700 EDT, while performing housekeeping and cleanout activities on the out of service 3A and 3B ductwork, degradation was discovered in an area not routinely or readily accessed in the bottom of the out of service filter house system. This discovery was made while performing clean-out activities covered under a Radiation Work Permit (RWP).

"The work was stopped, and Health Physics (HP) performed contamination surveys of the area. The degraded area was sealed and isolated. No additional radiological controls were needed, and access to the area was not restricted.

"No degradation was found in other out of service systems on the roof. A comprehensive extent of condition is ongoing.

"There was no actual or potential health and safety consequence to the workers, the public, or to the environment during this time."

Notified the R2DO (Bonser) and NMSS Event Notification Group (via email).

* * * UPDATE AT 1113 EDT ON 08/18/17 FROM NANCY PARR TO BETHANY CECERE * * *

"On August 17, 2017 at 11:17 a.m., it was reported to the Environment, Health and Safety (EH&S) department that additional residual material located within the out of service S-1056 scrubber was found. Material in this out of service system was previously reported on August 7, 2016. The material was removed and placed into favorable geometry storage. The material has been quantified and determined to contain less than 80 grams of uranium, which is well within safety margins.

"This information is being reported in accordance with the 24 Hour Event Notification criterion: 10 CFR 70 Appendix A(b)(1), 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 10 CFR 70.61.'

"The buildup was not visible until dismantling the abandoned equipment for removal from the roof. Demolition and removal has already been completed for ventilation system filter houses 2A, 2B, 3A, 3B and 7A.

"The discovery and sampling were documented in Redbook 72846 and in CAPAL 100488919. At no time was there any actual or potential health and safety consequence to the workers, the public, or the environment."

The licensee discussed this report with NRC Region 2 (Vukovinsky and Michel).

Notified the R2DO (Sykes) and NMSS Event Notification Group (via email).

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following report was received via e-mail:

"Manufacturer: Isolite, Model # SLX 60, 10 Ci tritium,

"[Tritium exit signs were shipped from the] manufacturer on 2/5/2009. The serial number of the isotope was not provided. Further information was requested from the company

"In processing the annual general license reports from CDPHE [Colorado Department of Public Health and Environment] one exit sign was not located. The sign is being reported as lost/abandoned. The company contact will continue to search for the sign, however, [the company] is reporting it as lost.

"Signs were purchased as part of a construction project in which 2 of the 10 signs ordered were not installed in the building. It may be in storage but it has so far not been located."

Colorado Event: CO16-I16-16 CO 160009

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

EXERCISE PRESS RELEASES AIRED ON RADIO AS AN ACTUAL EVENT

"During the planned NRC/FEMA evaluated drill exercise on 7/13/16, two press releases written in the Joint Information Center (JIC) were published in the Public Information and Emergency Response (PIER) system without 'THIS IS A DRILL' denoted at the top of the page. The original press release was stamped with 'THIS IS A DRILL' at the top of page 1 and at the bottom of page 2. When it was added into the PIER system for publication/faxing, it was not noticed the top of the document denoting 'THIS IS A DRILL' was cut off.

"The local radio station affiliate was not aware of STP's [South Texas Project's] exercise on 7/13/16. As a result, the affiliate station thought it was a real event and read the press releases over the airwaves at 1014 [CDT] and again at 1046 [CDT].

"At approximately 1400 [CDT] on the same day, the radio station told their listening audience of the mistake and stated STP was having a training exercise not a real event. The correction was broadcast over the airwaves three times every hour until midnight.

"This unplanned media event is being reported in accordance with 10CFR50.72(b)(2)(xi). This event is not significant with respect to the health and safety of the public."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - MISADMINISTRATION DURING A THYROID ABLATION PROCEDURE

The following was reported by the Colorado Department of Health Radioactive Materials Unit via email:

"CDPHE [Colorado Department of Public Health and Environment] became aware of the misadministration on the morning of Monday August 22, 2016. The event was reported to CDPHE on Friday August 19, 2016 at approximately 1630 [CDT] via a message that was left on an office voicemail inbox.

"The misadministration occurred during a thyroid ablation procedure on July 13, 2016. The prescribed dose was 75 milliCuries of I-131, and 78 milliCuries was delivered to the patient. The patient became aware that she was pregnant at the time of the procedure and notified St. Mary's Hospital and Medical Center on Tuesday, August 16, 2016. The gestation at time of procedure was estimated to be 9 days post conception. The Hospital's RSO reported an estimated dose to fetus of approximately 20 centiGray.

"The patient was given a pregnancy test prior to the procedure and the test results were negative. The licensee is claiming the misadministration was a result of patient non-compliance because the patient was instructed not to have sexual contact prior to the procedure. A written report from the licensee is pending; and will be followed-up by a formal investigation."

Colorado Event Identification Number: CO16-I16-17

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.