United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > July 14

Event Notification Report for July 14, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/13/2016 - 07/14/2016

** EVENT NUMBERS **


51344 51923 52063 52066 52068 52084

To top of page
Part 21 Event Number: 51344
Rep Org: FURMANITE
Licensee: FURMANITE
Region: 4
City: Houston State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KERRY J. KOSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/25/2015
Notification Time: 18:31 [ET]
Event Date: 08/25/2015
Event Time: [CDT]
Last Update Date: 07/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
STEVE ROSE (R2DO)
VIVIAN CAMPBELL (R4DO)
PAUL KROHN (R1DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 FURMANITE NUCLEAR GRADE LEAK SEAL MATERIAL FSC-N-1B

"Furmanite FSC-N-1B Batch #1026 was discovered (post-delivery) to have Chloride levels above acceptable limits. As Discovered: 2400 ppm Chloride. Furmanite Specification: 100 ppm Chloride.

"Part Name: Nuclear Grade Leak Seal Material FSC-N-1B.

"Specification: Furmanite Material Specification 1220.1 R2.

"Furmanite Notice Number: 25.08.2015

"Potential affected customers:
America Electric Power - DC Cook
Arizona Public Service - Palo Verde
DTE Energy - Fermi Power Plant 2
Duke - Catawba Nuclear Station
Duke - McGuire Nuclear Station
Exelon Nuclear - Limerick Generating Station
Florida Power & Light Co. - St. Lucie Nuclear Plant
Florida Power & Light Co. - Turkey Point Nuclear Plant"

* * * UPDATE AT 1629 EDT ON 7/13/16 FROM EDWARD RICH TO JEFF HERRERA * * *

The following update was received via email:

"This is an update to part 21 report 2015-63-00. Event # ML15243A174

"The remaining in process items 4 and 5 of the attached report have been completed.

"4. Team Furmanite has contacted all affected customers and has accounted for all boxes of batch # 26 that were manufactured. No material was installed and the boxes were either returned or destroyed by the plant.

"5. Root cause and corrective actions are complete and are listed below.

"Root cause:

"Inadequate controls during manufacturing process. Testing of concentration levels only at one time during process and it was determined this was not adequate to detect contamination.

"Corrective action:

"New procedure PRG.000284.022 was developed with concentration levels being checked at raw material stage and after final packaging. Compound is placed in a hold area before being shipped until third party test results have shown the batch to be acceptable."

Contact information for additional questions:
Edward Rich
Director of Quality - Team Furmanite
Phone: (281) 388-5567

Notified the R1DO (Ferdas), R2DO (Rich), R3DO (Kunowski), R4DO (Gaddy), Part 21 Reactors group (via email).

To top of page
Part 21 Event Number: 51923
Rep Org: AZZ - NUCLEAR LOGISTICS, INC.
Licensee: AZZ - NUCLEAR LOGISTICS, INC.
Region: 4
City: FORT WORTH State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: VINCE KLCO
Notification Date: 05/12/2016
Notification Time: 19:23 [ET]
Event Date: 05/10/2016
Event Time: [CDT]
Last Update Date: 07/13/2016
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 REACT (EMAI)

Event Text

PART 21 - INITIAL NOTIFICATION OF MASTERPACT BREAKER FAIL TO CLOSE

The following information was a licensee received facsimile;

"Pursuant to 10CFR 21.21(d)(3)(ii), AZZ/NLI is providing written notification of the identification of a potential defect or failure to comply.

"On the basis of our evaluation, it has been determined that there is sufficient information to determine if the subject condition is left uncorrected could potentially create a Substantial Safety Hazard or could create a Technical Specification Safety Limit violation as it relates to the subject plant applications. The plants will need to evaluate their application to determine if the identified condition could have an impact to the plant operation.

"The following information is required per 10CFR 21.21(d)(4):

"(i) Name and address of the individual or individuals informing the Commission.
Tracy Bolt, Director of Quality Assurance
Nuclear Logistics, Inc.
7410 Pebble Drive
Ft. Worth, TX 76118

"(ii) Identification of the facility, activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect.

"Masterpact NT and NW style circuit breakers.
-The failure of the breaker being ready to electrically close after being subjected to an 'Anti-Pump condition'.
Note: The specific application where the failures have occurred is when the breaker is being utilized as a starter for closing into an inductive load like a fan motor.

"(iii) Identification of the firm constructing or supplying the basic component which fails to comply or contains a defect.
AZZ/ Nuclear Logistics
Fort Worth, Texas 76118

"(iv) Nature of defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.

"Possible 'failure to close' condition of Masterpact breakers NT and NW style, that are being used with specific logic schemes that are subjected to 'anti-pump' conditions during normal operation. These breakers have a higher susceptibility to not return to the ready to close position after the close signal has been removed.

"PSEG reported approximately 14 instances with different breakers in different cubicles where they initiated an electric close order, and the breakers failed to close. All of the 14 instances were in applications of being used to start an inductive load.

"NLI inspected three of the breakers (all NWs) that were returned by PSEG and could not fully replicate the problem as described by the plant. NLI was only able to repeat the failure to close when performing an 'anti-pump' test. The failure to close was intermittent, but could be duplicated. When the anti-pump condition was not present, NLI could not duplicate a failure to close. Visual inspections of the tested breakers did not reveal any visible damage to the breaker linkages, latches, shunt close or shunt trip assemblies.

"Schneider Electric (SE) performed testing of three Masterpact NW08 breakers (operated to beyond design life) and duplicated the fail to close condition as described by the plant. It was determined that a standing close signal with a trip/open signal applied is determined to be the root cause of the fail to close issue. The SE testing confirms that the presence of this condition can cause the breaker anti-pump latch to receive excessive forward pressure. When the nose of the latch impacts the close coil plunger, it will 'rock' up in the rear, catching on the top of the mechanism plate. Once the close voltage is removed, and the plunger retracts, the latch may or may not let go. If the latch does not release, then application of the close coil voltage will simply activate the close coil plunger and without the latch underneath the plunger, the breaker will not close.

"PSEG performed extensive troubleshooting at the Hope Creek plant and discovered that all of the affected breakers were in an anti-pump condition when the breakers failed to close.

"(v) The date on which the information of such defect or failure to comply was obtained.

"This revised notification is being submitted based on the information gathered on 5/10/2016 after additional testing, at the request of River Bend, was performed. This additional testing was requested following the notification that was provided to the plants listed below, in the original issue of this letter in February 2016.

"The evaluation of the condition was originally completed in September of 2012. The issue was originally determined at that time to not be a reportable condition based on the breaker not containing a defect and the condition was believed to be attributed to the specific logic scheme at the plant. To date, this issue has only been reported to NLI from the following plants, PSEG Hope Creek and River Bend Station. No other plants have reported this specific fail to close condition. NLI was in direct communication with the plants when this issue was first being evaluated and the failure analysis were being conducted. The two affected plants were knowledgeable of the condition.

"(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for being supplied for, or may be supplied for, manufactured or being manufactured for one or more facilities or activities subject to the regulations In this part.

"Plants which have been supplied the Masterpact circuit breakers.

"PSEG Hope Creek - Issue Identified for NW style
River Bend - Issue identified for NT style
Callaway - This issue has not been identified however, the potential should be evaluated.
St. Lucie - This issue has not been identified however. the potential should be evaluated.
Turkey Point - This issue has not been identified however, the potential should be evaluated.
Beaver Valley - This issue has not been identified however, the potential should be evaluated.
Davis Besse - This issue has not been identified however, the potential should be evaluated.
Three Mile Island - This issue has not been identified however, the potential should be evaluated.
Calvert Cliffs - This issue has not been identified however, the potential should be evaluated.
Hatch -This issue has not been identified however, the potential should be evaluated.
STP - This issue has not been identified however, the potential should be evaluated.
SONGS - This issue has not been identified however, the potential should be evaluated.
KHNP Ulchin - This issue has not been identified however, the potential should be evaluated.
KHNP Kori - This issue has not been identified however, the potential should be evaluated.
Duke Oconee - This issue has not been identified however, the potential should be evaluated.
Duke McGuire - Non-safety (not supplied by NU), This issue has not been identified.

"(vii) The corrective action which bas 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.

"NLI originally created a technical bulletin to address the issue and recommendations. However, since new information has been recently identified, NLI TB-12-007 will be revised, as the proposed solution will not reliably solve the problem for all postulated events. Upon completion of the revised
technical bulletin, it will be re-submitted to the plants which have been supplied the Masterpact breakers from NLI.

"(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"NLI is currently working with the OEM of the circuit breaker to determine the permanent solution to correct the possible failure to close event after the breaker is subjected to an Anti-Pump condition.

"Advice for plants with breakers currently installed: Evaluate the applications where the breakers may be potentially subjected to an Anti-Pump condition; where the close coil will be energized for an extended period of time.

"The circuit breaker will continue to operate if this condition is present however there may need to be human interaction with the circuit breaker by manually pressing the trip/open button on the front of the circuit breaker to free the mechanism.

"Please contact NLI with any questions or comments.
Sincerely,
Tracy Bolt
Director of Quality Assurance"

* * * UPDATE ON 5/13/16 AT 1153 EDT FROM TRACY BOLT TO BETHANY CECERE * * *

"Added 4 additional plants that were inadvertently left off the list.

"Browns Ferry - This issue has not been identified however, the potential should be evaluated.
Fort Calhoun - This issue has not been identified however, the potential should be evaluated.
Wolf Creek - This issue has not been identified however, the potential should be evaluated.
Seabrook - This issue has not been identified however, the potential should be evaluated."

Notified R1DO (Burritt), R2DO (Heisserer), R3DO (Duncan), R4DO (Campbell), and Part 21 Group via email.

* * * UPDATE AT 1612 EDT ON 7/13/16 FROM TRACY BOLT TO JEFF HERRERA * * *

The following information was received via facsimile:

Additional information in attachment has been updated since the original report provided on 5/13/2016.

Additional facility identified as impacted:
St. Lucie - Issue identified

For additional information contact:
Tracy Bolt
Director of Quality Assurance
AZZ/NLI Nuclear Logistics
7410 Pebble Drive
Fort Worth, Texas 76118

Notified the R1DO (Ferdas), R2DO (Rich), R3DO (Kunowski), R4DO (Gaddy) and Part 21 Reactor group (via email).

To top of page
Non-Agreement State Event Number: 52063
Rep Org: GEORGETOWN HOSPITAL
Licensee: GEORGETOWN HOSPITAL
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-30577-01
Agreement: N
Docket: 03035409
NRC Notified By: DR. DAVID SMITH
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/05/2016
Notification Time: 16:03 [ET]
Event Date: 05/19/2016
Event Time: [EDT]
Last Update Date: 07/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NMSS_EVENTS_NOTIFIC (EMAI)
FRED BOWER (R1DO)

Event Text

MEDICAL EVENT - WRITTEN DIRECTIVE NOT FOLLOWED

The following is excerpted from the report sent via email:

"On June 16, 2016 [the licensee's Director of Radiation Safety] was notified by the Authorized User (AU) of an issue regarding the May 19, 2016 radioembolization of a patient. During the subsequent review of the patient's treatment plan in preparation for an additional radioembolization of the Right Hepatic Lobe (scheduled for June 16, 2016) the AU observed the May 19, 2016 Written Directive/treatment plan was completed for the Right Hepatic Lobe, but treatment had been delivered to the Left Hepatic Lobe.

"Review of the physician notes for the case reveal the intended primary treatment site, as noted by the Interventional Radiologist (IR) was the Left Hepatic Lobe, however, communication between the IR and AU requested a treatment plan for the Right Hepatic Lobe. On 16 June 2016 the AU confirmed with the IR that the Left Hepatic Lobe was indeed the intended treatment site for the 19 May 2016 procedure. Of note, the 19 May 2016 delivery was not completed as stasis was achieved.

"The AU and Medical Physicist (MP) recalculated the 19 May 2016 treatment plan based on the administered activity and the treatment volume for the Left Hepatic Lobe. The resultant delivered dose was 119.4% of the prescribed dose. The AU determined there was no harm to the patient.

"After review of the circumstances relative to the requirements stipulated in 10 CFR 35.3045 Report and Notification of a Medical Event, it does not appear this is a Medical Event and therefore, does not meet the reporting requirements of 10 CFR 35.3045. The dose was delivered to the Left Hepatic Lobe prior to the planned delivery to the Right Hepatic Lobe, i.e. both lobes were intended for treatment at different times; the original Written Directive was reviewed and corrected to account for the delivery to the Left Hepatic Lobe and the resultant dose did not exceed any thresholds specified in 10 CFR 35.3045.

"Although not believed to be reportable as a Medical Event, this incident may be a violation of 10 CFR 35.40, Written Directives, paragraph (c) and/or 10 CFR 35.41, Procedures for Administrations Requiring a Written Directive, paragraphs (a)(2) and (b)(2). Therefore, I am submitting this report for your review.

"Actions taken to preclude a recurrence:
1. A Time Out will occur wherein the AU, Medical Physicist and Interventional Radiologist (IR) communicate the specifics of the treatment plan by asking open-ended questions requiring more than a 'yes/no' answer. The Time Out will be documented via signatures from each of the aforementioned team members.
2. After the mapping study, the IR will clearly indicate the preferred treatment site(s) in his notes so the AU is clear as to the development of the treatment plan.
These have been incorporated into the Radiation Medicine Sirsphere Policy and each member of the team has been instructed regarding the changes. Additionally, this incident is being tracked through our internal Risk Management system for further review and potential improvements to the program. These actions/reviews have been conducted and implemented prior to the next case, which is scheduled for 30 June 2016.

"Details of Incident
1. Original Written Directive for Right Hepatic Lobe (19 May 2016)
a. Activity prescribed: 25.49 mCi
b. Dose to Lobe prescribed: 32.13 Gy
c. Activity delivered: 23 .48 mCi
d. Dose to Lobe delivered: 29.59 Gy
2. Revised Written Directive for Left Hepatic Lobe (16 June 2016)
a. Activity prescribed: 19.67 mCi
b. Dose to Lobe prescribed: 43.37 Gy
c. Activity delivered: 23.48 mCi
d. Dose to Lobe delivered: 51. 77 Gy
e. Percent variation of administered activity to that prescribed = 19 .4%"

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: 52066
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: RABA-KISTNER CONSULTANTS, INC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 01571
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/06/2016
Notification Time: 11:27 [ET]
Event Date: 07/06/2016
Event Time: [CDT]
Last Update Date: 07/06/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

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

"On July 6, 2016, the licensee reported to the Agency [Texas Department of State Health Services] that one of its moisture density gauges had been run over and damaged, a Troxler Model 3411 containing 10 millicurie cesium-137 source and a 40 millicurie americium-241/beryllium source, serial number 10471 [at a highway construction site near Robstown, TX]. The technician had started the test and the source rod was extended into the ground. While the test was in progress the step-up grader hit the gauge, causing the source rod to bend. The technician stopped all work at the jobsite and setup a boundary of fifteen feet because the source rod could not be retracted. The technician called the RSO [Radiation Safety Officer] and RSO contacted a service company, Qual-Tek, to respond to the site to retrieve the gauge. The site foreman moved the road crew down the highway to avoid the gauge. The technician will stay at the site near the gauge until it is collected by Qual-Tek. [The RSO is investigating.] No member of the public or worker received any exposure as a result of this event. An update will be provided as obtained in accordance with SA300."

Texas Incident: I-9417

To top of page
Agreement State Event Number: 52068
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: COCA-COLA REFRESHMENTS, MID-SOUTH
Region: 1
City: MEMPHIS State: TN
County:
License #: GL #1113
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: VINCE KLCO
Notification Date: 07/06/2016
Notification Time: 16:48 [ET]
Event Date: 07/06/2016
Event Time: [EDT]
Last Update Date: 07/06/2016
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 GENERALLY LICENSED DEVICE

The following information was received from the State of Tennessee via email:

"A licensee reported a generally licensed device as missing. Further details will be reported as the information becomes available. The specifics on the device are as follows: Manufacturer- Industrial Dynamics, Model-FT-50B, Serial-113439, Isotope-Am-241, Activity-100 mCi."

State Event Report ID No.: TN-16-098

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
Power Reactor Event Number: 52084
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF YEAGER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/13/2016
Notification Time: 22:43 [ET]
Event Date: 07/13/2016
Event Time: 19:55 [EDT]
Last Update Date: 07/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

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."

Page Last Reviewed/Updated Thursday, July 14, 2016
Thursday, July 14, 2016