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Event Notification Report for October 31, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/28/2016 - 10/31/2016

** EVENT NUMBERS **


52311 52312 52313 52314 52327 52329 52331 52332

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Agreement State Event Number: 52311
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: THE NEBRASKA MEDICAL CENTER
Region: 4
City: OMAHA State: NE
County:
License #: 01-88-01
Agreement: Y
Docket:
NRC Notified By: BRYAN MILLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/20/2016
Notification Time: 15:16 [ET]
Event Date: 10/13/2016
Event Time: [CDT]
Last Update Date: 10/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - DIAGNOSTIC RADIOACTIVE SOURCE MISSING

On the morning of 10/13/16, a patient received a diagnostic 0.297 mCi I-125 seed implant to characterize a breast lesion. That afternoon, the tissue and implanted seed were removed and sent to pathology for assessment. The bio-waste was received in pathology as a non-radioactive sample contrary to hospital procedures. A subsequent search of the pathology lab could not locate the missing source.

The State of Nebraska was notified of the incident on 10/19/16.

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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Non-Agreement State Event Number: 52312
Rep Org: AGILENT
Licensee: AGILENT
Region: 1
City: WILMINGTON State: DE
County:
License #: 07-28762-01
Agreement: N
Docket:
NRC Notified By: DAVID BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/21/2016
Notification Time: 08:28 [ET]
Event Date: 09/21/2016
Event Time: [EDT]
Last Update Date: 10/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST ELECTRON CAPTURE DEVICE

Four electron capture detectors (ECDs) were shipped at the same time from Shanghai to Wilmington, DE. The ECDs were shipped by air freight and three of the ECDs arrived at the beginning of October. The remaining ECD has not arrived and a search is ongoing.

Source: Ni-63, 15 mCi fully encapsulated

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: 52313
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TONY'S MARKET
Region: 4
City: DENVER State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/21/2016
Notification Time: 10:16 [ET]
Event Date: 06/21/2008
Event Time: [MDT]
Last Update Date: 10/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via e-mail:

"Planned Parenthood purchased the exit sign when they sold the building. No transfer information was provided. The principals of Dunkeld-Broadway purchased the building and had the interior demolished. All the material was placed in dumpsters and removed by waste management providers."

Source Description: SRB Technologies Inc., tritium exit sign H-3, Model # BX10BK, Serial Number CO16875, 9210 mCi.

Colorado Report ID: #CO16-I16-24

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: 52314
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ACUREN INSPECTION, INC.
Region: 4
City: LA PORTE State: TX
County:
License #: 01774
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/21/2016
Notification Time: 15:31 [ET]
Event Date: 10/20/2016
Event Time: [CDT]
Last Update Date: 10/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The State of Texas provided the following report via email:

"On October 21, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee that one of its radiography crews were unable to retract a 71 curie iridium-192 source into a QSA 880D radiography device. The radiographers had placed the guide tube stand on a wooden box to complete an exposure when, during the exposure, the stand fell off the box and landed on the guide tube crimping it enough that the source would not pass by it.

"The radiographers contacted the licensee's radiation safety officer who sent a team of individuals to recover the source. The recovery team placed lead shielding over the source and was able to remove the crimp enough to retract the source back into the exposure device. No one involved in the event received an exposure that exceeded any limit. No member of the general public was exposed due to this event. Additional information on this event will be provided in accordance with SA-300."

The event location was Exxon Mobil in Beaumont, TX.

Texas Incident #: I-9433.

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Power Reactor Event Number: 52327
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ARIC HARRIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/28/2016
Notification Time: 17:14 [ET]
Event Date: 10/28/2016
Event Time: 09:24 [CDT]
Last Update Date: 10/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

Event Text

SHUTDOWN COOLING SYSTEM DECLARED INOPERABLE

"At 0851 [EDT] on October 28, 2016, Division 1 RHR was started in shutdown cooling (SDC) mode of operation. Prior to starting the RHR system, the Alternate Decay Heat Removal (ADHR) system was maintaining RPV and Spent Fuel Pool temperature.

"At 0924 on October 28, 2016, RHR [pump A] tripped due to RHR-MOV-17 (SDC suction valve) closing. This is considered to be an event or condition that could have prevented fulfillment of a safety function, and is reportable under 10 CFR 50.72(b)(3)(v)(B). RHR SDC subsystem A was declared inoperable. CNS [Cooper Nuclear Station] entered LCO 3.9.7, Condition A - Required Action A.1: Verify an alternate method of decay heat removal is available within 1 hour and once per 24 hours thereafter; Condition C - Required Action C.1: Verify reactor coolant circulation by an alternate method within 1 hour from discovery of no reactor coolant circulation and once per 12 hours thereafter, and Required Action C.2: Monitor reactor coolant temperature hourly. All LCO conditions specified have been met.

"ADHR remained in service throughout the event and the plant remained aligned for natural circulation. Spent fuel pool weir temperature monitoring was commenced to verify natural circulation. No increase in RPV [reactor pressure vessel] temperature has been observed. There was no impact to plant operations.

"Initial investigation indicates that installation of PCIS relay K27 during a maintenance activity physically agitated the adjacent relay, K30, which actuated and caused RHR-MOV-17 to close.

"The NRC Resident Inspectors have been informed."

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Power Reactor Event Number: 52329
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID ARCELUS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/28/2016
Notification Time: 17:36 [ET]
Event Date: 10/28/2016
Event Time: 09:40 [EDT]
Last Update Date: 10/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BLAKE WELLING (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 72 Power Operation 72 Power Operation

Event Text

UNANALYZED CONDITION DUE TO FIRE BARRIER/HELB DOOR INOPERABLE

The licensee reported an unanalyzed condition under 10 CFR 50.72(b)(3)(ii)(B) due to a fire barrier/HELB (high energy line break) door being inoperable during maintenance. This resulted in two of five safe shutdown panels to be declared inoperable.

The door, located between the Turbine and Administrative Buildings, was opened for approximately two minutes for 'tool pouch work'. When Operations discovered the door was opened for maintenance, they declared the door inoperable until Operations performed the surveillance required to declare the door operable. The total time the door was inoperable was approximately 1 hour and 11 minutes.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52331
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: CHRIS MCEACHRAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/28/2016
Notification Time: 21:58 [ET]
Event Date: 10/28/2016
Event Time: 15:00 [EDT]
Last Update Date: 10/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PATTY PELKE (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

STANDBY LIQUID CONTROL TECHNICAL SPECIFICATION NOT MET

"On October 28, 2016, at 1500 EDT, the Standby Liquid Control system was declared inoperable. Technical Specification (TS) Limiting Condition for Operation (LCO) 3.1.7 Condition B was entered due to sodium pentaborate concentration not within limits.

"Standby Liquid Control sodium pentaborate concentration was found to be low outside of the acceptable region following a Standby Liquid Control system tank high level alarm in the Main Control Room. Sodium pentaborate was added to the Standby Liquid Control tank by chemistry personnel and the concentration was then verified to be acceptable. Standby Liquid Control was declared Operable on 10/28/16 at 1935 EDT. The cause of the out-of-acceptable concentration was due to make-up water leaking by a closed valve. [The licensee cycled this valve and closed an upstream valve.]

"Declaring the Standby Liquid Control system inoperable is reportable under 10 CFR 50.72(b)(3)(v)(A), (C), and (D) as an event or condition that could have prevented the fulfillment of a safety function of a system needed to shut down the reactor and maintain it in a safe shutdown condition, control the release of radioactive material, and mitigate the consequences of an accident."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52332
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: VINCENT LEETH
HQ OPS Officer: DANIEL MILLS
Notification Date: 10/29/2016
Notification Time: 15:31 [ET]
Event Date: 10/29/2016
Event Time: 10:32 [EDT]
Last Update Date: 10/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
EUGENE GUTHRIE (R2DO)

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

TECHNICAL SUPPORT CENTER (TSC) AND EMERGENCY OPERATIONS FACILITY (EOF) VENTILATION SYSTEM OUT OF SERVICE

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility.

"A deficiency with the TSC and EOF ventilation system was discovered on October 29, 2016 at 1032 [EDT]. The deficiency involved a fire alarm unable to be reset impeding the ability to place the TSC and EOF in recirculation mode in the event of a radiological release. The fire alarm was reset at 1204 [EDT] on October 29, 2016, restoring capability to perform full emergency assessment to the TSC and EOF.

"If an emergency had been declared while the fire alarm was unable to be reset requiring TSC or EOF activation during this period, the TSC and EOF would be staffed and activated using existing emergency planning procedures unless the TSC or EOF became uninhabitable due to ambient temperature. radiological, or other conditions. If relocation of the TSC or EOF became necessary, the Emergency Response Manager would relocate the TSC and/or EOF staff to an alternate location in accordance with applicable site procedures.

"This condition had no impact on the health and safety of the public.

"The NRC Resident Inspector has been notified."

A malfunctioning smoke detector was removed from the system. Compensatory measures are being employed.

Page Last Reviewed/Updated Monday, October 31, 2016
Monday, October 31, 2016