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Event Notification Report for November 28, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/25/2016 - 11/28/2016

** EVENT NUMBERS **


52372 52373 52375 52376 52379 52395 52396

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Non-Agreement State Event Number: 52372
Rep Org: U.S. NAVY
Licensee: U.S. NAVY
Region: 1
City: WEST BETHESDA State: MD
County:
License #: 45-23645-01NA
Agreement: Y
Docket:
NRC Notified By: CAPTAIN DOUG FLETCHER
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/17/2016
Notification Time: 10:56 [ET]
Event Date: 11/16/2016
Event Time: 15:00 [EST]
Last Update Date: 11/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BRICE BICKETT (R1DO)
PART 21 MATERIALS (EMAI)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

PART 21 - NOTIFICATION OF DEFECT - IRRADIATOR MALFUNCTION

The following is excerpted from an email/fax received from the U.S. Navy, Radiological Controls Office:

An irradiator located as Naval Surface Warfare Center, Carderock on 16 November [2016] at approximately 1500 [EST] malfunctioned.

During routine use of the JLS 81-20 self-shielded irradiator (Co-60 source with all attenuators 1000, 100, 10, 1, 2, in place) the device did not terminate the shot at the end of the exposure period. The end-user attempted to use the emergency stop at the control panel, which did not work as intended. The panel displayed the source was in "MOVEMENT" status for approximately 70 minutes.

No injuries or overexposures occurred, there seems to be an operational issue with the irradiator source moving from an exposed position to the shielded position, which Carderock is taking steps to correct. They have verified the source returned to the shielded position and have placed the calibrator out of commission until maintenance can be performed.

The licensee has notified the NRC Project Manager (Seeley).

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Agreement State Event Number: 52373
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INEOS USA LLC
Region: 4
City: ALVIN State: TX
County:
License #: L01422
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/17/2016
Notification Time: 14:07 [ET]
Event Date: 11/16/2016
Event Time: 14:00 [CST]
Last Update Date: 11/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED NUCLEAR GAUGE

The following was excerpted from information received from the Texas Department of State Health Services by email:

"On November 17, 2016, the licensee notified the Agency [Texas Department of State Health Services] that on November 16, 2016 at approximately 1400 CST, during its semi-annual fixed nuclear gauge inspection [at Chocolate Bayou Works], it had discovered that the shutter mechanism on an Ohmart Model SHLM-BR-2, which contains a 1,000 millicurie cesium-137 source (SN: 2807CG), had become inoperable. The licensee's radiation safety officer reported the source could be moved up/down inside the source tube, but it could not be retracted into the housing. He suspects there is an issue with the positioning of the pin that holds the 2-piece source rod together. Repairs are scheduled to be completed during an operations shut-down in January/February 2017. The source is in its normal operating position and there is no risk of exposure to any individual due to its location."

Texas Incident #: I-9441

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Agreement State Event Number: 52375
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: B. BRAUN MEDICAL GROUP, INC.
Region: 1
City: ALLENTOWN State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/18/2016
Notification Time: 10:20 [ET]
Event Date: 09/01/2016
Event Time: [EST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - POLONIUM-210 STATIC ELIMINATOR GAUGE MISSING

The following information was obtained from the Commonwealth of Pennsylvania via email:

"Event Description: During an inventory record check on September 1, 2016, the general licensee discovered that the static eliminator gauge was missing. Its last known use was during the first six months of the year 2011. The general licensee was unaware of its reporting responsibility.

"Gauge info:
Radionuclide: Polonium-210
Manufacturer: NRD, Inc.
Model: P-2021-5000
Device SN#: A2HM769
Activity: 10.2 milliCuries

"Cause of the Event: Unknown at this time, the general licensee believes that the equipment was lost when the company reconfigured its machinery at some point during 2012.

"Actions: A reactive inspection is planned by the Department [PA Department of Environmental Protection]. More information will be provided upon receipt. Note: Given that over 13 half-lives have transpired since the gauge was lost, there is no current public health and safety hazard."

PA Event Report ID: PA160035

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: 52376
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MOUNT AUBURN HOSPITAL
Region: 1
City: CAMBRIDGE State: MA
County:
License #: 44-0017
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/18/2016
Notification Time: 12:22 [ET]
Event Date: 11/16/2016
Event Time: 09:00 [EST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL RADIATION TREATMENT OVERDOSE

The following information was received via E-mail:

"The licensee reported on November 17, 2016 that the licensee administered on November 16, 2016 to a patient a first fraction dose of 1100 centigray to the vagina instead of the prescribed first fraction dose of 600 centigray to the vagina.

"This dose was the first of three fractionated doses, the second and third fractionated doses have not yet been administered. Each fractionated dose was prescribed to be 600 centigray for a total dose of 18 gray (1,800 centigray).

"The licensee used a Varian Medical Systems, Inc. GammaMed plus iX High Dose Rate (HDR) remote afterloader unit containing 7 curies of iridium-192 to deliver the dose.

"This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(a)3.

"The licensee reported that the patient and the referring physician have been notified and that no harmful effect to the patient has been reported.

"The licensee reported that the event occurred because the physician's plan was not performed as prescribed in the written directive and that no other cause was known at time of report.

"The Agency (Massachusetts Radiation Control Program) Director requested the licensee to cease HDR use until a corrective action to prevent recurrence has been implemented.

"The Agency plans to perform a special inspection and considers this event to be open."


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: 52379
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TUV RHEINLAND-NORTH AMERICA (TUVR)
Region: 1
City: WOODSTOCK State: AL
County:
License #: TX-L06724
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/18/2016
Notification Time: 19:57 [ET]
Event Date: 11/18/2016
Event Time: 12:00 [CST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - AUTOMATIC LOCKING DEVICE FAILURE

The following is a synopsis of information received via E-mail from the Louisiana Department of Environmental Quality (LDEQ):

TUV Rheinland (TUVR) was working at the Sasol Mega Project in Westlake, Louisiana under reciprocity (RC-662). TUVR was utilizing four industrial radiography exposure devices but only had a problem with one device.

TUVR made an exposure and then retracted the source into the shielded position. The source returned to the shielded position, but the automatic locking device did not lock/engage. The exposure device was manually locked with the plunger-lock and then key locked. It appears that the spring in the locking mechanism was either broken or blocked from working. The device is a Sentinel model 880D with S/N D13509. The device contains an INC model 7 source with 36.9 Curies of Ir-192 with S/N T0274. Safety surveys were made and there appears to be no radiation exposure hazard. The device was taken out of service, 'locked and tagged' out of service, and is being transported back to Woodstock, Alabama for a complete evaluation.

LDEQ was notified of the event by a phone call and a follow-up written report. From the report, it appears there is not a Radiation Safety Officer named on the Texas license at this time. A copy of the complete evaluation report will be provided when available.

Louisiana Event Report ID No.: LA-160014

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Power Reactor Event Number: 52395
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BLAKE MITCHELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/27/2016
Notification Time: 03:08 [ET]
Event Date: 11/27/2016
Event Time: 00:26 [CST]
Last Update Date: 11/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMIE HEISSERER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP WITH AUTOMATIC AUXILIARY FEEDWATER SYSTEM ACTUATION DUE TO VOLTAGE OSCILLATIONS

"At 0026 [CST] on November 27, 2016, Farley Unit 1 was manually tripped from 100% reactor power due to voltage swings suspected to be caused by the Auto Voltage Regulator. All control rods fully inserted and Auxiliary Feedwater (AFW) auto-started as expected.

"All systems responded as expected. The plant is currently stable in Mode 3 (Hot Standby). The cause of the main generator voltage oscillations is under investigation.

"The NRC Resident Inspector has been notified."

The trip was uncomplicated. Decay heat is being removed via the steam dumps to condenser. The plant is at normal operating pressure and temperature with auxiliary feedwater supplying the steam generators. The electrical grid is stable and supplying plant loads. All safety equipment is available, if needed. Unit 2 was unaffected by the event and remains at 100% power.

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Power Reactor Event Number: 52396
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ROBERT BALDWIN
HQ OPS Officer: STEVEN VITTO
Notification Date: 11/27/2016
Notification Time: 21:22 [ET]
Event Date: 11/27/2016
Event Time: 14:47 [CST]
Last Update Date: 11/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)

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

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"At 1447 [CST] on 11/27/2016 while troubleshooting a minor leak on the High Pressure Coolant Injection (HPCI) turbine, it was discovered that the HPCI turbine exhaust drain pot high level bypass switch was not functioning per design to support removal of condensate from the HPCI turbine casing. This resulted in some water accumulation within the HPCI turbine casing. Subsequently, HPCI was declared INOPERABLE and this issue is being reported under 10CFR50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function at the time of discovery. The plant remains at 100 percent power with no challenges to the health and safety of the public. The NRC Resident Inspector has been notified."

Technical Specification limiting condition for operation requires HPCI to be Operable within 14 days. The licensee will be notifying the State of Minnesota regarding the event.

Page Last Reviewed/Updated Monday, November 28, 2016
Monday, November 28, 2016