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Event Notification Report for December 16, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/15/2016 - 12/16/2016

** EVENT NUMBERS **


52311 52410 52411 52417 52434 52435 52436 52437 52438

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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: 12/15/2016
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.

* * * UPDATE ON 12/15/16 AT 0958 EST FROM BRYAN MILLER TO DONG PARK * * *

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

"A Radioactive Seed Localization (RSL) procedure was performed on Thursday October 13, 2016, and contrary to procedures, the seed was sent to Pathology without an escort from the radiation safety office. Since there was no presence from radiation safety, pathology treated the excised sample as non-radioactive. It was not until the next day on Friday, the Thursday's RSL procedure was made known to the Radiation Safety Office. During Friday's procedure, the CNMT inquired why the paperwork from the Thursday's procedures was not picked up. This alerted Radiation Safety that a seed was sent to pathology without their presence to retrieve the seed and that there may be a misplaced seed. With the help from a radiologist, Radiation Safety reviewed the x-ray from the excised tissue to ensure the seed was removed from the patient. The x-ray did in fact indicate the seed was removed from the patient. Since the tissue is sent to the pathology lab, Radiation Safety surveyed the pathology lab and it's personnel intensively. They source could not be found. Radiation Safety has two theories where the source may have ended up. Down the sink or in a 20 gallon biological waste container. The Licensee is changing the name of the lumpectomy procedure to make a clear distinction between a non-radioactive lumpectomy and a lumpectomy that includes a radioactive material source. This will alert the staff that the radioactive seed needs to have Radiation Safety escort the seed to pathology. It will also alert the pathology staff of the radioactive seed and to ensure to locate and separate the seed from the sample prior to dissecting the tissue. Another precaution is that the mammography tech is going to label the sample container/slide with a 'Caution, Radioactive Materials' label to confirm the seed has been found and to also alert the pathology staff of the presence of the radioactive seed. Training of these changes has been performed and Radiation Safety will keep a close watch on the next procedures to ensure the new procedure has been implemented."

Item Number: NE160001

Notified R4DO (Kellar) and NMSS Events Notification via email.

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: 52410
Rep Org: AGILENT TECHNOLOGIES
Licensee: AGILENT TECHNOLOGIES
Region: 1
City: WILMINGTON State: DE
County:
License #: 07-28762-01
Agreement: N
Docket:
NRC Notified By: DAVID BENNETT
HQ OPS Officer: VINCE KLCO
Notification Date: 12/07/2016
Notification Time: 09:15 [ET]
Event Date: 11/07/2016
Event Time: [EST]
Last Update Date: 12/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST SOURCES

Agilent Technologies is a manufacturer of a part containing an electron capture detector (ECD) that fits into a gas chromatograph. The ECD contains an embedded sealed source (Ni-63; 15 milliCuries) and is manufactured in Shanghai, China and is transferred into the United States through the JFK Airport Worldwide Flight Services Warehouse. When the licensee's Philadelphia truck shipping service attempted to retrieve the two ECD sources at the JFK warehouse, the sources were discovered missing. The warehouse was searched without success.

The ECD source serial numbers are U30355 and U30356. The model number is 62397AECD.

Agilent Technologies holds an NRC license and is located at 2850 Centerville Road, Wilmington, DE 19808.

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: 52411
Rep Org: ACRUEN USA INSPECTIONS
Licensee: ACRUEN USA INSPECTIONS
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-32443-01
Agreement: N
Docket:
NRC Notified By: CHRIS DIXON
HQ OPS Officer: KARL DIEDERICH
Notification Date: 12/07/2016
Notification Time: 11:27 [ET]
Event Date: 12/07/2016
Event Time: 06:30 [YST]
Last Update Date: 12/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSC (CANADA) (FAX)

This material event contains a "Category 2 " level of radioactive material.

Event Text

RADIOGRAPHY CAMERA LOST WHEN BARGE SANK IN BERING SEA

At approximately 1030 EST, a QSA 880 industrial radiography camera containing an Ir-192 source of approximately 26.3 Ci (source serial number - 32186G) was lost when the barge named Exito sank in the Bering Sea outside Dutch Harbor, Alaska. The ship was in transit and the camera was stored in a pelican case and not in use, with the source in the protected position. There were no unintended exposures to individuals. The licensee has notified the local area Coast Guard command.

Notified the following Federal Agencies: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, EPA EOC. Notified the following Federal Agencies via email only: FDA EOC, Nuclear SSA, FEMA National Watch Center, and DNDO-JAC.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. 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: 52417
Rep Org: COMMUNITY MEDICAL CENTER
Licensee: COMMUNITY MEDICAL CENTER
Region: 4
City: MISSOULA State: MT
County: MISSOULA
License #: 503-620-6617
Agreement: N
Docket:
NRC Notified By: DAN DUGAN
HQ OPS Officer: KARL DIEDERICH
Notification Date: 12/08/2016
Notification Time: 10:51 [ET]
Event Date: 12/07/2016
Event Time: 10:30 [MST]
Last Update Date: 12/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

SURFACE CONTAMINATION INSIDE HIGH DOSE RATE AFTERLOADER

On 12/7/16 at approximately 1030 MST, surface contamination was discovered on the interior of a High Dose Rate (HDR) afterloader. The contamination is limited to the inside of the housing and the interior portions of the transfer cables. The contamination was discovered by the manufacturer when the manufacturer was replacing the Ir-192 seeds used by the afterloader. Direct radiation readings could not be taken due to the proximity to the sources. Wipes were observed at 200 to 4000 counts per minute. There was no observed damage to the sources. There was no contamination of personnel. The room has been secured. The resolution planned is for the manufacturer to replace the afterloader.

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Power Reactor Event Number: 52434
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/15/2016
Notification Time: 03:40 [ET]
Event Date: 12/14/2016
Event Time: 23:45 [EST]
Last Update Date: 12/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMNES CAMERON (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 MOMENTARY LOW PRESSURE DUE TO HIGH WINDS

"On December 14, 2016, starting at 2345 EST, high wind conditions encountered on site resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met numerous times. The duration of time that the secondary containment Technical Specification was not met was approximately one second for each instance.

"All plant equipment responded as required to the changing environmental conditions and Reactor Building HVAC returned secondary containment pressure within TS limits. At 0300 EST on December 15, 2016, high wind conditions had subsided and 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 10CFR50.72(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."

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Power Reactor Event Number: 52435
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ANDREW LISTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/15/2016
Notification Time: 06:55 [ET]
Event Date: 12/15/2016
Event Time: 04:10 [MST]
Last Update Date: 12/15/2016
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
RAY KELLAR (R4DO)
BILL DEAN (NRR)
KRISS KENNEDY (R4RA)
BERNARD STAPLETON (IRD)

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

Event Text

ALERT DECLARED - CATASTROPHIC FAILURE OF AN EMERGENCY DIESEL GENERATOR

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"During a scheduled surveillance test run of the PVNGS [Palo Verde Nuclear Generating Station] Unit 3 'B' Train Emergency Diesel Generator, there was a catastrophic failure of a piston to include crankcase damage and diesel trip. The Emergency Plan has been entered and an ALERT was declared at 0410 [MST] on 12/15/16 based on an explosion resulting in visible damage to a safety system required for safe shutdown. The cause of the failure is unknown at this time. PVNGS Fire Department responded and no fire was observed. Unit 3 remains on line at 100% power. No other safety functions are impacted."

No personnel injuries occurred. The unit is in a ten day technical specification on an emergency diesel generator being inoperable.

The licensee notified the NRC Resident Inspector.

Notified DHS, DOE, EPA, FEMA, NICC, USDA, HHS, FDA, NSSA, Mexico, and OIP (Skeen).

* * * UPDATE AT 0947 EST ON 12/15/2016 FROM MICHAEL GOODRICH TO MARK ABRAMOVITZ * * *

"This serves as the notification of the termination of Alert HA2.1 declared at 0410 MST at Palo Verde Nuclear Generation Station. The event terminated at 0636 MST."

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Keller), NRR EO (Miller), IRD (Stapleton), DHS, DOE, EPA, FEMA, NICC, USDA, HHS, FDA, NSSA, Mexico, and OIP (Skeen).

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Power Reactor Event Number: 52436
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID VAN DER KAMP
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/15/2016
Notification Time: 10:23 [ET]
Event Date: 10/28/2016
Event Time: 01:39 [CST]
Last Update Date: 12/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RAY KELLAR (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

INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

"This telephone notification is being made in lieu of a Licensee Event Report in accordance with 10CFR50.73(a)(1) to notify the NRC of on invalid actuation of a group isolation, reportable under 10CFR50.73(a)(2)(iv)(A).

"On October 28, at 0139 Central Daylight Time, electricians were removing a test jack from a terminal on a primary containment isolation system relay due to the test jack being installed on the wrong relay. During removal of the test jack, a neutral wire came out of the terminal causing multiple relay actuations resulting in a half Group 2 isolation signal on the Division 2 side. Because of the plant being in Mode 5, refueling, the only isolation valves that closed because of the invalid isolation signal were the Division 2 isolation valves associated with the drywell ventilation monitor and the drywell floor and equipment sumps.

"The specific train and system actuated was the Primary Containment Isolation System [PCIS] Division 2 portion of the Group 2 isolation circuit (i.e. half group isolation). This was a partial actuation affecting only half of the logic and causing isolation of two systems. Based on the inadvertent actuation of the affected PCIS relays, the system isolated and functioned as expected. The isolation signal was reset at 0230 and the affected systems restored to service."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52437
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: KELLEY BELENKY
HQ OPS Officer: VINCE KLCO
Notification Date: 12/15/2016
Notification Time: 11:47 [ET]
Event Date: 12/15/2016
Event Time: 10:10 [EST]
Last Update Date: 12/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMNES CAMERON (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 MOMENTARY LOW PRESSURE

"On December 15, 2016, at 1010 EST, the startup of the Reactor Building HVAC [Heating Ventilation and Air Conditioning] system resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met for approximately 1 second. The maximum secondary containment pressure observed during that time was approximately 0.044 inches of vacuum water gauge.

"Secondary containment pressure was returned to within the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4. 1.1) by Reactor Building HVAC and Standby Gas Treatment System already in operation. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable is reportable under 10CFR50.72(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."

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Power Reactor Event Number: 52438
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: DON TAYLOR
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/15/2016
Notification Time: 13:50 [ET]
Event Date: 12/15/2016
Event Time: 11:30 [EST]
Last Update Date: 12/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ERIC MICHEL (R2DO)

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

Event Text

OFFSITE NOTIFICATION MADE FOR POTENTIAL FUEL OIL LEAKAGE

"On 12/14/16 at 1206 [EST], 0-PT-89.9K (underground fuel-oil piping pressure test), was performed UNSAT after a failed attempt to maintain pressure in the supply line to the Unit 2 'H' Emergency Diesel Generator (EDG) Day Tank. The exact source of the leakage is unknown at this time but is reasonable to believe some fuel oil was released underground. The associated Fuel Oil line is currently tagged out and isolated. This condition is reportable to the Virginia Department of Environmental Quality [VA DEQ] as part of the Underground Storage Tank Program. Pressure tasting of the other EDG fuel oil supply lines has been previously completed satisfactorily. The 2H EDG remains Operable as the redundant fuel oil transfer pump and its fuel oil piping are Operable and capable of maintaining adequate day tank level. The VA DEQ was notified of this condition
at 1130 [EST] on 12/15/16.

"This event is reportable in accordance with 10CFR50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'"

The licensee has notified the NRC Resident Inspector and will notify Louisa County.

Page Last Reviewed/Updated Friday, December 16, 2016
Friday, December 16, 2016