Event Notification Report for January 18, 2017

BOTH SECONDARY CONTAINMENT AIRLOCK DOORS OPEN SIMULTANEOUSLY

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(C), event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material and 10 CFR 50.72(b)(3)(v)(D), event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. An employee entered a secondary containment interlock [airlock] and identified that both doors of the interlock opened simultaneously when the door on the reactor building side was opened. The employee immediately secured both doors in the interlock and notified the Main Control Room Supervisor. Both doors in the interlock were open for approximately five seconds. With both doors open, TS SR 3.6.4.1.2 was not met. This rendered secondary containment inoperable per TS 3.6.4.1. Reactor Building differential pressure, as observed in the Main Control Room has remained less than -0.25 in. H2O at all times. Initial investigation determined that the interlock for the doors was malfunctioning. Administrative controls have been put in place to ensure the doors remain closed pending repairs to the interlock."

The licensee notified the NRC Resident Inspector.

Notified R3DO (McCraw).

VIOLATION OF TECHNICAL SPECIFICATIONS

During startup of the reactor with reactor power less than one kilowatt, one of the two required reactor period channels was deenergized. Technical Specification 3.2.3 requires that the reactor shall not be made critical unless there are two such operable channels. For a period of approximately 10 seconds one of the operators inadvertently lifted the wrong cable. The operator identified the error and realized Technical Specifications had been violated. The reactor was shutdown at 1134 EST.

An evaluation was performed to identify corrective actions. A labeling issue was identified which contributed to the incident.

The licensee notified the NRC RTR Project Manager.

LOST RADIOACTIVE MATERIAL

The following report was received via email:

"1. The lost radioactive material consisted of one in flight blade inspection system (IBIS) pressure indicator which was installed on one CH-53E aircraft. The IBIS pressure indicator (P/N: 12210-1, S/N: 293) contained one 500 microCurie Strontium-90 source.

"2. The IBIS pressure indicator was last visually accounted for prior to an aircraft flight on January 18, 2017. Much of the flight was over water and maneuvers were conducted over unpopulated woodland adjacent to Marine Corps Air Station (MCAS) New River, North Carolina. During the flight, nothing out of the ordinary was noted. After the flight, a post flight inspection was conducted and it was then discovered that an IBIS pressure indicator was missing.

"3. The IBIS pressure indicator was discovered missing at 0545 [EST] on January 18, 2017 during a post flight inspection when the crew chief went to reinstall the IBIS pressure indicator covers. The likely location of the IBIS pressure indicator is in the water or unpopulated wooded area beneath the aircraft flight path in the New River, North Carolina region.

"4. Exposure to individuals from radiation from the IBIS pressure indicator is unlikely due to its likely location in an uninhabited area.

"5. Upon discovery of the missing IBIS pressure indicator, the aircraft maintenance crew at MCAS New River immediately performed an inspection of the flight line in the vicinity of the aircraft. On January 18, 2017 at approximately 1500 [EST] an extensive foreign object detection walk was conducted on the aircraft parking line. No debris associated with the missing IBIS pressure indicator was found.

"6. An inspection was completed on all IBIS pressure indicators installed on aircraft associated with the MCAS New River in order to verify that the IBIS pressure indicators did not exhibit excessive wear indicating the potential for the displacement of an IBIS pressure indicator from the aircraft. MCAS New River aircraft operational and maintenance crew were re-briefed on the importance of vigilant pre-flight and post-flight aircraft inspections in order to identify potential material defects of aircraft components."

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

LOST IODINE-125 IMPLANT SEED

"In compliance with 10 CFR 20.2201(a), this report serves as notification of the loss of licensed material under West Virginia University Hospital Broad Scope License 47-23066-02.

"On January 18, 2017, the Radiation Safety Department discovered that one Iodine-125 seed used in a Radioactive Seed Localization (RSL) procedure was missing. The seed in question had been implanted on November 8, 2016 and contained 241 microCuries of I-125. The patient had surgery to excise the specimen with the seed on the same day as implantation.

"The specimen went to the Breast Care Center for imaging and then to the Pathology gross room where the seeds are removed and placed into plastic vials to await pick up by Radiation Safety staff. Radiation Safety staff documented that the seed in question plus 3 others were picked up from the gross room on November 9, 2016 and taken to the radioactive waste storage area.

"The seed was discovered missing on January 18, 2017 during preparation of a return shipment of seeds to the manufacturer. WVU Radiation Safety promptly investigated the cause of the incident and performed thorough radiation surveys in the Pathology gross room, radioactive waste storage area, and specimen blocks in Pathology, however all surveys were indistinguishable from background. WVU Hospital feels it is likely that the seed was extracted from the specimen in the gross room but was never placed into the plastic vial and subsequently ended up discarded in the gross room waste.

"During pick up by Radiation Safety, the seed was falsely identified by a visual verification as being present in the plastic vial. A blue plastic spacer, which comes preloaded in the syringe with the seed, may have been mistakenly identified as the seed due to its similar size and shape. WVU Hospital has instituted corrective actions to include more intense radiation surveys and better documentation of those surveys to prevent a future occurrence. In compliance with 10 CFR 20.2201(b), please expect a written report within the next 30 days for more details regarding this incident."

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