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Event Notification Report for January 30, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/27/2017 - 01/30/2017

** EVENT NUMBERS **


52312 52410 52498 52500 52513 52516 52517

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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: 01/27/2017
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

* * * UPDATE ON 1/27/17 AT 1457 EST FROM DAVID BENNETT TO DONG PARK * * *

As a corrective action, the licensee has changed warehouse operations to a different warehouse used to receive devices manufactured in China.

Notified R1DO (Welling) 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: 01/27/2017
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.

* * * UPDATE ON 1/27/17 AT 1457 EST FROM DAVID BENNETT TO DONG PARK * * *

As a corrective action, the licensee has changed warehouse operations to a different warehouse used to receive devices manufactured in China.

Notified R1DO (Welling) 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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Agreement State Event Number: 52498
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TOTAL PETROCHEMICALS & REFINING USA, INC
Region: 4
City: DEER PARK State: TX
County:
License #: 00302
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/19/2017
Notification Time: 11:50 [ET]
Event Date: 01/19/2017
Event Time: [CST]
Last Update Date: 01/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK CLOSED ON FIXED NUCLEAR GAUGE

The following information was provided by the State of Texas via email:

"On January 19, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that the shutter on a Ronan model SA1-F37 gauge, S/N 5432GK containing a 50 millicurie cesium - 137 source would not open during an inspection. The RSO stated the gauge does not create an exposure risk to their employees or any member of the general public. The RSO stated a service provider has been contacted to repair the gauge. Additional information will be provided in accordance with SA-300.

"Texas Incident #: I-9459"

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Agreement State Event Number: 52500
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY
Region: 1
City: DURHAM State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/20/2017
Notification Time: 15:04 [ET]
Event Date: 01/19/2017
Event Time: 13:00 [EST]
Last Update Date: 01/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT DRUG DELIVERED TO PATIENT

The following was received via E-mail:

"The North Carolina Radioactive Materials Branch (RMB) is submitting a report of a possible Medical Event reportable under 10 CFR 35.3045(a)(2)(i). Specifically, a dose was delivered to a patient with an effective dose equivalent (50 rem) to an organ through the administration of a wrong radioactive drug containing byproduct material. The RMB received the report of the possible Medical Event on 1/19/2017.

"NC Licensee Duke University, License 0247-4, reported to the RMB that around 1300 EST on 1/19/2017 a patient scheduled for a thyroid uptake scan in the Diagnostic Nuclear Medicine Department was incorrectly identified and received an oral dose of 2.0 mCi of Iodine-123 instead of the intended dose of 5-12 microCi of Iodine-131.

"An investigation was held on 1/20/2017 with members of Duke University to include the individual that delivered the incorrect dose to the patient. Following a review of the licensee's current procedures, it was noted that there is a minimum of two methods of patient verification prior to the administration of any diagnostic radioactive drug to any patient. An interview was conducted with the CNMT [Certified Nuclear Medicine Technologist] that delivered the incorrect dose and they freely admitted to not following the proper protocol which consists of confirming the Name and Date of Birth of the patient. Other factors may have attributed to this misadministration to include the volume of patients being treated that day and that there were two patients present that day with very similar first and last names. The patient with the similar name received the proper dose for their procedure.

"Following interviews with Duke personnel, it was determined that the CNMT received the proper training to adhere to this two factor authentication as dictated by internal procedures and was authorized under an approved AU for such uses. At this time, it appears the cause for this misadministration is due to human error.

"This investigation is ongoing and more details are to follow to update this report. Several records were requested of the licensee to include a dose assessment to verify the EDE of 50 rem or any excess of 50 rem delivered to the organ. The licensee is compiling it's 15 Day Report and will be providing it to the RMB as required by the Rule. Following receipt of that report, this event will be updated."

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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Power Reactor Event Number: 52513
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MICHAEL SMITH
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/27/2017
Notification Time: 07:25 [ET]
Event Date: 01/27/2017
Event Time: 06:41 [EST]
Last Update Date: 01/27/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
BLAKE WELLING (R1DO)
WILLIAM DEAN (NRR)
DAVID LEW (DRA)
WILLIAM GOTT (IRD)
CHRIS MILLER (NRR)

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

UNUSUAL EVENT DECLARED DUE TO UNVERIFIED FIRE ALARM IN CONTAINMENT

"An Unusual Event [HU.4] was declared at BVPS [Beaver Valley Power Station] Unit 1 at 0641 EST due to a fire alarm in Containment which was unable to be verified extinguished within 15 minutes. Current Containment parameters do not indicate an actual fire. The Fire Alarm has subsequently been reset [at 0648 EST].

"The Licensee notified the NRC Resident Inspector."

The Licensee has notified State and local government agencies.

A containment entry is planned for 1000 EST to verify that there is no fire. Unit 1 continues at 100 percent power. Unit 2 was unaffected.

Notified DHS SWO, FEMA Ops Center, and NICC Watch Officer. E-mailed FEMA NWC and Nuclear SSA.

* * * UPDATE FROM MICHAEL SMITH TO STEVEN VITTO ON 1/27/2017 AT 0952 EST * * *

"The time of the fire alarm reset was at 0648 EST on 1/27/2017.

"The Unusual Event has been terminated at 0934 EST on 1/27/2017 after a containment entry and visual inspection determined no fire or indications of a fire exist.

"The following notifications were made: Commonwealth of Pennsylvania Emergency Management Agency, Beaver County in Pennsylvania, The State of Ohio Emergency Management Agency, Columbia County in Ohio, The State of West Virginia Emergency Management Agency and Hancock County in West Virginia."

The Licensee notified the NRC Resident Inspector.

Notified R1DO (Welling), NRR EO (Miller), and IRD MOC (Gott).

Notified DHS SWO, FEMA Ops Center, and NICC Watch Officer. E-mailed FEMA NWC and Nuclear SSA.

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Power Reactor Event Number: 52516
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JOSEPH GRAHAM
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/27/2017
Notification Time: 23:05 [ET]
Event Date: 01/27/2017
Event Time: 18:08 [CST]
Last Update Date: 01/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JESSE ROLLINS (R4DO)

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

Event Text

HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE

"This notification is to report a loss of safety function in accordance with 10 CFR 50.72(b)(3)(v)(D). At approximately 1808 CST hours on Friday, January 27, 2017, the Grand Gulf Nuclear Station Unit 1 High Pressure Core Spray (HPCS) system was declared inoperable due to the trip of the HPCS Jockey Pump.

"At the time of discovery, Unit 1 was in Mode 2 and raising power in the source range to return to power operations. No other safety systems were inoperable at the time of this event.

"Investigation into the cause of the event is ongoing and the system will be returned to operational status prior to proceeding to Mode 1."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52517
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN CARTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/29/2017
Notification Time: 16:30 [ET]
Event Date: 01/29/2017
Event Time: 02:09 [CST]
Last Update Date: 01/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
JESSE ROLLINS (R4DO)

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

Event Text

LOSS OF BOTH DIVISIONS OF CONTROL BUILDING CHILL WATER AND VENTILATION SYSTEM

"At 0209 CST, on January 29, 2017, while the plant was in MODE 4 for a refueling outage, the main control room crew removed the AC/DC inverter in the Division 1, 120 VAC electrical distribution system from service due to an equipment malfunction. Removing the inverter from service caused a loss of the associated 120 VAC instrument buss. This instrument buss loss caused a trip of the Division 1 Control Building Chill Water and Ventilation system. The Division 2 Control Building Chill Water and Ventilation System was locked out for surveillance testing at the time of the equipment failure. This condition rendered both divisions of Control Building Chill Water and Ventilation Systems unable to perform the support function for cooling Division 1 and 2 AC and DC power distribution systems. These systems are required to support the operability of two required divisions of shutdown cooling. Division 2 Shutdown Cooling System was in service and remained in service through out the event.

"The Division 2 Control Building Chill Water and Ventilation System was returned to service at 0220 CST on January 29, 2017.

"Division 1 Control Building Chill Water remains inoperable pending restoration with the installed backup Division 1 DC/AC inverter. Actions are ongoing to place this component in service and restore the associated 120 VAC instrument buss.

"The equipment malfunction was limited to the Division 1 inverter. The investigation of the inverter failure is ongoing. This condition is being reported in accordance with 10 CFR 50.72(b)(3)(v)(B).

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, January 30, 2017
Monday, January 30, 2017