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Event Notification Report for February 23, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/22/2017 - 02/23/2017

** EVENT NUMBERS **


52548 52549 52550 52551 52553 52559 52568 52570

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Agreement State Event Number: 52548
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL WELL SERVICES, INC.
Region: 1
City: MEADVILLE State: PA
County:
License #: PA-1446
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/14/2017
Notification Time: 14:17 [ET]
Event Date: 02/06/2017
Event Time: [EST]
Last Update Date: 02/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER MALFUNCTION

The following information was received via facsimile:

"On February 13, 2017, the Department [PA DEP Bureau of Radiation Protection] was notified by Universal Well Services that a malfunction of a roll pin on a shutter handle occurred at a temporary job site in Zelienople, Pennsylvania. It is initially reportable per 10 CFR 30.50(b)(2).

"A roll pin, which holds the shutter handle to the shutter shaft, on one of the in-line density gauges became sheared off during an attempt to move the shutter to the open position, rendering the gauge unusable. The shutter is in the closed position and out-of-service awaiting repair from a service provider. No exposures occurred.

"The shutter is in the closed position and the gauge is out-of-service and secure. There was no other damage to the gauge. A reactive inspection is planned by the Department.

"The gauge was a Berthold, Model LB 8010, Serial Number 10055, containing 20 mCi of Cs-137."

Pennsylvania Event Report ID No.: PA170002

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Non-Agreement State Event Number: 52549
Rep Org: U.S. NAVY
Licensee: U.S. NAVY
Region: 1
City: WASHINGTON State: DC
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: JERRY SANDERS
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/15/2017
Notification Time: 10:06 [ET]
Event Date: 01/18/2017
Event Time: 05:45 [EST]
Last Update Date: 02/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

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

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Agreement State Event Number: 52550
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: PRODUCERS SERVICE CORP.
Region: 4
City: HENNESSEY State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/15/2017
Notification Time: 10:30 [ET]
Event Date: 02/14/2017
Event Time: [CST]
Last Update Date: 02/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED DENSITY GAUGE

The following report was received via e-mail:

"On February 14, 2017, we [Oklahoma Department of Environmental Quality] were informed by Producers Service Corp. that a routine inspection of a generally-licensed Berthold Technologies Model LB 8010 (S/N 10456) fixed density gauge revealed a crack in the rod which operated the shutter. The shutter operated normally despite this. A leak test was performed and was negative. The device contains 20 mCi of Cs-137. The rod and source shield have been replaced, and the damaged parts will be returned to Berthold."

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Non-Agreement State Event Number: 52551
Rep Org: WEST VIRGINIA UNIVERSITY HOSPITAL
Licensee: WEST VIRGINIA UNIVERSITY HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: NASSER RAZMIANFAR
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/15/2017
Notification Time: 14:05 [ET]
Event Date: 01/18/2017
Event Time: [EST]
Last Update Date: 02/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

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

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Agreement State Event Number: 52553
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ENVISION INC.
Region: 4
City: FORT CARSON State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/15/2017
Notification Time: 19:08 [ET]
Event Date: 02/15/2017
Event Time: 10:09 [MST]
Last Update Date: 02/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

The following information was received via e-mail from the Colorado Department of Public Health and Environment:

"The general license section of the Radioactive Materials Program sent out annual notifications requesting response regarding tritium exit signs reported in use at locations given by the manufacturer. Upon an audit of the annual mailing for non-responders, Envision Inc. was contacted. After a complete inspection of the base store they are reporting the store was remodeled approximately 8 years ago; at that time the 4 tritium exit signs were removed. It is unknown if the exit signs were lost, destroyed or placed into the dumpster with the debris from the demolition. No further information is available due to time of reporting loss and lack of response by Envision Inc.

"Number of Tritium exit signs were 4, Model #2040. Since Isolite Corporation did not report serial numbers on quarterly reports in 2001, no serial numbers are available. Each tritium exit sign contained 7500 mCi [milliCuries] of H-3, they were shipped from Isolite on 9/28/2001."

CO Event Report ID No.: CO17-0005

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 52559
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNKNOWN
Region: 4
City: DESERT HOT SPRINGS State: CA
County:
License #: UNKNOWN
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/16/2017
Notification Time: 21:43 [ET]
Event Date: 02/16/2017
Event Time: 13:00 [PST]
Last Update Date: 02/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - CPN INSTROTEK NOTIFIED CALIFORNIA OF MISSING CPN NUCLEAR GAUGE LOCATION

The following information was received from the State of CA via email:

"[The] President of CPN InstroTek in North Carolina called Thomas G. Miko of Los Angeles County Radiation Management, the LEA for Radiologic Health Branch [RHB], on February 16, 2017, from his office in North Carolina. [The CPN President] received a phone call from an anonymous caller in California who found a nuclear gauge from CPN InstroTek. The anonymous caller told [the CPN President] that the gauge is in a shed on a ranch in Southern California. [The CPN President] provided the anonymous caller's cell phone number. Thomas G. Miko spoke with the anonymous caller at 4:30 p.m. on February 16, 2017. The anonymous caller stated that he is in Palm Springs, and that the gauge is in a storage shed of items removed from a pawn shop in Temecula, California, after it went out of business. He said that this shed is in Desert Hot Springs, California, outside of Los Angeles County's jurisdiction.

"Arrangements were made with the anonymous caller for him to drop off the gauge in its original case at the Riverside County Fire Station, where he would contact [a designated] Firefighter.

"[The CPN President] requested that Radiologic Health Branch provide him with the serial number of the gauge for his own reference, once Radiologic Health Branch employees take possession of the gauge from Riverside County Fire Department.

"Arrangements were made for [a] Radiologic Health Branch employee to drive from the Brea, Orange County, California office to take possession of the device from Riverside County Fire Department on Friday, February 17, 2017.

"RHB Brea will follow up to see if they can match the gauge's serial number with that of any previously reported lost or stolen gauges."

CA 5010 Number: 021617

* * * UPDATE AT 1229 EST ON 2/17/17 VIA EMAIL * * *

The missing gauge was not in the case. Law Enforcement is conducting an investigation. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).

* * * RETRACTION AT 1603 EST ON 2/17/17 FROM THOMAS MIKO TO S. SANDIN * * *

The State of California is retracting this report since no gauge was identified or recovered. Notified R4DO (Gepford), NMSS (McIntosh) and ILTAB (Pearson).

* * * UPDATE AT 0116 EST ON 2/22/17 VIA EMAIL * * *

The missing radiological source was returned tonight (2/21/17) and is currently at a fire station in Riverside County. The gauge will remain at the station overnight and will be picked up by California Department of Public Health, Radiologic Health Branch tomorrow (2/22/17).

Notified R4DO (Pick), ILTAB (Whitney) and NMSS (McIntosh).

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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Power Reactor Event Number: 52568
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN CARTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/20/2017
Notification Time: 17:24 [ET]
Event Date: 02/20/2017
Event Time: 12:40 [CST]
Last Update Date: 02/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
HEATHER GEPFORD (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

UNANALYZED CONDITION DUE TO POTENTIAL FAILURE OF CONTROL ROOM AND CONTROL BUILDING AIR HANDLING UNITS

"During the investigation associated with Event Notification 52566 that was reported on 2/18/17, it has been determined that an unanalyzed condition (new potential single failure concerns) exists. This condition exists only during periods of manually alternating divisions of Control Building Chilled Water systems; in that potential failures of Control Room Air Handling Units (HVC-ACU1A or B) or Control Building Air Handling Units (HVC-ACU2A or B) could fail in a manner that challenges the operability of the alternate division.

"As reported in Event Notification 52566, the impact of this event was a loss of safety function cooling to both Division 1 and 2 AC/DC power distribution systems and Divisions 1 and 2 Control Room Fresh Air systems.

"Contingency actions are in development to address the impact of the potential failure mode. The plant remains in a planned refueling outage, Mode 5 with water level greater than 23' above the vessel flange. Shutdown cooling remains in service and is not affected by this issue. Investigation is ongoing.

"The NRC Resident Inspector has been briefed on this issue."


* * * UPDATE FROM ROB MELTON TO DONALD NORWOOD AT 2129 EST ON 2/20/2017 * * *

The licensee updated information in the first paragraph of the original above with the following:

"During the investigation associated with Event Notification 52566 that was reported on 2/18/17, it has been determined that an unanalyzed condition (new potential single failure concerns) exists. During periods of alternating divisions of Control Building Chilled Water systems, the potential exists for failures of Control Room Air Handling Units (HVC-ACU1A or B) or Control Building Air Handling Units (HVC-ACU2A or B) that could challenge the operability of the alternate division."

The licensee notified the NRC Resident Inspector of this update.

Notified R4DO (Gepford)


* * * UPDATE FROM STEVEN CARTER TO MARK ABRAMOVITZ AT 1513 EDT ON 2/22/17 * * *

"After further investigation it has been determined that an unanalyzed condition (new single failure concerns) exists with the dampers associated with the Control Room Fresh Air system. The potential exists for damper failures for HVC-FN1A Control Room Booster Fan 1A motor and HVC-FN1B Control Room Booster Fan 1B motor that could challenge the operability of the alternate division.

"Contingency actions are in development to address the impact of the potential failure mode. The plant remains in a planned refueling outage, Mode 5, with water level greater than 23 feet above the vessel flange. Shutdown cooling remains in service and is not affected by this issue. Investigation is ongoing.

"The NRC Resident Inspector has been briefed on this issue."

Notified R4DO (Pick).

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Non-Agreement State Event Number: 52570
Rep Org: DBI, INC.
Licensee: DBI, INC.
Region: 4
City: OVERLAND PARK State: KS
County:
License #: 15-29301-02
Agreement: Y
Docket:
NRC Notified By: MATT SLAYMAKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/22/2017
Notification Time: 10:59 [ET]
Event Date: 02/21/2017
Event Time: 13:23 [CST]
Last Update Date: 02/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MARK JEFFERS (R3DO)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

RADIOGRAPHY SOURCE CABLE DISCONNECTED FROM SOURCE

"On February 21, 2017, DBI Inc. had an industrial radiography source disconnect incident occur while at a pipeline customer's field site in Rutledge, MO (approx. 4hrs. from Overland Park, KS office). At approximately 1323 CST during the crew's first source retraction it was determined that the source had become disconnected from the drive cable. The crew immediately recognized the situation through the use of their dosimetry equipment and established the emergency 2 mR/hr boundaries.

"The Corporate Radiation Safety Officer (CRSO) was immediately notified of the issue. The CRSO informed the crew to maintain surveillance of the restricted area barricades and to wait until he arrived before any further actions were taken. The CRSO arrived at the job site at approximately 1705 CST to retrieve the source. The source was secured back into the exposure device by 1730 CST. The CRSO received less than 1 mR during the retrieval procedure.

"Listed below are the manufacturer and model number of equipment involved in the incident:
- QSA Global 880 Delta Exposure Device
- QSA Global lr-192 Source (45 Curies) Model A424-9
- QSA Global 35 foot Extreme Weather Control Cables
- QSA Global 7 foot Extreme Weather Source Tube with a 4hvl Collimator

"The level II radiographer involved holds a current Iowa Industrial Radiographer Trainer Card and the assistant is a trainee."

Page Last Reviewed/Updated Thursday, February 23, 2017
Thursday, February 23, 2017