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Event Notification Report for May 12, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/11/2017 - 05/12/2017

** EVENT NUMBERS **


52726 52728 52730 52745 52747 52748 52749

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Agreement State Event Number: 52726
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: EVOQUA WATER TECHNOLOGIES
Region: 1
City: UNION State: NJ
County:
License #: 506782
Agreement: Y
Docket:
NRC Notified By: JOSEPH POWER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 12:28 [ET]
Event Date: 06/04/2015
Event Time: [EDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (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 - LOST SOURCE

The following was received from the State of New Jersey via email:

"An inspection of Evoqua Water Technologies was conducted on 4/30/15. During the inspection, a device listed on Generally Licensed Device Registration Form #664 could not be found. The device was a model 4000 [SN 732], manufactured by Metorex Inc, and contained 10 mCi of Am-241. The device was listed as being at the facility since 1989. However, no current employee remembered the device being in use for several years. On 5/15/15, the original unit was discovered, but without the attached probe which contained the source. On 6/4/15, after repeated search attempts, the probe was declared lost."

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: 52728
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: VA NEW JERSEY HEALTH CARE SYSTEM
Region: 1
City: EAST ORANGE State: NJ
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: LYNN L. GRAVES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 12:58 [ET]
Event Date: 12/03/2015
Event Time: [EDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

ADMINISTERED DOSAGE DIFFERENT FROM PRESCRIBED DOSAGE

The following was received from the Veterans Affairs National Health Physics Program via email:

"As requested via a telephone conversation with the NRC Operation Center, this is a written notification, pursuant to 10 CFR 35.3045(a)(1), regarding a series of medical events that occurred at the VA New Jersey Health Care System in East Orange, New Jersey. A brief description of the events, cause of the events, and other required information are contained in the enclosure. The East Orange VA facility holds VHA Permit Number 29-04481-01 under our master material license, NRC License No. 03-23853-01VA.

"There are six apparent medical events with four resulting from the use of a pre-printed form with the incorrect unit selected; the first occurring on December 3, 2015 involving a dosage of 155 microCuries of radium-223 dichloride; the second on March 7, 2016 involving a dosage of 128 microCuries of radium-223 dichloride; the third on June 3, 2016 involving a dosage of 131 microCuries and the fourth on August 14, 2016 involving a dosage of 155 microCuries of radium-223 dichloride that was administered to patients for treatment of osseous metastases from prostate cancer. The written directives incorrectly stated the intended dosages as 155 milliCuries; 128 milliCuries; 131 milliCuries and 155 milliCuries, respectively. The fifth medical event occurred on February 20, 2016 involving a dosage of radium-223 dichloride 121 microCuries when the written directive stated 211 microCuries. The prescribed dose was 211 microCuries. The dose administered was 121 microCuries, which is a 43% variance. The whole body dose calculation is 85.50 rad/mCi x 0.09 mCi = 7.7 rem, which exceeds the 5 rem dose limit. However, the physician intended to administer 121 microCuries and had transposed the numbers on the written directive. The sixth occurred on March 28, 2017 with 25 milliCuries of sodium iodide iodine-131 where the written directive stated 25 milliCuries of radium-223 dichloride with the intended dose of 25 milliCuries of sodium iodide iodine-131 ordered and administered. No harm to the patients is expected since these treatments were successfully performed by administration of a dosage that was in accordance with the intentions of the authorized user physician. The details of corrective actions are being ascertained at the facility due to the absence of the Radiation Safety Officer at the time of discovery. NHPP [National Health Physics Program] staff was on site and discovered the events on May 2, 2017, during a routine inspection. We notified the NRC Operations Center by telephone on May 3, 2017.

"As part of our routine, we evaluated circumstances of the medical events, reviewed actions to prevent a recurrence, and assessed regulatory compliance."

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: 52730
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EXXON MOBILE CHEMICAL
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2316-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 15:57 [ET]
Event Date: 05/02/2017
Event Time: 14:00 [CDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - LEVEL DENSITY GAUGE SHUTTER STUCK OPEN

The following information was obtained from the state of Louisiana via email:

"On 05/03/2017, the Assistant Radiation Safety Officer (RSO) for ExxonMobil Chemical received notice that a level density gauge was having difficulty with the operation of the shutters on a gauge installed on a process. During follow-up checks, the one level gauge was found with shutters that were stuck in the open position and the manual operation handle had broken. The report was received by the RSO at approximately 1400 [CDT] on May 02, 2017.

"The gauge was an Ohmart Corporation Gauge, devices involved, Model Number SHF-2-45. The gauge/device S/N unknown is loaded with approximately 200 mCi of Cs-137 and the S/N 5828GK. The source and source holder usually have one S/N for the whole device. BBP Sales/Service Company was contacted to fix the problem by repairing the gauge or replacing the device. The gauge is installed on processes and does not pose a health and safety threat to the general public or the employees. The source survey revealed the readings were less than 2 mR/hr and proper safety precautions will be taken when personnel enters the area. This is considered an equipment failure with the manual shutter handle device breakage."

LA Event Report ID No.: LA-170007

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Part 21 Event Number: 52745
Rep Org: TIOGA PIPE, INC.
Licensee: SUMMERILL TUBE CORP.
Region: 4
City: HOUSTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RUSSELL LION
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/11/2017
Notification Time: 09:40 [ET]
Event Date: 04/28/2017
Event Time: [CDT]
Last Update Date: 05/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
MIKE ERNSTES (R2DO)
PART 21/50.55 REACTO (EMAI)

Event Text

INTERIM REPORT CONCERNING SUPPLY OF STAINLESS STEEL TUBING

The following is a summary of a report received via fax:

"This [interim report is being provided] in accordance with 10 CFR Part 21.21 concerning the supply of 0.5 inch Stainless Steel Tubing to the Duke/Progress Energy Brunswick Nuclear Generating Station. Mackson Nuclear subcontracted Tioga Pipe to supply the tubing. Tioga Pipe in-turn subcontracted Summerill Tube; in which Summerill Tube procured the tubing commercially utilizing the provisions of ASME Section III, NCA 3855.5. However, Summerill failed to properly implement the requirements of NCA-3855.5(a)(2) in that a product analysis of each piece of unqualified source material was not performed.

"Tioga Pipe does not have the capabilities to conduct an evaluation of the defect to determine if a substantial safety hazard exists in the tubing supplied to Duke/Progress Energy. As such, Tioga cannot provide a timeframe as to an expected completion date, and is relying on the licensee, Duke/Progress Entergy, to make the final determination.

"If you have any questions, please feel free to contact William Kotcher at (713) 512-3569 or our Quality Director, Russell Lion, at (484) 546-5612."

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Power Reactor Event Number: 52747
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: THOMAS COOPER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/11/2017
Notification Time: 13:21 [ET]
Event Date: 03/20/2017
Event Time: 02:16 [EDT]
Last Update Date: 05/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 4 Power Operation 4 Power Operation

Event Text

60-DAY OPTIONAL TELEPHONE NOTIFICATION FOR AN INVALID HIGH PRESSURE COOLANT INJECTION SYSTEM ACTUATION

"Pursuant to 50.73(a)(1) the following information is provided as a sixty (60) day telephone notification to the NRC. This notification, reported under 50.73(a)(2)(iv), is being provided in lieu of the submittal of a written LER to report a condition that resulted in an invalid actuation of the high pressure coolant injection (HPCI). At Nine Mile Point Unit 1, HPCI is a flow control mode of the normal feedwater system and is not an emergency core cooling system.

"On March 20, 2017 at 0216 EDT, Nine Mile Point Unit 1 reactor shutdown was in progress. The Unit 1 generator was off line, the 100 percent capacity 13 feedwater pump (13 FW) was removed from service, and the Unit 1 main turbine had been tripped appropriately per procedure while entering a planned refueling outage. At approximately 4 percent reactor power, a clearance tagging evolution was in progress to support shutdown activities. During this evolution a tag was applied that caused an unanticipated activation of a lock out (86) relay due to the failure to bypass this relay prior to the tag application. This 86 relay activation in turn resulted in a generator trip signal followed by a turbine trip signal. With the generator off line and the turbine already tripped there was no actual change in any plant parameter or condition that would have created a valid turbine trip signal and the associated HPCI initiation.

"The plant configuration at the time of the main turbine trip signal had one motor operated feedwater pump, 12 Feedwater Pump (12 FW), in service and providing normal reactor level control. HPCI did initiate as designed upon receiving the generator and main turbine trip signals caused by the activation of the 86 relay. The 12 FW pump, which was providing normal reactor level control, transitioned the level control from automatic mode into HPCI mode of operation. Per design, the 11 FW pump automatically started but was not required to and did not flow water since 12 FW pump was in operation. The 11 FW pump was subsequently secured by operations. At no point in time did the HPCI system receive a valid initiation signal (due to high DW pressure, low reactor water level, or a valid turbine trip with loss of the turbine driven 13 FW pump). Operators reset HPCI and returned water level to Automatic Control at 0218.

"The Licensee has notified the NRC Resident Inspector."

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Non-Power Reactor Event Number: 52748
Facility: NORTH CAROLINA STATE UNIVERSITY
RX Type: 1000 KW PULSTAR POOL TYPE
Comments:
Region: 0
City: RALEIGH State: NC
County: WAKE
License #: R-120
Agreement: Y
Docket: 05000297
NRC Notified By: GERRY WICKS
HQ OPS Officer: VINCE KLCO
Notification Date: 05/11/2017
Notification Time: 15:24 [ET]
Event Date: 05/10/2017
Event Time: 17:00 [EDT]
Last Update Date: 05/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
DUANE HARDESTY (NRR)
ANTHONY MENDIOLA (NRR)
ALEXANDER ADAMS (NRR)

Event Text

RESEARCH TEST REACTOR - TECHNICAL SPECIFICATION VIOLATION

"On Wednesday May 10, 2017 at approximately [1700 EDT], the Reactor Operator (RO) that was signed in on the reactor console logbook completed a ['key on'] checklist in preparation for a routine reactor startup. The RO left the control room and brought the log book to the reactor bridge for the Designated Senior Reactor Operator (DSRO) to sign off for the ['key on'] startup. The RO immediately realized his mistake concerning the procedural requirement for a reactor operator to be present in the control room at all times when the reactor is not secured (procedure OP-103), and returned to the control room.

"The DSRO followed the RO to the control room and observed that the reactor key was in the on position, the control rods were all fully inserted, and reactor power was at residual levels. The reactor was shutdown, but was not secured. The DSRO determined that this constituted a violation of procedure OP-103 and could be a Reportable Occurrence as defined under Technical Specification 1.2.24 h.

"The DSRO reviewed Technical Specification (TS) 6.6.2, Action to be Taken in the Event of a Reportable Occurrence. The DSRO determined that under TS 6.6.2a that reactor conditions had been returned to normal by the presence of the licensed operator in the control room. The DSRO then signed the Key On checklist authorization for reactor startup and the reactor was started.

"The DSRO spoke with the Manager of Engineering and Operations (MEO) by telephone about this matter at approximately 1800 on May 10, 2017. The MEO concurred that procedure OP-103 was violated and would be reportable to the Nuclear Regulatory Commission (NRC). The DSRO and MEO agreed to discuss this matter with the Director, Nuclear Reactor Program and the Reactor Health Physicist on May 11, 2017. The MEO stated on May 11, 2017 that TS 6.1.3a, the specification implemented by procedure OP-103, was not met. It was agreed that required notifications to NRC would be made by [1700] on May 11, 2017 to meet the 24 hour notification requirement."

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Power Reactor Event Number: 52749
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: VINCE KLCO
Notification Date: 05/11/2017
Notification Time: 18:11 [ET]
Event Date: 05/11/2017
Event Time: 08:10 [CDT]
Last Update Date: 05/11/2017
Emergency Class:
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVID HILLS (R3DO)

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

FITNESS FOR DUTY - UNOPENED CAN OF ALCOHOL DISCOVERED IN ADMINISTATION BUILDING

A can of alcohol (16.9 ounce foreign beer) was discovered unopened in an administration building refrigerator. Site security took possession of the can of alcohol. The owner of the can of alcohol is unknown. This licensee is making this 24 hour notification in accordance with 10CFR26.719(b)(1).

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, May 12, 2017
Friday, May 12, 2017