Event Notification Report for October 28, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/27/2014 - 10/28/2014

** EVENT NUMBERS **


50502 50547 50548 50552

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50502
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: KENT MILLS
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/01/2014
Notification Time: 15:07 [ET]
Event Date: 10/01/2014
Event Time: 01:24 [EDT]
Last Update Date: 10/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)
CYBER ASSESSMENT TEA (EMAI)

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

PARTIAL LOSS OF COMMUNICATIONS IN EMERGENCY OPERATIONS FACILITY AND JOINT INFORMATION CENTER

"At 0750 EDT on October 1, 2014, the Shift Manager was notified that site Information Technology (IT) personnel were being mobilized to investigate a potential voice and network loss at the Emergency Operations Facility (EOF) and Joint Information Center (JIC). Site IT personnel were notified by offsite IT resources at 0727 EDT on October 1, 2014 of the issue that was first identified by IT monitoring software at 0124 on October 1, 2014.

"The site IT personnel that responded to the EOF and JIC reported to site Control Room and Emergency Preparedness (EP) personnel at 0845 that connectivity to the Exelon network and the internet was unavailable at both the EOF and the JIC. This loss of connectivity would prevent the ability of the EOF Emergency Response Organization (ERO) personnel to directly monitor key plant parameters via the site's Plant Process Computer (including the Site Parameter Display System) and other network-based plant parameter display systems.

"Site IT and EP personnel determined that the following communications equipment was not impacted by the connectivity issue:

- Dedicated Offsite Agency Phones (primary method for contacting state and local agencies)
- Commercial Phones and dedicated bridge line (primary method for contacting other site Emergency Response Facilities)
- FTS-2001 Phones (e.g., ENS and HPN lines)
- ERDS

"Additionally, EP personnel verified with Dose Assessment Office personnel that dose assessment and dose monitoring functions from the EOF could still be performed without delay.

"Site IT personnel reported to the Control Room at 1135 that connectivity to the Exelon network and the internet had been restored to a fully functional status.

"While site and fleet IT personnel continue to address and verify all appropriate corrective actions have been taken to prevent recurrence of the connectivity issue, the site has employed appropriate compensatory measures to ensure that the verbal transmission of key plant parameters from the site (Technical Support Center or Control Room) to the EOF is recognized and maintained.

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM TIM HUBER TO JEFF ROTTON AT 1208 EDT ON 10/27/2014 * * *

"This update retracts Event Report #50502, which reported that a loss of connectivity to the Exelon network and internet at the Emergency Operations Facility (EOF) and Joint Information Center (JIC) had impacted the ability of staff in these facilities to directly monitor key plant parameters via the site's Plant Process Computer and other network-based plant parameter display systems.

"Subsequent to the identification of this event, further investigation by site and fleet staff determined that adequate direction was included in applicable Emergency Response Organization (ERO) procedures to respond to data display system failures of this type. Specifically, the checklist (procedure) for the Operations Communicator in the EOF provided adequate direction for this ERO member to obtain required plant data from the Operations Communicator located in the Control Room via alternate methods (e.g., over the phone - phone lines remained functional throughout the time that the loss of computer connectivity condition existed).

"Therefore, this event did not result in a major loss of emergency assessment capability and was not reportable to the NRC under 10CFR50.72(b)(3)(xiii).

"The NRC Resident Inspector has been notified."

Notified R1DO (Bickett) and Cyber Assessment Team via email.

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Agreement State Event Number: 50547
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: PROJECT ENGINEERING CONSULTANTS
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800498
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/17/2014
Notification Time: 11:54 [ET]
Event Date: 10/16/2014
Event Time: 13:45 [MDT]
Last Update Date: 10/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENTS RESOURCE (EMAI)
JAMES RUBENSTONE (NMSS)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

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

"Event Description: The licensee failed to properly secure a moisture density gauge in a locked transportation case before leaving a temporary jobsite in a pickup truck. The device fell out of the truck onto the road. The licensee has not been able to locate the device. The local law enforcement agency has been notified."

The event location was 900 East and 5200 South, Murray, Utah. The device is a Troxler Model 3440, Serial number - 69079. This device contains 8 mCi of Cs-137 and 40 mCi of Am-241.

UT Event Report ID No.: UT140004

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: 50548
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY ASSOCIATES
Region: 4
City: GLENDALE State: AZ
County:
License #: AZ 07-639
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/17/2014
Notification Time: 12:16 [ET]
Event Date: 10/15/2014
Event Time: 10:30 [MST]
Last Update Date: 10/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
JAMES RUBENSTONE (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MOVEMENT OF TREATMENT CYLINDER

"At approximately 1030 [MST] on October 15, 2014, the Agency [Arizona Radiation Regulatory Agency] was informed that the licensee had a medical event involving a High Dose Rate afterloader containing a 4.641 curie Iridium-192 source. A patient was receiving the third of three fractions involving a vaginal cylinder. When the Physicist entered the room after the treatment had concluded, he noticed that the cylinder had fallen out of the vaginal canal and was lying on the treatment table. The patient was unaware of the cylinders' position, but remembers feeling an 'oozing sensation' at the beginning of the treatment. The treatment time was for 431.3 seconds and the total prescribed dose for the fraction was 600 centigray and the total dose for all three fractions was 1800 centigray. The patient was also receiving external beam therapy at a rate of 200 centigray for 26 fractions, for a total dose of 5200 centigray. The patient received the last fraction on October 16th.

"The Agency is investigating the event.

"The Governor's office is being notified of this event."

Arizona First Notice Event No.: 14-025


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: 50552
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: PHARR State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/20/2014
Notification Time: 16:03 [ET]
Event Date: 10/20/2014
Event Time: [CDT]
Last Update Date: 10/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE RETRACTION FAILURE

The following information was received via facsimile:

"On October 20, 2014, the Agency [Texas Department of State Health Services] received notice that there had been a radiography source retraction failure at a temporary field site. A pipe had fallen from a stand onto the guide tube, causing a crimp. The source was retrieved by squeezing the crimp with pliers several times, allowing retraction. The individual performing the retrieval received 198 mR according to a pocket dosimeter. The camera was an INC IR-100 (sn 6832) with an Ir-192 source at 44 Ci (sn W644 ). Additional information will be supplied as it is received in accordance with SA-300."

This event occurred at a field site in Encinal, Texas.

Texas Incident #: I-9245

Page Last Reviewed/Updated Thursday, March 25, 2021