Event Notification Report for March 25, 2015

RESEARCH AND TEST REACTOR TECHNICAL SPECIFICATION VIOLATION

"We would like to report a potential violation of our Technical Specifications, section 6.7.2.a.8 which states an observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy causes or could have caused the existence or development of an unsafe condition with regard to reactor operations. The details of the event are as follows:

- January 14, [2015,] the Reactor Supervisor submitted paperwork for license renewal of an SRO [Senior Reactor Operator] to the director for signature. The director signs the paperwork. It was then assumed that the paperwork would be routed to the NRC for license renewal. The paperwork was signed but not sent to the NRC.
- March 10, [2015,] the license for the SRO expires.
- March 19, [2015,] the SRO completes the control room portion of the startup checklist. This includes manipulation of console controls and placing the reactor in 'OPERATING' condition. The SRO does not perform the reactor startup.
- March 25, [2015,] staff determines that the reactor was placed in an OPERATING condition without a licensed operator at the console on March 19. No other staff was present in the control room during the performance of the startup checklist.
- March 26, [2015,] reactor operation was suspended.

"It has been determined that the SRO did not perform any other license duties after his license had expired. The SRO will not perform license duties until his license is officially renewed."

* * * UPDATE AT 1905 EDT ON 04/08/15 FROM STEVEN REESE TO S. SANDIN * * *

"On March 26, 2015, the Oregon State TRIGA Reactor staff self-reported a potential violation of Technical Specifications, section 6.7.2.a.8 which states 'an observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy causes or could have caused the existence or development of an unsafe condition with regard to reactor operations.' The report was submitted due to the fact that the license of an SRO had expired on March 10, 2015, but that the operator performed licensed duties including placing the reactor in the 'operating' state on March 19, 2015. This individual did not perform any other license duties between the date his license expired and the date that a new license was issued. The initial notification e-mail sent by the reactor staff on 3/26/2015 (event notification 50927) informed the NRC of the event.

"In retrospect, we [Oregon State University] believe this event falls well below the threshold that would constitute a violation of Technical Specification 6.7.2.a.8. The individual has been a licensed operator of the Oregon State TRIGA Reactor for six years. None of the activities he [the operator] performed during the short period that his license was expired could realistically be construed as 'development of an unsafe condition with regard to reactor operations.' All duties that were performed during the event were reviewed by a licensed SRO as part of the daily start-up checklist.

"A new license was issued on April 2, 2015 (SOP-70794, Docket# 55-70933). The staff currently tracks all licensee due dates and it has been emphasized that maintenance of one's license is the responsibility of each licensed operator as well. The staff intends to add a tracking item to verify that 1) a license renewal is submitted at least 2 months prior to license expiration and 2) a license renewal is received at least one month prior to license expiration. It is expected that this information will reviewed during our [Oregon State University] next normally scheduled NRC inspection. No other follow-up or remedial actions are planned.

"This letter serves to retract the initial self-reported potential technical specification violation. Since it is deemed that a violation did not actually occur, there will be no subsequent 14-day written report."

Notified NRR PM (Adams)

SHEEPSHEAD MINNOW MORTALITY IN COOLING CANAL SYSTEM

"This is a non-emergency notification in accordance with 10 CFR 50.72(b)(2)(xi) for notification to 'other government agencies.'

"On March 25, 2015 at approximately 1525 EDT, Florida Power & Light Company notified the State of Florida Fish and Wildlife Conservation Commission of an observed increase in the mortality of sheepshead minnows in the cooling canal system; an industrial wastewater facility. No other animal or fish species were affected. The impact is estimated to be a very small fraction of the total minnow population. The condition has had no adverse impact on station operations.

"The NRC Resident Inspector has been notified."

Sheepshead minnows are not an Endangered Species.

OFFSITE NOTIFICATION DUE TO EFFLUENT BELOW NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM PH LIMITS

"At time 1719 CDT it was determined that notification of the Nebraska Department of Environmental Quality (NDEQ) was required based on the results of a quarterly sample drawn at 1632 CDT on 3/25/2015 from the headwall effluent flow 002C sample point identifying a Ph of 4.4 which is below the allowable levels of the National Pollutant Discharge Elimination System (NPDES) requirements for Ph of 6.5-9.0. Notification of NDEQ will be made within 24 hours in-accordance with the requirements of NPDES Permit NE0001244. The notification to the NDEQ will be made during normal business hours 3/26/15.

"This sample point is supplied by floor drains in Auxiliary Steam Boiler room, Turbine Building HVAC Fan room and DG [Diesel Generator] Building sumps. Discharge from this line is approximately 76 gallons per day. All flow from this sample point was isolated at 2008 CDT. Investigation of the cause of the low Ph levels is on-going."

No indications of environmental impact were reported by the licensee.

The licensee notified the NRC Resident Inspector.

OFFSITE TRANSPORTATION OF CONTAMINATED AND INJURED INDIVIDUAL

"On March 25, 2015, at approximately 1413 CDT, a Browns Ferry Nuclear (BFN) employee fell approximately 6 feet and sustained a laceration to his forehead and potential other injuries. The individual had been working in the Unit 2 drywell, which is a contaminated area. The individual was able to be removed from his anti-contamination clothing prior to leaving the Radiological Controlled Area (RCA).

"The individual was surveyed by a Radiation Protection (RP) technician and had slight contamination (150 cpm [counts per minute]) on his forehead in the area near the laceration. No survey of his back was performed due to being on a stretcher. At 1457 CDT, the individual was transported to an off-site medical facility. A BFN RP technician accompanied the individual to the hospital. Subsequent survey of the individual at the medical facility determined that no other areas of contamination existed. The individual was successfully decontaminated at the medical facility during initial treatment and all locations have been free released. All contaminated materials have been properly controlled.

"This event is reportable in accordance with 10CFR50.72(b)(3)(xii) any event requiring the transport of a radioactively contaminated person to an offsite medical facility for treatment.

"This event has been entered into the Corrective Action Program (CAP) in SR# 1004507.

"The NRC Resident Inspector has been notified."

The individual was transported to Decatur Morgan General Hospital in Decatur, Alabama for decontamination and follow-up medical treatment.

AGREEMENT STATE REPORT - MEDICAL EVENT DURING PROSTATE BRACHYTHERAPY

The following report was received via e-mail:

"RHB [Kentucky Radiation Health Branch] was notified by telephone on 3/26/15, by the licensee's RSO [Radiation Safety Officer] of a medical event involving an I-125 permanent prostate brachytherapy implant. A CT [computerized tomography] scan performed approximately 5 weeks post-implant revealed that 30% of the implanted activity was administered outside the treatment site (PTV). The delineation of PTV corresponds to a 3 mm margin around the contoured prostate gland, except in the direction of the rectum, prostate base and apex. The error was caused by the inherent difficulty in ultrasound imaging of the prostate, changes in the prostate volume before, during, and after an implant, subjectivity in the contouring of the prostate gland, and a common tendency to drop the seeds slightly inferior to the gland as the needle is retracted. The authorized user reviewed the post plan metrics with the patient and referring physician within 24 hours of the discovery of the medical event. The KY RHB [Kentucky Radiation Health Branch] has requested additional information."

Kentucky Report #: KY150002

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.

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK IN GUIDE TUBE

The following report was received via e-mail:

"Radiograph work was being performed on March 25, 2015, at Dominion Power in Dumfries, VA. After the second exposure was finished, the magnetic stand holding the source fell on the guide tube. The source became stuck inside the guide tube. [The radiographers] tried multiple times to retract the source, but did not succeed. At that time, the licensee secured the area and called the RSO [Radiation Safety Officer]. This occurred around 1830 EDT. The RSO and President [of MQC Labs] arrived at approximately 2200 EDT. The RSO called QSA Global, Inc. to retrieve the source. Subsequently, the RSO contacted the Virginia EOC to notify the VRMP [Virginia Radiation Materials Program] of the incident. QSA Global, Inc. arrived at 1330 EDT on March 26,2015, to retrieve the source at Dominion Power in Dumfries, VA. VRMP staff was present to observe the source retrieval. MQC LABS will submit its written report within 30 days. VRMP will review the report and discuss any corrective action with MQC Labs and Maryland RMP [Radiation Materials Program]".

MQC was performing work in Virginia under a reciprocity program with Maryland.

Virginia Report # VA-15-05