Event Notification Report for November 17, 2015

PLANNED MAINTENANCE ON SEISMIC SYSTEM FUNCTIONAL TEST

"This notification is being made due to planned maintenance during the Semi-Annual Seismic System Functional Test. This test will result in a major loss of emergency assessment capability for emergency action level (EAL) HA6 (natural or destructive phenomena affecting VITAL AREAS), while the control room 0.1g acceleration alarm is non-functional. The emergency preparedness plan requires the 0.1g acceleration alarm indication to declare EAL HA6 during a seismic event greater than the Operating Basis Earthquake (OBE). This condition requires an 8 hour non-emergency immediate reportability to the NRC in accordance with 10 CFR 50.72(b)(3)(xiii), Major Loss of Assessment, Response, or Communication Capability.

"At approximately 1200 CST on November 17, 2015, the Semi-Annual Seismic System Functional Test will commence. While this test is in progress, seismic alarm capability is not available for EAL declaration purposes. ANO procedures provide compensatory measures of using offsite sources to obtain seismic data. It should be noted that seismic data will still remain capable of being recorded and only alarm capability is lost. The Semi-Annual Seismic System Functional Test will occur intermittently over the next four days."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM STEVE KIRSCHBERGER TO VINCE KLCO ON 11/18/15 AT 1940 EST * * *

The licensee returned the Seismic System to service at 1347 CST on 11/18/15.

The licensee notified NRC Resident Inspector.

Notified the R4DO (Warnick).

HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE

"At 2355 (CST) on 11/17/2015, River Bend Station declared the High Pressure Core Spray [HPCS] system inoperable in accordance with Technical Specification 3.8.9, Condition E (Declare HPCS system and Standby Service Water System Pump 2C inoperable immediately) due to Division 1 Control Room Air Conditioning System HVK-CHL1C being inoperable because of a significant Freon leak on SWP-PVY32C.

"Actions taken to exit LCO: Alternated divisions of Control Room Air Conditioning System to Division 2 HVK-CHL1D in service and Division 1 HVK-CHL1A in standby."

The basis for declaring High Pressure Core Spray inoperable was that the control room chiller also chills the switchgear room that supplies power to the HPCS. HPCS was out of service for less than one hour while the chillers were swapped from Division 1 to Division 2.

The licensee has notified the NRC Resident Inspector.

LOST IODINE-125 SEED

"One 180 microCi I-125 seed for breast radioactive seed localization (I-125 RSL) was lost at Brooke Army Medical Center (BAMC) on 17 November 2015.

"Loss of the I-125 seed occurred in BAMC Pathology on 17 November 2015 due to lack of training and supervision of new Residents during the removal of the seed while grossing the specimen. Health Physics Service (HPS) was notified and responded to Anatomic Pathology/Histology at approximately 1130 on 20 November.

"According to events leading up to the loss, the I-125 seed was not removed from the specimen prior to being submitted for sectioning. Typically, RSL seeds are tracked on a BAMC I-125 Seed Tracking Form, which indicates when the seed is removed from the specimen. In this case, the tracking form was completed only to the point of Pathology receiving the specimen with the seed still within. A radiograph illustrating the seed within the specimen was taken on 16 November 2015 in Mammography and delivered with the specimen to Pathology. Due to a lack of supervision and training, [the Pathology Resident] did not verify on the tracking form that the seed had been removed. The I-125 Seed Tracking Form was found incomplete on 20 November 2015 by the RSO [Radiation Safety Officer], who then contacted [the Pathology Resident] and informed the Health Physics personnel. Health Physics personnel immediately responded and performed a survey of the entire Histology suite focusing on all work stations and processing equipment used in the preparation of this specimen; the seed was not located within the Histology suite. According to [the Pathology Resident], the step to verify seed removal was overlooked, and confirmation of the seed's absence with a radiation probe was skipped. Furthermore, the tissue was grossed and submitted entirely for sectioning. Most likely, the seed stuck to the grid and was disposed of as biohazard waste. The biohazard disposal route from Pathology on the 4th floor to the hospital exit passes through radiation monitors located on the fourth floor and in basement utility rooms and the biohazard waste room, but due to the low activity of one I-125 seed in biohazard bag with unknown amount of material the monitors would not alarm.

"Initial activity of the I-125 RSL seed was 300 microCi on 7 October 2015, and had decayed to 180 microCi on 20 November 2015. Assuming no shielding, an exposure rate of 0.03 mR/hr at 1 meter is to be expected. Personnel are not likely to handle the waste for an extended period of time and the waste was likely incinerated at Stericycle.

"Steps have been taken since the incident to prevent recurrence.
A. Procedure: The grossing staff pathologist will ensure seed disposal via inspection of appropriate paperwork and scanning with appropriate probe rather than verbal assurance.
B. Additional training sessions on the use of the NeoProbe and I-125 RSL seed procedure.

"Based on accounts above, the I-125 seed was left with the specimen during grossing and was then submitted to sectioning and the seed was lost. In addition to ensuring the proper training and SOPs [Standard Operating Procedures] are in place and followed, we will continue to have radiation monitors in place on each floor and the back loading docks of the facility to make certain there is full accountability of the I-125 seeds."

The licensee notified NRC Region 4 (Torres).

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

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

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

"Event Date and Time: 11/17/15. Time is unknown as the current owner took possession of the property after a business had remodeled the interior of the structure. This report is for an exit sign that was disposed of between 2007 to 2012.

"Event Type: Lost Exit Sign

"Event Description: An exit sign was purchased during the renovation of a church to an office. By Design Homes purchased the property in 2007 and used the property for their offices until the renovation was completed and resold as private residence in 2012. The disposition of the exit [sign] is unknown. By Design Homes was unaware of the exit sign containing Tritium.

"Detail: During an audit of the records, a contact was made with one of the investors who worked with By Design Homes. During the discussion, we [Colorado Department of Public Health and Environment (CDPHE)] discovered the transition [of] the property from a church to By Design Homes. They renovated the property [into] a private residence. It is unknown what happened with the exit sign. Speculation is the sign was taken down and disposed of in a dumpster during the renovation from the business to a residence.

"The current owner does not have any record of an exit sign being in the home when purchased in 2012.

"Our [CDPHE] office made contact with By Design Homes, leaving emails with the investor to relay the incident and to obtain a corrective action report. No further communication has been received at this date."

Colorado Event Report ID No.: CO15-I15-34


* * * UPDATE FROM LINDA BARTISH TO DONALD NORWOOD AT 1211 EST ON 12/1/2015 * * *

The following information was received via E-mail:

"Additional information regarding the exit sign: Model Number is 1091, Serial Number is U1796, Activity is 7.5 Ci of H-3, Manufacturer is Safety Light, Shipped on 7/25/2007."

Notified R4DO (Gepford). E-mailed ILTAB (Johnson) and NMSS Events Notification group.


* * * UPDATE FROM LINDA BARTISH TO DONALD NORWOOD AT 1438 EST ON 12/1/2015 * * *

The following information was received via E-mail:

"Correction, the Model Number is 101."

Notified R4DO (Gepford). E-mailed ILTAB (Johnson) and NMSS Events Notification group.

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