Event Notification Report for July 18, 2016

AGREEMENT STATE REPORT - RADIOGRAPHER UNPLANNED EXPOSURE

The following report was received via e-mail:

"On July 18, 2016, at approximately 1705 MT, the Colorado Department of Public Health and Environment received a call on its incident notification phone from the acting Radiation Safety Officer (RSO) for Mistras Group, Inc., (CO License CO 963-01). The acting RSO reported that while a Grand Junction, CO based crew was performing industrial radiography activities at a fabrication shop/area in Coburn, CO on June 18, 2016. A radiographer received an estimated whole body dose of approximately 500 mrem, and an estimated extremity dose of approximately 12 rem (12,000 mrem) due to the radiographer handling the guide tube while the source was still present in the guide tube. The source had reportedly become hung up in the guide tube, but at the time of the exposure the radiographer believed the source had been returned to the shielded position. The radiographer was not reportedly using a survey instrument at the time he approached the source just prior to the exposure event. The assistant radiographer remained near the source crank and did not have direct contact with the source containing guide tube. The assistant radiographer reportedly received approximately 20 mrem (whole body dose), based upon his pocket dosimeter reading. The source in use at the time of the incident was contained in a SPEC 150 imaging device with approximately 60 Ci of Iridium-192. Dosimeters for the radiographer and assistant radiographer have been submitted to the licensee dosimetry provider and results are pending. The radiographer has been restricted from further work involving radioactive materials until the licensee can complete an investigation. The guide tube equipment has been taken out of service and is being evaluated by the licensee for possible defects."

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system).'

"On 07-18-2016 at 0730 [EDT], both Control Rooms were notified by the Emergency Preparedness Manager, that the Everbridge Emergency Response Organization [ERO] Notification System may not notify all ERO individuals within the required 10 minutes of system initiation. This constitutes a loss of offsite communications capability. The Everbridge vendor is working to resolve the issue. Compensatory measures are in place."

All ERO personnel received the page but not all received the notification within the required ten minutes.

The licensee notified the NRC Resident Inspector and the State.

* * * UPDATE AT 1728 EDT ON 7/20/2016 FROM CLARK WILLETT TO MARK ABRAMOVITZ * * *

"The Everbridge System was restored and retested at 1930 EDT on 7-19-2016 to provide offsite communications capability."

The licensee notified the NRC Resident Inspector and the state.

Notified the R1DO (DeFrancisco).

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"At 1600 EDT, testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system was not able to notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue was reported resolved by the vendor and site testing has verified resolution as of 2130.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

Some of the ERO personnel did not receive a test page. The requirement is to have all ERO personnel receive the page within ten minutes. Compensatory measures were instituted while the system was not functional.

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified that the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. Compensatory measures (ERO phone lists) were put in place.

"The Everbridge system capability loss for Dresden Station was identified at 1500 CDT on July 18, 2016, due to an undetermined loss of system communications. Emergency Response Data System (EROS) capability was not lost.

"This event is reportable under 10 CFR 50.72(b)3(xiii) as a major loss of communication capability.

"On July 18, 2016 at 1957 CDT, an Everbridge ERO call in drill was initiated and verified successful at 2030 CDT.

"The NRC Resident Inspector has been notified."

Some of the ERO personnel did not receive a test page. The requirement is to have all ERO personnel receive the page within ten minutes and to be fully staffed within one hour.

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified that the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue has subsequently been reported resolved by the vendor and both site testing and common ERF [Emergency Response Facility] (EOF [Emergency Operations Facility] at Cantera) has verified resolution.

"The Everbridge system capability loss for Quad Cities was identified at approximately 1450 (CDT) hours on July 18, 2016, due to an undetermined loss of system communications, which is currently being investigated. Emergency Response Data System (ERDS) capability was not lost.

"The Everbridge system capability loss for the common ERF (EOF at Cantera) was identified at approximately 1500 (CDT) on July 18, 2016.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of EP offsite communications capability.

"The NRC Resident inspector has been notified."

The site was developing compensatory measures when the event was terminated.

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"During testing of the Everbridge Emergency Response Organization (ERO) notification system, it was found that the system may not have notified corporate ERO members within the required ten minutes from system initiation. This constitutes a loss of offsite communication capabilities. The Everbridge vendor has since restored and successfully tested the system. Additionally, the site successfully conducted an ERO call-in drill using the same Everbridge notification system.

"The Emergency Response Data System was not affected.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

The requirement is to have all ERO personnel receive the page within ten minutes. Compensatory measures were instituted while the system was not functional. The system was returned to service at 2100 CDT following repair and testing.

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system was not able to notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue was subsequently reported resolved by the vendor and site testing has verified resolution at 2037.

"The Everbridge system capability loss for Limerick was identified at approximately 1600 EDT on July 18, 2016, due to a loss of system communications. Emergency Response Data System (ERDS) capability was not lost.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident inspector has been notified."

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue has subsequently been reported resolved by the vendor.

"Emergency Response Data System (ERDS) capability was not lost.

"The Everbridge system capability loss for the common ERF (EOF at Cantera) was identified at approximately 1500 CDT on July 18, 2016. Site and EOF testing verified resolution at 2029 CDT.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability."

The licensee will notify the NRC Resident Inspector.

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Offsite Emergency Response Organization (ERO) notification system (Everbridge) identified that the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability.

"The Offsite ERO notification system (Everbridge) capability loss for Braidwood was identified at approximately 1500 CDT on July 18, 2016, due to an undetermined loss of system communications, which is currently being investigated.

"The Offsite ERO notification system (Everbridge) capability loss for the common Emergency Response Facility (ERF), (i.e. the Emergency Offsite Facility at Cantera) was identified at approximately 1500 CDT on July 18, 2016.

"The issue has subsequently been reported resolved by the vendor at 1912 CDT and site testing has verified resolution at 2108 CDT.

"The onsite communication system was not affected.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"This telephone notification is provided in accordance with the Exelon Reportability manual, 'Major Loss of Emergency Preparedness Capabilities', and 10 CFR 50.72(b)(3)(xiii).

"On July 18, 2016 at 1500 CDT, it was determined during testing of the Everbridge ERO [Emergency Response Organization] notification system that the system would not notify the corporate EOF [Emergency Operations Facility] individuals if the system had been activated. This constitutes a loss of offsite communication capability. Exelon and Everbridge have identified and corrected this issue. A follow-up test of the LaSalle Everbridge ERO notification system was completed satisfactorily on July 18, 2016 at 2100.

"The Emergency Response Data System (ERDS) capability was not lost.

"The licensee has notified the [NRC] Senior Resident Inspector of the issue."

Compensatory measures were in place during this event.

SEALED SOURCE LEAK

During a sealed source leak test of two (2) cesium-137 needles, prior to implant into an animal, leakage greater than 0.005 microcuries was measured. The leakage was contained in the source holder. The Cs-137 needles have been stored in shielding pending disposal. There was no contamination or over- exposure. The needles contain 10 mCi of Cs-137 total (for both). The licensee has notified NRC Region 3 and expects to submit a 30 day follow up report.


* * * UPDATE FROM JACK CRAWFORD TO DONALD NORWOOD AT 1721 EDT ON 7/27/2016 * * *

Follow-up leak tests have been performed on all remaining Cs-137 needles used for equine brachytherapy. One additional leaking needle was identified. The activity for the additional leaking needle, as of 7/18/2016, was 7.1 mCi. The additional leaking needle was manufactured in 1982. The additional leaking needle has been taken out of service, put into secondary containment, and is awaiting waste disposal. The licensee notified NRC Region 3.

Notified R3DO (Peterson) and via E-mail NMSS Events Notification.


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