Event Notification Report for April 28, 2017

AGREEMENT STATE REPORT - RADIOGRAPHER TRAINEE BADGE READ GREATER THAN 5 REM

"On April 29, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that on April 28, 2017, one of its radiographer trainees had reported their self-reading dosimeter had gone off-scale. The licensee stopped all work and sent the trainee's OSL [Optically Stimulated Luminescence] dosimeter to be processed. The licensee received a verbal report from the processer on April 29, 2017, and the dose was reported as 5.392 REM. The licensee did not know if the dose was static or dynamic. The licensee stated that the trainee had not operated the exposure device and did not know how the trainee could have received the exposure. The licensee stated there was a chance that the dose was to the badge only. The licensee is conducting a formal investigation into the event. No other individual reported an unusual exposure. The exposure device was a QSA 880D camera containing a 51 Ci Ir-192 source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9482

* * * UPDATE AT 1121 EDT ON 06/08/17 FROM IRENE CASARES TO STEVE SANDIN VIA EMAIL * * *

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

"On May 30, 2017 a detailed report was received by the corporate RSO [Radiation Safety Officer] stating the details of this event. The amount of information was limited and an on-site investigation was conducted on June 7, 2017. By interviewing employees who were at the event, it was determined that the individual did receive the dose of 5.392 REM (whole body) on April 28, 2017 as indicated on his badge reading. He was wearing monitoring devices and an alarming rate meter. There was extreme noise in the area. The exposed employee was a trainee and did not operate the radiography device, although the trainee was experienced in rope repelling in this specific situation and positioned the camera 30 feet above the floor in a pipe rack and collected the film. He did not crank the source in or out. He mounted the camera in the pipes, repelled down the ropes out of the area while the weld was imaged. He returned to the area after the trainer cranked in the source, checked a survey meter on the floor level, 30 feet below the camera, and shielded (there were pipes containing fluids and concrete columns shielding the area), while the trainee climbed the distance to collect the film. The trainee did not take the survey meter with him to do a post exposure survey near the camera or film (the meter is routinely snapped on the harness or cow-tail lanyard, but not this time). He collected the film and lowered it by rope to the trainer. The trainee decided on his own to stay in the rope harness near the camera, unknown to him that the source was slightly exposed. His alarming rate meter may have alarmed although he wouldn't have heard it, nor did he check it. The trainer took the film to the developer in another trailer onsite. When he returned (about 20 minutes) to say, film good, the trainee tried to unhook the cable. When it failed to unhook, another trainer in the crew had seen him and turned the crank handle to fully retract the source (uncertain, about half a turn). The trainee immediately lowered himself to the ground and both went to the vehicle. It was found that his pocket dosimeter was off scale, alarming rate meter was not alarming at this point and trainer phoned the RSO to get advice. Work stopped and the employees stayed on site. The RSO collected badge and sent it for immediate processing and gathered as much information as possible. It is believed the trainee's dose, according to the trainers, was to his whole body and possibly a few seconds to his right hand while trying to disconnect the cable. Within days, the trainee was released from employment from the company and disciplinary action taken against the other trainers. In an attempt to contact the trainee, the trainee responded to a phone text message stating he has not had any redness or tingling in his hand. He also stated he did not touch the collimator. The hand dose is estimated to be less than 2.5 millirem for three seconds or less."

Notified R4DO (Rollins), NSIR (Milligan), NMSS (Rivera-Capella), and NMSS Events Notification via email.

* * * UPDATE FROM IRENE CASARES TO HOWIE CROUCH VIA EMAIL AT 1410 EDT ON 6/16/17 * * *

"The RSO has finally completed and provided a rough calculation of the extremity dose on June 16, 2017. The hand dose was difficult to calculate due to deficiencies in rationale of where the source was in position to the exit port on the camera. The company dose was initially rejected due to rationale that if the whole body dose was 5 rem; how could the extremity dose be smaller. The deficiency in knowing the time, distance and actual
source shielding was resulting in varied numbers for the extremity dose. After discussing the situation and calculations with the RSO, it was agreed that the dose be assigned 10 rem to the right hand which is below the 50 rem reportable limit."

Notified R4DO (Campbell) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - HIGH DOSERATE AFTERLOADER CHECK SOURCE CABLE FAILURE

The following is an excerpt of a report received from the Oregon Department of Health via email:

Yesterday, April 27, 2017, while treating a patient with a 2 channel plan the licensee received the fault that the 'dummy' cable could not extend to the end of the applicator on the second channel. The licensee's procedure is to go into the HDR vault, check connections and position of the transfer tubes and then retry. The retry failed as well.

Because this was a 2 channel treatment, the patient had received only half of the treatment. The licensee explained what was going on to the patient and gave them the option of ending the treatment that day or waiting while the licensee did some testing and, if all went well, would finish the treatment. The patient opted to wait.

The licensee changed some of the applicators and transfer tubes, tested without failure, then brought the patient back into the vault to finish the treatment without any issues.

After the patient completed treatment and left, the licensee was able to extend the check source cable out of the afterloader and could see right away that the dummy source/end of cable had a bend in it. The licensee inspected the applicator that was used during the fault and thought there was a slight 'burr' in it. Between the bent cable and burr, there might have been snagging, leading to a fault.

The licensee called service (ELEKTA, Inc.) to come change the check source cable, which was done today, April 28, 2017.

After the check source cable change was completed, the licensee ran all combinations of transfer tubes and applicators without any failures. The licensee believed their theory about the burr and snag may have been wrong as that particular combination ran multiple times without any issues. Therefore, the bent cable caused the fault.

There were no adverse or unintended results for the patient, other than waiting 15 minutes while the licensee did some equipment testing. The patient received the prescribed dose. The system is designed so that if the check source/dummy cable cannot extend all the way to the end of the applicator you cannot proceed with the treatment so no possible way in this event to deliver an unintended dose to the patient.

OFFSITE NOTIFICATION FOR RELEASE OF WASTEWATER

"This report is being made pursuant to 10 CFR 50.72(b)(2)(xi), as an event where notification to other government agencies has been made. On April 28, 2017, notification to the Minnesota State Duty Office was made due to a non-compliance with release of wastewater requirements in the Monticello Nuclear Generating Plant's National Pollutant Discharge Elimination System permit. There were no consequences to the health and safety of the public."

The licensee notified the NRC Resident Inspector.

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."

* * * UPDATE AT 1400 EDT ON 09/22/17 FROM RUSSELL LION TO JEFF HERRERA * * *

The following is an excerpt from a report submitted via facsimile:

"Closure of Interim Report Notification Pursuant To 10 CFR Part 21.21, Regarding Supply Of 0.5 inch OD X 0.065 inch MW SA213 TP 316/316L Tubing.

"This letter is being provided to update the status of a recent interim report submitted by Tioga Pipe Co in accordance with 10 CFR 21.21. The interim report was provided on Tioga letter (TP-LTR-NRC-17-01) dated May 10, 2017 (NRC Log No. 2017-31-00, Accession No. ML17142A323). In a joint effort with Duke Energy, Brunswick Nuclear Plant, the evaluation of the condition identified in the interim report has been completed. The condition reported has been determined to be not reportable in accordance with 10 CFR 21. If you have any questions, please feel free to contact our Quality Director, Russell Lion, at (484) 546-5612 or myself at (713) 512-3569."

See EN 52734.

Notified R2DO(Musser) and Part 21 Reactors group (via email).

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID AUXILIARY FEEDWATER ACTUATION

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid Auxiliary Feedwater (AFW) actuation at Watts Bar Nuclear Plant (WBN) Unit 1.

"On April 28, 2017 at approximately 0500 Eastern Daylight Time (EDT), Unit 1 maintenance personnel were performing 1-IMI-3.005, '18 Month Calibration of Anticipated Transient Without Scram System Actuation Circuitry (AMSAC),' when an AMSAC actuation signal was received. Both Motor Driven Auxiliary Feedwater Pumps (MDAFWPs) were already in service when this actuation occurred. The Turbine Driven Auxiliary Feedwater Pump (TDAFWP) did not start as it had been removed from service. Additionally, steam generator blowdown isolated as required. During this event, AMSAC actuation was complete and equipment functioned as expected by its operating state.

"Upon identification of the AMSAC actuation, maintenance activities were halted and a prompt investigation was initiated. WBN found that the procedure in use for the 18 month calibration had been recently revised. The procedure called for maintenance to connect an analog multi-meter set on resistance to incorrect points during performance of the procedure. When the analog multi-meter was connected to the incorrect points, a relay was energized resulting in an AMSAC actuation. The procedure was revised and the test completed.

"The licensee notified the NRC Resident Inspector."