Event Notification Report for August 16, 2018

FITNESS-FOR-DUTY TEST POSITIVE FOR LICENSED EMPLOYEE

"In accordance with 10 CFR 26.719(b)(2)(ii), this notification reports a licensed Operations employee had a confirmed positive for alcohol during a random fitness for duty test. The individual was not in the protected area and not performing licensed duties at the time of discovery. The employee's access to the plant has been suspended.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - SOURCE GUIDE TUBE DAMAGED

The following was received via email from the State of Illinois:

"On 8/16/18 at approximately 1900 [CDT], the licensee was conducting radiography operations at O'Hare Airport in Chicago, IL. At or around this time, a pipe being analyzed fell off the pipe stand onto the source guide tube, denting it and prohibiting source retraction. Chicago Fire Dept. personnel were contacted at approximately 2030 [CDT] and arrived at the facility. The licensee had established a control boundary at 2 mR/hr and maintained line of sight control over the source. The licensee's recovery team was concurrently deployed and was approximately one hour away. Chicago Fire Dept. contacted and advised IEMA [Illinois Emergency Management Agency] at 2150 [CDT]. Agency staff immediately began coordination with Chicago Fire Dept. and licensee personnel. Agency personnel were deployed at 2335 [CDT] for support operations. Licensee staff (authorized for source retrieval) were able to shield the source and subsequently work out the kink in the guide tube so the source could be cranked back into the device. Based on agency inspector observation, it is believed there were no overexposures as the scene was roped off and constant surveillance maintained. Individual dosimeters worn by the licensee staff indicate a maximum exposure of 25 millirem. Reenactments of the incident conducted after source retrieval support this conclusion.

"The licensee contacted IEMA at 0330 [CDT] on 8/17/18 to confirm that the source had been secured at 0204 [CDT]. A written report was received from the licensee on 8/18/18. There was some confusion on the associated reporting requirements with this incident as 350.3048 (10 CFR 34.101) requires a report within 30 days. Additionally, 340.1220 (10 CFR 30.50(b)) requires reporting within 24 hours. Language in 340.1220(a) that is unique to Illinois and differs from its Federal counterpart (30.50(a)), may require reporting immediately. While compliance with this Illinois reporting requirement and the licensee emergency procedures remain under review, this matter is being considered closed."

The device involved was a Delta 880, serial number D8400, equipped with a 52.6 Ci Ir-192 source, serial number 66323G.

Illinois Item Number: IL 180032

AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED

The following was received from the State of Florida:

"[The State of Florida Bureau of Radiation Control] received a call from [the Medical Physicist] to report the loss of a [190 microCurie] I-125 brachytherapy seed. It is believed that the seed was removed from a patient between July 25 and 26 and placed into the biohazard waste container. The lost seed was discovered missing on Aug. 7th and all attempts to locate the seed have failed.

"There was no adverse outcome in patient care from this incident.

"No personnel or general public exposure would have been significant based upon the low exposure rate and the nature of controlled biohazard waste. The waste was incinerated. The majority of the radioactivity would have been released through the stack with minimal residual activity. No environmental impact is expected."

Corrective actions taken include reeducation of proper documentation methods and reeducation of the proper use and checkoff of the inventory log.

Florida Incident Report #: FL18-110


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

INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.

"On August 16, 2018, at approximately 1736 CDT, Browns Ferry Nuclear Plant (BFN), Unit 2 experienced an unexpected loss of the 2B Reactor Protection System (RPS). This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of Standby Gas Treatment Trains A, B, and C and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected with the exception of the Unit 1 Refuel Zone Supply Fan Outboard Isolation Damper, 1-FCO-64-5, that failed to indicate closed position.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The cause of the RPS MG [Motor Generator] Set trip was a failed (shorted) operating coil associated with the 480 VAC motor starter inside the control box.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Reports 1440047 and 1440050.

"The NRC Resident Inspector has been notified of this event."

FITNESS-FOR-DUTY TEST POSITIVE FOR NON-LICENSED EMPLOYEE

At 1519 EDT on August 16, 2018, Exelon determined a non-licensed employee had a confirmed positive for a controlled substance during a random Fitness-for-Duty test. The employee's unescorted access to the plant has been terminated.

The NRC Resident Inspector has been notified.


* * * UPDATE FROM MICHAEL FITZWATER TO DONALD NORWOOD AT 1310 EST ON 1/8/2019 * * *

The following is a correction to the reason for the Fitness-for-Duty test:

At 1519 EDT on August 16, 2018, Exelon determined a non-licensed employee had a confirmed positive for a controlled substance during a follow-up Fitness-for-Duty test. The employee's unescorted access to the plant has been terminated.

The NRC Resident Inspector has been notified of this correction.

Notified R1DO (Bower) and FFD E-mail group.