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Event Notification Report for September 13, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/12/2013 - 09/13/2013

** EVENT NUMBERS **


49320 49322 49325 49339

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Agreement State Event Number: 49320
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: CODER X-RAY SERVICE
Region: 4
City: MCPHERSON State: KS
County:
License #: 21-B165-01
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/04/2013
Notification Time: 15:07 [ET]
Event Date: 08/05/2013
Event Time: [CDT]
Last Update Date: 09/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENT RESOURCES (E-MA)

Event Text

AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY SOURCE TO RETRACT

The following report was received from the Kansas Bureau of Environmental Health via facsimile:

"During radiography operations on the night of 5 Aug 2013, two employees, a radiographer and an assistant radiographer of Coder Welding & X-ray Service were finishing an 8 hour shift (which is 2nd shift for Alstom), when the source and crank assembly would not operate correctly. At that time, they could only determine that the source had not fully retracted into the camera correctly. After several additional attempts, they concluded a malfunction of unknown causes prevented the source from retracting to a full and locked condition. Following Coder Operating and Emergency protocol, the first action was to secure and maintain a 2mr/hr boundary. A complete survey of the area determined that the original roped and placarded boundaries were still correct and valid. Next the RSO was contacted as well as the assistant RSO. The RSO advised the radiographer to secure and maintain the 2mr/hr boundary and asked if any personnel or workers had been exposed to radiation levels in excess of those in Kansas Radiation Protection Regulations, Part 4 and following, and they stated no. They were advised that the RSO would be on site in 90 minutes to oversee the incident and resolve the situation. While waiting for the RSO to arrive, the two Coder employees decided to extend the roped boundaries an additional 75 feet in addition to the existing roped area and inform Alstom management of the situation. Since this was the end of 2nd shift for Alstom workers, and no Alstom workers were in the area at the time, there was no disruption of production or evacuation needed. Any Alstom employees on site were advised not to enter plant area as a precaution. At no time were Coder or Alstom employees at risk or in danger of overexposure.

"The RSO arrived on site at approximately 12:15 p.m. and made a radiation survey of the area and boundaries. The RSO found correct actions had been taken and 2mr/hr boundaries were maintained. In fact, 1mr/hr was the highest reading. The RSO then walked up to the crank-out reel and found the radiation level to be 5mr/hr. He concluded that the source was in fact in the tungsten collimator (4.3 hvl [half value integers]) secured on the pipe weld where it was during earlier radiographic operations. Several attempts to return the source to its shielded and locked condition failed, so plans were made to allow for closer inspection of the cables and source tube. At this point, the assistant RSO was contacted and advised to bring additional drive cables and source tube in the event they could be needed. While the radiographer and assistant radiographer maintained security over the boundaries and source, the RSO and several Alstom management, who had arrived on site, went outside to look for suitable shielding that could be brought in. Two one inch plates were chosen for use. The plates were tack welded together and moved to an area where overhead cranes could be used to move into position. This was accomplished by using the remote controls of the crane system so no person would have to be in a high radiation environment. With help from Alstom personnel, the steel plates were directed into place by the RSO next to the source camera, providing additional shielding. It was then possible for the RSO to walk up to the source camera with a survey level of 32mr/hr. It was then possible to inspect the drive cables and look at the source tube for possible causes of the return failure. A small depression was noted some 6 to 7 feet from the camera and cable attachment. Using a hacksaw, pliers, and other tools, the outer cable shielding was removed and the RSO returned to the cable crank, and was able to retract the source into the camera in the full and locked position. During the entire operation the RSO received a whole body dose of 35 mr.

"Due to the time and distance for the RSO, late arrival of the assistant RSO arrival on site, and the caution taken to resolve the situation, some 3-1/2 hours elapsed from the start to the end. The help and materials provided by Alstom management aided in the safe and satisfactory conclusion of this incident. At this time, it is unknown what might have caused the depression in drive cables or why it suddenly caused a failure to retract situation."

Kansas Report Number: KS130006

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Agreement State Event Number: 49322
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FOX NDE LLC
Region: 4
City: DILLEY State: TX
County:
License #: 06411
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 13:50 [ET]
Event Date: 09/04/2013
Event Time: [CDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED GUIDE TUBE PREVENTS SOURCE RETRACTION IN A RADIOGRAPHY CAMERA

The State of Texas submitted the following information via email:

"On September 5, 2013, the Agency [Texas Department of Health] was notified by the licensee that on September 4, 2013, a radiography crew was unable to retract an iridium - 192 source into a QSDA 880 D exposure device. The failure was caused when the camera fell from a pipe it was set on and hit the ground crimping the guide tube at the outlet nozzle of the camera to a point where the source could not pass through the tube at the crimp.

"The radiographers isolated the area, and contacted their Radiation Safety Officer (RSO). The RSO went to the location to recover the source. The RSO stated that he had to cut both the guide tube and the drive cable so that the guide tube connection to the camera could be broken and the connector removed. The cable was then threaded through the camera and the cable pulled by hand to return the source to the fully shielded and locked position. The camera was returned to the licensee's facility for further inspection.

"No one involved in the event received an exposure that exceeded any regulatory limit. No member of the general public was exposed to any radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9110

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Agreement State Event Number: 49325
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: WESLEY LONG HOSPITAL
Region: 1
City: GREENSBORO State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 18:50 [ET]
Event Date: 07/22/2013
Event Time: 10:00 [EDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SEED LOST

On July 22, 2013, it was discovered that one I-125 0.5 mCi prostate implant seed from a procedure that took place on July 10, 2013, was unaccounted for. Cartridges are assumed to be preloaded with 100 seeds with delivery documentation attesting to the count.

Fluoroscopic x-rays confirmed that seventy two (72) I-125 seeds were implanted in a patient following brachytherapy prostate seed implantation using a Nucletron seed Selectron implantation system on July 10, 2013.

During the initial seed calibration process one (1) seed was disposed into a sterile pig. The implant went smoothly except at one point where due to patient movement three (3) seeds were ejected into a sterile pig.

On July 22, 2013, the medical physicist unloading the seeds from the cartridge found 23 seeds which was 1 less than expected. Surrounding hallways, rooms, and the implant robotic equipment along with the equipment storage area and sterilization areas were surveyed but no additional seeds were discovered.

No foul play is suspected and no unusual levels of radiation have been detected from the operating room or radiation oncology staff.

As a corrective action the licensee will x-ray incoming seed cartridges to take a physical count of the seeds prior to the procedure. Immediately following the implant procedures seed cartridges will be removed from the delivery system and a second x-ray image will be acquired to perform another physical inventory. Images will be retained for record keeping.

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.

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

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Power Reactor Event Number: 49339
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/11/2013
Notification Time: 20:37 [ET]
Event Date: 09/11/2013
Event Time: 17:31 [CDT]
Last Update Date: 09/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MICHAEL HAY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 50 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF COOLING TO SWITCHGEAR ROOMS

"Wolf Creek has commenced a plant shutdown in accordance with Technical Specifications. The A Train Class 1E Electrical Equipment Air Conditioning unit was declared non-functional due to a possible failed compressor cylinder, as indicated by increased vibration. This failure could prevent the unit from performing its required function over its required mission time, as required by Technical Specifications 3.8.4, 3.8.7, and 3.8.9. The following safety related electrical equipment was declared inoperable: 4.16KV Bus NB01; 480 Volt AC buses NG01 and NG03; 120 Volt Instrument AC inverters and buses NN11, NN13, NN01 and NN03; 125 VDC chargers and buses NK11, NK13, NN01 and NN03.

"Technical Specification 3.0.3 was entered at 1645 CDT on 9/11/2013 from Technical Specification 3.8.7 due to two out of four 120 VAC inverters (NN11 and NN13) being inoperable. Plant shutdown to Mode 5 commenced at 1731 CDT. The unit is currently at approximately 50% power.

"All electrical systems listed above remain available but are declared inoperable due to inadequate room cooling capability.

"No major equipment is out of service.

"The NRC Resident Inspector has been notified."

No switchgear room temperature limits were challenged.

See EN #49008 (May 6, 2013) and EN #49126 (June 17, 2013) for similar events.

* * * UPDATE ON 9/12/13 AT 0215 EDT FROM MARCY BLOW TO HUFFMAN * * *

"At 00:36 CDT 9/12/13, Wolf Creek had an Auxiliary Feedwater Actuation during a plant shutdown in accordance with Technical Specifications. The plant was in Mode 3, all control rods inserted, with reactor trip breakers closed when low steam generator levels prompted a manual reactor trip. A Valid Auxiliary Feed Actuation signal was received due to low steam generator levels. All Auxiliary Feedwater pumps started and operated as expected."

The licensee has informed the NRC Resident Inspector. R4DO (Hay) notified.

Page Last Reviewed/Updated Friday, September 13, 2013
Friday, September 13, 2013