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Event Notification Report for September 16, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/13/2013 - 09/16/2013

** EVENT NUMBERS **


49322 49325 49329 49330 49331 49332 49341 49342 49343 49344

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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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Agreement State Event Number: 49329
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL X-RAY & TESTING CORPORATION
Region: 4
City: HOUMA State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 15:11 [ET]
Event Date: 01/28/2012
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

"Individual badge received 3.491 REM through September 2012. His exposure for October wear period was 0.565 REM, which gave him a total of 4.056 REM through October 2012. On 01/02/2013, November badge results came back 1.040 REM. On 01/10/2013, the December badge results came back with 0.043 REM. Making the annual exposure for the individual 5.139 REM for 2012."

LA Event Report ID No. LA130002

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Agreement State Event Number: 49330
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAYOU INSPECTION SERVICES INC.
Region: 4
City: AMELIA State: LA
County:
License #: LA-7112-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:51 [ET]
Event Date: 07/19/2013
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

"Dosimetry badge result were reported to the licensee around July 19, 2013 with an individual's badge having received a total annual occupational dose exposure exceeding 7,437 mrem. 2013 badge history results showed exposures for the following months: January - 538 mrem, February - 410 mrem, March - 287 mrem, April 367 mrem, May 2,412 - mrem, and June - 3,423 mrem."

LA Event Report ID No. LA130003

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Agreement State Event Number: 49331
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-213-27
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:29 [ET]
Event Date: 09/06/2013
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG SITE

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

"The planned/prescribed dose that was to be delivered to a patient's tumor volume was 400cGy (4Gy) on this fraction. Due to medical event, [approximately] 0cGy (0Gy) was delivered to the tumor volume during HDR treatment fraction #2 of 6. The prescribed fraction dose of 400cGy (4Gy) was unintentionally delivered 5.4cm superiorly to the tumor volume in the patient's small bowel/external bladder wall region.

"The HDR remote afterloader at Abbott-Northwestern being used/in use during this patient's treatment is a Nucletron/Elekta V2 mHDR, serial number 31823; mHDR Ir-192 source #D36E-6829. The Ir-192 source activity at time of above medical event was 6.407 Ci.

"Abbott-Northwestern Radiation Oncology is actively investigating the cause of the above medical event, corrective action(s) to implement to prevent such an event from happening in the future, and any medical follow-up/expected implications to the patient from the above medical event. These items will be detailed in Abbott-Northwestern's full written report to be submitted within 15 days of discovery.

"MDH [Minnesota Department of Health] will submit more information as it becomes available."

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.

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Power Reactor Event Number: 49332
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: QUOC VO
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/09/2013
Notification Time: 07:11 [ET]
Event Date: 09/09/2013
Event Time: 04:07 [PDT]
Last Update Date: 09/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VINCENT GADDY (R4DO)

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

Event Text

MAINTENANCE ON TECHNICAL SUPPORT CENTER / OPERATIONS SUPPORT CENTER VENTILATION

"Scheduled maintenance of the Technical Support Center (TSC) / Operations Support Center (OSC) HVAC system for maintenance on the Air Handler (AMA-AH-S1) recirculation fan, outside air duct heater, and thermostat will start at approximately 0400 hours PDT on 09/09/13 and will last approximately 40 hours (estimated time from equipment tag out back to OPERABLE). During this time the TSC and OSC will not be available for use to support emergency response activities. Established compensatory measures direct Emergency Response Organization (ERO) members normally responding to either of these facilities to respond to alternate locations. No other emergency response facilities are impacted by the scheduled TSC / OSC Facilities HVAC maintenance work.

"This event is being reported as a loss of emergency preparedness capabilities in accordance with 10 CFR 50.72(b)(3)(xiii). The resident inspector has been notified. A follow up notification will be made when HVAC maintenance to the TSC / OSC Facilities has been completed and operability of these EP Facilities has been restored."

* * * UPDATE FROM VERLE KESZLER TO PETE SNYDER AT 0823 EDT ON 9/15/13 * * *

"Scheduled maintenance of the Technical Support Center (TSC) / Operations Support Center (OSC) HVAC system is completed. The HVAC system has been returned to service and declared functional at 05:05 PDT on 9/15/13.

"The licensee has notified the NRC Resident Inspector."

Notified R4DO (Hay).

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Fuel Cycle Facility Event Number: 49341
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/13/2013
Notification Time: 10:55 [ET]
Event Date: 09/13/2013
Event Time: 10:45 [EDT]
Last Update Date: 09/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
SCOTT SHAEFFER (R2DO)
MERAJ RAHIMI (NMSS)
WILLIAM GOTT (IRD)

Event Text

ITEM RELIED ON FOR SAFETY MAY NOT BE RELIABLE

"At about 1045 EDT on 9/13/13, it was discovered that the feed tube level sensor on a press operation is not fail safe upon loss of signal. The sensor is a sole IROFS [Item Relied On For Safety] for a particular sequence. Criticality controls remained in place. Affected equipment has been shut down. No unsafe condition exists. Feed tube level sensor is in place for the sequence to limit mass. At no time was the mass limit exceeded. We are reporting under Part 70, Appendix A, (a)(4) which states that credited IROFS must remain available and reliable. We cannot evaluate reliability in the time required for a 1 hour report. In addition, the affected equipment has been secured. An investigation is underway to determine corrective actions and extent of condition."

The license will notify NRC Region 2.

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Power Reactor Event Number: 49342
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DOUG LAMARCA
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2013
Notification Time: 05:15 [ET]
Event Date: 09/14/2013
Event Time: 03:30 [EDT]
Last Update Date: 09/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 14 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO FEEDWATER TRANSIENT DURING SHUTDOWN

"At approximately 0330 hours on September 14, 2013, Susquehanna Steam Electric Station Unit 2 reactor was manually scrammed while transitioning the 'A' reactor feed pump from flow control mode to discharge pressure mode. Reactor water level rose to +54 inches causing a trip of reactor feedpumps. Subsequently the mode switch was taken to shutdown to manually scram the Unit 2 reactor.

"All control rods inserted. Reactor water level lowered to approximately +18 inches. There were no automatic emergency core cooling system initiations. No steam relief valves opened during the event. No containment isolations occurred. All safety systems operated as expected. RCIC system was manually initiated for level control until a reactor feedpump was recovered, then RCIC was manually shutdown. The cause of the feedwater flow transient and trip of the reactor feedwater pumps is under investigation.

"This report is being made per 10CFR50.72(b)(2)(iv)(B) for a 4 hour report, and 10CFR50.72(b)(3)(iv)(A) for an 8 hour report.

Decay heat is being removed via the turbine bypass valve to the condenser. Offsite power remains stable, and there was no impact on Unit 1.

The licensee has notified the NRC Resident Inspector. The Pennsylvania Emergency Management Agency will be notified, and the licensee will be making a press release.

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Power Reactor Event Number: 49343
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES LEDBETTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2013
Notification Time: 05:47 [ET]
Event Date: 09/14/2013
Event Time: 02:00 [CDT]
Last Update Date: 09/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CHRISTINE LIPA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

LIQUID PENETRATION EXAMINATION RESULTS IN INDICATION ON REACTOR VESSEL HEAD PENETRATION

"On September 14, 2013, during the A1R17 Braidwood Station Unit 1 refueling outage, an inservice Liquid Penetration examination was performed on the previously repaired Penetration 69. This repair was performed during A1R16. The PT [Penetrant Testing] examination revealed 22 recordable indication and 5 non-relevant indications. Rounded indications that exceed 3/16" are rejectable. All 22 indications are rounded and 13 of these indications exceed the 3/16" criteria.

"This is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A) since the as found indication did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-1 to remain in-service without repair.

"NRC Resident Inspector has been informed."

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Power Reactor Event Number: 49344
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/15/2013
Notification Time: 11:52 [ET]
Event Date: 09/15/2013
Event Time: 11:23 [EDT]
Last Update Date: 09/15/2013
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
WILLIAM DEAN (RA)
DAN DORMAN (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R N 0 Hot Shutdown 0 Hot Shutdown

Event Text

UNUSUAL EVENT DECLARED AT SUSQUEHANNA UNIT 2 DUE TO FLOODING IN A RHR PUMP ROOM

"At 1123 EDT, [on 9/15/13], Susquehanna Unit 2 received a Division 2 RHR [Residual Heat Removal] room Flooded alarm. Plant operators reported 3 inches of water in the room with water coming from the 2B RHR pump suction relief valve. The Suppression Pool Isolation valve was closed to isolate the leaking relief valve from the Suppression Pool. This action stopped Suppression Pool level from lowering. The Leak is isolated at this time. Further water is being added to the room as the system piping is being drained. The cause of the relief valve lifting is unknown at this time and is under investigation. At the time of the event, Division 2 RHR system had been declared inoperable for unrelated equipment issues."

At 1222 EDT, the licensee confirmed that leakage from the 2B RHR pump suction relief valve had stopped. Susquehanna Unit 2 remains stable and there was no impact on Susquehanna Unit 1.

The licensee notified the NRC Resident Inspector, State, and Local authorities.

Notified DHS SWO, FEMA, DHS NICC, and Nuclear SSA (email only).

* * * UPDATE FROM MARTIN LICHTNER TO JOHN SHOEMAKER AT 1641 EDT ON 9/15/13 * * *

"U2 SSES [Susquehanna Steam Electric Station] has exited the Unusual Event for Division 2 RHR room flooded as of 1552 EDT. The leak has been isolated, water removed from the room and Division 1 RHR is operating in shutdown cooling proceeding to Mode 4 (Cold Shutdown)."

"A press release for this event was authorized at 1613 and issued at 1628 [on 9/15/13]."

The licensee has notified the NRC Resident Inspector.

Notified R1DO (Cahill), NRR (Dorman), IRD (Gott), DHS SWO, FEMA, DHS NICC, and Nuclear SSA (email only).

Page Last Reviewed/Updated Monday, September 16, 2013
Monday, September 16, 2013