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Event Notification Report for August 7, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/06/2014 - 08/07/2014

** EVENT NUMBERS **


50317 50318 50319 50321 50322 50323 50325 50346 50347

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Agreement State Event Number: 50317
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS LP
Region: 4
City: PASADENA State: TX
County:
License #: 04322
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/29/2014
Notification Time: 08:16 [ET]
Event Date: 07/26/2014
Event Time: [CDT]
Last Update Date: 07/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following information was obtained from the state of Texas via email:

"On July 28, 2014, the Agency [Texas Department of State Health Services] received notice that a radiography source retraction failure had occurred at a temporary field site [Houston] on July 26, 2014. The guide tube had separated at the crimp between the flexible portion and the fitting to the camera. The flexible portion had pushed out when the source was cranked out. The source was retrieved by manually pulling the drive cable back through the camera. The guide tube was removed from service and replaced. The camera was a Sentinel 880 Delta with about 40 curies of selenium-75. No overexposures resulted from this event. An investigation into this event is ongoing. Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident #: I-9215

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Agreement State Event Number: 50318
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: ALLWEST TESTING AND ENGINEERING
Region: 4
City: SPOKANE VALLEY State: WA
County:
License #: I0557
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/29/2014
Notification Time: 11:59 [ET]
Event Date: 06/25/2014
Event Time: [PDT]
Last Update Date: 07/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

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

"On June 25, 2014 at 1600 PDT, a CPN portable gauge (model MC1-DR, SN: MD00405577) containing 50 mCi of Am-241/Be and 10 mCi of Cs-137 was damaged by a front end loader. An AllWest employee was [performing] an in-place moisture/density test in a parking lot at the URM warehouse project in Spokane, Washington. A front end loader was brought into the same parking lot to work on another part of the project. The AllWest employee walked 20 feet away from the gauge to direct the loader operator. The loader made a hard right turn while backing up to do a line up for a proof roll. The AllWest employee realized the loader was traveling in the direction of the portable gauge. The AllWest employee tried to get the loader operators attention by yelling and waving his hands. The operator noticed and stopped the loader just as the tire bumped the portable gauge. The employee looked at the gauge and did not notice any obvious damage until the loader was moved away. The AllWest employee noticed the gauge guide tube was slightly bent. The employee was able to retract the source rod (which was at 2 inch depth at the time of the accident) and verified the slide plate was in the safe position. The loader was checked for contamination and none was found. The AllWest employee notified the office manager at the time of the accident and was told to return to the office since there was no major damage to the gauge. The office manager contacted the company RSO to report the incident and to report that a leak test would be performed before the gauge would be sent to CPN/Instrotek for repairs. The leak test showed no sign of leaking sources. The gauge was sent to CPN/Instrotek on July 1, 2014 and on July 14, 2014, AllWest was notified that the source rod was also slightly bent and could not be repaired and needed to be disposed of."

Incident Number: WA-14-030

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Agreement State Event Number: 50319
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ENERGY SOLUTIONS
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73016-A15
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/29/2014
Notification Time: 15:53 [ET]
Event Date: 07/29/2014
Event Time: 09:00 [EDT]
Last Update Date: 07/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL PACKAGE ON CONTACT RADIATION READING ABOVE LIMIT

The following information was provided by the State of Tennessee via email:

"[State of Tennessee Division of Radiological Health] was notified on 7/29/2014 by the Radiation Safety Officer of Energy Solutions [Oakridge, TN] that a package (55 gallon drum) [on flat bed truck] was delivered above the 200 millirem an hour non-exclusive use limit. This drum was surveyed with an ion chamber and it was determined to be 300 millirem an hour. Tennessee Division of Radiological Health inspector also surveyed this drum and found it to be 300 millirem an hour on contact."

TN Event ID Number: TN-14-147

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Agreement State Event Number: 50321
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: COVENANT HEALTH SYSTEM
Region: 4
City: LUBBOCK State: TX
County:
License #: 06028
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/30/2014
Notification Time: 10:48 [ET]
Event Date: 07/28/2014
Event Time: [CDT]
Last Update Date: 07/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PAMELA HENDERSON (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DUE TO TREATMENT GIVEN TO WRONG PATIENT

The following information was obtained from the state of Texas via email:

"On July 30, 2014, the Agency was notified by the licensee that a patient had received a portion of a treatment intended for a different patient. The licensee's Risk Compliance Officer (RCO) stated two patients had arrived for treatment. Both patients were female of similar size. Both were to receive treatment to the brain, one patient to the right side and the other to the left side. The treatment head frame had been placed on both patients. It was decided that patient two would be treated first. This information was not provided to the individual entering the program into the treatment system so the program for patient one was entered into the treatment system. Patient two was placed on the treatment table and the treatment started. About two minutes into the treatment, a physician reviewing the treatment realized the wrong plan for the patient was being used and halted the treatment.

"The licensee determined the patient received 3.7 gray to 0.5 cc of brain tissue during the treatment. The patient and the patient's physician were notified of the error. The RCO stated the patient's doctor evaluated the event and stated the patient should not experience any adverse effects from the exposure. The patient was later treated using the correct treatment plan.

"The licensee has implemented several corrective actions as a result of the event. They include adding a second time out prior to treatment and requiring multiple staff to identify.

"The device was a Leksell Gamma System Model 24001 containing about 1800 curies of cobalt-60.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9217

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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Non-Agreement State Event Number: 50322
Rep Org: BLEVINS ASPHALT CONSTRUCTION CO.
Licensee: BLEVINS ASPHALT CONSTRUCTION CO., INC.
Region: 3
City: MT VERNON State: MO
County:
License #: 24-32645-01
Agreement: N
Docket:
NRC Notified By: DAVID SNYDER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/30/2014
Notification Time: 11:50 [ET]
Event Date: 07/30/2014
Event Time: 08:30 [CDT]
Last Update Date: 07/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

DAMAGED MOISTURE/DENSITY GAUGE

With the moisture/density gauge still on the ground after performing a standard count, the licensee Radiation Safety Officer backed over the gauge with his pickup truck. The source was not exposed at the time and the source remained shielded. Damage noted to the gauge was a broken shaft that sets the depth of test which is also part of the handle along with some surface scarring to the gauge housing. The gauge was checked with a survey meter for leakage from the sources. At one meter the survey meter reading was less than 0.2 mrem/hr which is comparable to a non-damaged gauge. A leak test wipe was also performed and sent to Humboldt Mfg. for measurement. The gauge was transported and placed in its secure storage location until a determination has been made on how repairs will be accomplished.

The gauge is a Humboldt Model 5001 moisture/density gauge containing 10 mCi Cs-137 and 40 mCi Am-241/Be.

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Agreement State Event Number: 50323
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: KENNETH E TAND AND ASSOCIATES
Region: 4
City: HOUSTON State: TX
County:
License #: 05137
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 07/30/2014
Notification Time: 12:06 [ET]
Event Date: 07/29/2014
Event Time: [CDT]
Last Update Date: 07/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

The following information was received from the State of Texas by facsimile:

"On July 29, 2014, the Agency [Texas Department of State Health Services] was notified by the licensee that a Humboldt Scientific Inc. model 5001 moisture density gauge containing a 10 millicurie Cesium-137 and a 40 millicurie Americium-241 source was damaged at a field site. The technician had placed the device at a sample location and extended the cesium source into the inspection hole. The area had been compacted and the technician did not believe there was any heavy equipment in the area he was working. While waiting for the results of the sample, the technician received an email. The technician needed his glasses to read the email so he walked 70 feet to his truck to get his glasses. While at the truck, the device was run over by a soil compactor (steam roller). The technician went to the gauge and restricted access to the area. He then contacted his Radiation Safety Officer (RSO). The licensee's RSO contacted a service provider (SP) who responded with the RSO to the scene. The device case was severely damaged, but the licensee was able to return the Cesium source to the shielded position and secure it in position. The SP's technician verified the Americium source was still in the device. The SP's technician surveyed the device and did not find any abnormal dose rates. The SP took the damaged device to their facility for disposal. No individual received any significant additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident: I-9216

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Agreement State Event Number: 50325
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ECS MID-ATLANTIC LLC
Region: 1
City: CHANTILLY State: VA
County:
License #: 107-314-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/30/2014
Notification Time: 13:07 [ET]
Event Date: 07/29/2014
Event Time: [EDT]
Last Update Date: 07/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

The following was received via facsimile:

"The licensee reported on July 29, 2014, that a portable density gauge had been damaged by a compaction roller at a temporary job site in Loudoun County, Virginia. The gauge was a CPN Model MC with a 10 millicurie Cesium-137 source and a 50 millicurie Americium-241 source. Investigation by the licensee's radiation safety officer indicated there was no damage to the gauge casing and that the sources were in their shields when the accident occurred. The control rod for the Cesium source was slightly bent as a result of the accident, but both sources remained in their shielded positions. The gauge was returned to the licensee's office and a leak test wipe was sent for analysis. The licensee plans to transport the gauge to an authorized repair facility after the leak test results are received. A written report is required within 30 days."

Virginia Event Report ID Number: VA-2014-05

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Power Reactor Event Number: 50346
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JASON ADAMS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/05/2014
Notification Time: 22:20 [ET]
Event Date: 08/05/2014
Event Time: 17:34 [CDT]
Last Update Date: 08/06/2014
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):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM

"This notification is being provided pursuant with SAF 1.6 10CFR50.72(b)(2)(iv)(B) and SAF 1.7 10CFR50.72(b)(3)(iv)(A).

"At 1734 CDT on August 5, 2014, LaSalle Unit 2 automatically scrammed due to an RPS actuation. The MSIVs isolated on a Group 1 signal, the cause is under investigation. The reactor water cleanup system isolated during the transient. The plant is stable with Reactor Pressure Control being maintained by the Reactor Core Isolation Cooling System and SRVs and level being controlled by the Low Pressure Core Spray System. The plant is planned to remain in hot shutdown pending investigation of the trip."

The Unit 2 electric plant is in a normal shutdown lineup. All control rods inserted fully on the scram. Unit 1 was not affected by the Unit 2 transient.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY MICHAEL FITZPATRICK TO JEFF ROTTON AT 1650 EDT ON 8/6/2014 * * *

The initial notification to the NRC stated that the reactor water cleanup system had isolated during the transient. The actual status is being corrected to state that the reactor water cleanup pump tripped during the transient.

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Stone).

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Power Reactor Event Number: 50347
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROB DORMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/06/2014
Notification Time: 05:36 [ET]
Event Date: 08/06/2014
Event Time: 05:16 [EDT]
Last Update Date: 08/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (R2DO)

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

Event Text

TSC HVAC AND FILTRATION REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"This is a non-emergency notification per Vogtle U1 & U2 Technical Requirements Manual (TRM) 13.13.1, Emergency Response Facilities, Action 8.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance activities on the TSC support systems. Alternate facilities are available to provide emergency response functions, and, actions are proceeding to return the TSC to functional status with high priority. A 10 CFR 50.54(q) evaluation has been prepared and approved for this planned maintenance activity. The NRC Resident Inspector has been notified."


* * * UPDATE FROM RUDY JOHNSON TO DONALD NORWOOD AT 1132 EDT ON 8/6/14 * * *

As of 1124 EDT maintenance has been completed and the TSC has been returned to service.

The NRC Resident Inspector has been notified.

Notified R2DO (Nease).

Page Last Reviewed/Updated Thursday, August 07, 2014
Thursday, August 07, 2014