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Event Notification Report for March 2, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/27/2015 - 03/02/2015

** EVENT NUMBERS **


50627 50832 50833 50834 50837 50838 50852 50853 50854 50855

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Power Reactor Event Number: 50627
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PATRICK HARTIG
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/19/2014
Notification Time: 09:57 [ET]
Event Date: 11/19/2014
Event Time: 09:43 [EST]
Last Update Date: 02/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (R1DO)

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

Event Text

EAL REQUIRED GASEOUS WASTE EFFLUENT RADIATION MONITORS REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"The Beaver Valley Power Station (BVPS) Unit 1 Special Particulate, Iodine and Noble Gas (SPING 4) monitors were removed from service for a planned equipment upgrade/replacement. During the replacement process certain Emergency Action Level (EAL) required monitors will not be functional, therefore, alternate methods of monitoring have been placed in effect. The replacement activities are expected to take approximately 60 days. A follow-up notification will be made after the required monitors are returned to service and declared functional.

"This is an 8 hour notification per 10 CFR 50.72(b)(3)(xiii). No BVPS Unit 2 systems will be adversely affected by the Unit 1 replacement activity.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM PATRICK HARTIG TO CHARLES TEAL AT 1728 EST ON 2/27/15 * * *

"The planned equipment upgrade was completed and the Beaver Valley Power Station (BVPS) Unit 1 Particulate, Iodine and Noble Gas (PING) monitors were returned to service and declared functional at 1714 EST on 2/27/2015.

"The NRC Resident Inspector has been notified."

Notified R1DO (Gray).

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Agreement State Event Number: 50832
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: TUFTS MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 68-0263
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/19/2015
Notification Time: 10:15 [ET]
Event Date: 02/10/2012
Event Time: [EST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following report was received via e-mail:

"During a routine inspection, an Agency [Massachusetts Radiation Control Program] inspector identified a past possible gamma stereotactic radiosurgery (GSR also known as gamma knife) medical event that occurred on February 10, 2012 and had not been reported by the licensee.

"The licensee's written directive was incomplete. Page three of the written directive that described plug placement in the helmet used for treatment was not printed. As a result of the missing information, sixteen gamma knife plugs were not placed in position as intended and instead collimators were placed, the same size collimators used for the remaining plug pattern. Consequently, the patient received an 8.8% overdose to the treatment site. Based on the initial exposure determination to the treatment site by the licensee, the licensee concluded this was not a reportable medical event.

"However, the dose to tissue other than the treatment site exceeded 0.5 Sv (50 rem) and 50% of the dose expected from the administration defined in the written directive. This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(c).

"The dose to tissue other than the treatment site, tissue located beneath the skin and each of the sixteen collimators was calculated to be 71 rem, and greater than 50% of the dose expected from the administration. The dose expected to the tissue, tissue beneath the skin other than the treatment site from the administration defined in the written directive was expected to be less than 710 mrem.

"The gamma knife, a Leksell Gamma System model 24001 Type C device contained 201 Elekta model 43685 sealed sources totaling approximately 2,519 total curies of cobalt-60 on the date of the event, February 10, 2012.

"The licensee reported that the authorized user determined that the plug omission error would have no significant detrimental effect on the outcome of the treatment or patient condition and that no further action was necessary in the care of the patient. The licensee reported that that the authorized user reported the event in detail to the patient and provided a written description to the referring physician.

"The Agency issued notice of violations to the licensee and the licensee described its corrective actions in its response to the notice of violations.

"Corrective action: The licensee reported that following the omission of the plugs, the Radiation Oncologist Authorized User would designate on page 1 of the written directive if plugs were used and that this would alert the treatment team to identify and implement the appropriate plug pattern; that the licensee replaced the model 24001 Type C gamma knife with a model Perfexion gamma knife that does not use plugs; and that written directive printouts now contain both the individual page number and the total number of pages in the written directive."

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: 50833
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: NORTH LITTLE ROCK State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2015
Notification Time: 15:40 [ET]
Event Date: 12/29/2014
Event Time: [CST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - UNDERDOSE

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Medical Center, Durham, North Carolina.

"On December 29, 2014, a dosage of 1.569 millicuries of I-131 sodium iodide was administered to a patient for a diagnostic whole body scan, and the prescribed dosage on the written directive was 2 millicuries.

"The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage by more than 20 percent and the absorbed dose is estimated to differ from that dose that would have resulted from the prescribed dose by more than 50 rem to remnant thyroid tissue.

"The medical event was discovered today (February 19, 2015) during a routine audit by the facility Radiation Safety Officer. The facility has notified the referring physician and the patient of the medical event. No biological harm to the patient is expected from this under-dosing event.

"The NHPP [National Health Physics Program] plans to perform a reactive inspection regarding the medical event within the next 10 working days. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone.

"Additional information: The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 32-01134-01. National Health Physics Program makes required notifications to NRC."


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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Agreement State Event Number: 50834
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EQUISTAR CHEMICAL
Region: 4
City: DEER PARK State: TX
County:
License #: L00204
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/19/2015
Notification Time: 17:35 [ET]
Event Date: 02/19/2015
Event Time: [CST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO CLOSE SHUTTER ON NUCLEAR GAUGE

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

"On February 19, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that during routine gauge testing, they were unable to close the shutter on a nuclear gauge. The gauge is an Ohmart model SHLG-2 containing 8,000 millicuries of cesium-137. The RSO stated the gauge is used for level indication on a vessel and open is the normal operating position for the gauge. The RSO stated the gauge does not present an increased exposure risk to their employees or members of the general public. The RSO stated they had lubricated the gauge operating mechanism in an attempt to free up the shutter, but the shutter remained stuck. The RSO stated they intend to contact the manufacturer for repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I 9280

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Agreement State Event Number: 50837
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: GLOBE X-RAY SERVICES
Region: 4
City: TULSA State: OK
County:
License #: OK-15194-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: VINCE KLCO
Notification Date: 02/20/2015
Notification Time: 11:30 [ET]
Event Date: 01/31/2015
Event Time: [CST]
Last Update Date: 02/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - POTENTIAL RADIOGRAPHER OVER-EXPOSURE

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

"[The Oklahoma Department of Environmental Quality has] been notified by Globe X-Ray Services (OK-15194-02) that one of their assistant radiographers received a reported dose of 5.083 R for the month of January, 2015. The assistant has been suspended and stated that he dropped his badge at some point during the monitoring period but did not report it until now. Landauer reported that the reading was 'inconclusive'. Investigation is ongoing."

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Agreement State Event Number: 50838
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: LA PORTE State: TX
County:
License #: L01774
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 02/20/2015
Notification Time: 13:14 [ET]
Event Date: 02/19/2015
Event Time: 16:30 [CST]
Last Update Date: 02/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT CAMERA SOURCE

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

"On February 20, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee that on February 19, 2015, one of its radiography crews working at a remote field site [near Kennedy, Texas] was unable to retract a 31.9 Curie Iridium 192 source into a QSA 880D exposure device. The radiographers were examining a pipe on a pipe pad with the collimator being held in place with a magnetic stand. As the radiographer began to retract the source after a shot, the stand fell and struck the source guide tube crimping the tube to a point where the source could not be moved. The radiographers stopped work in the area and moved their boundaries to prevent exposures to members of the general public. The radiographers contacted their radiation safety officer (RSO), but he was located 8 hours from the work site. The RSO contacted the licensee's office in Corpus Christi, Texas and the RSO from that location responded to the event. The Corpus Christi RSO is [at the location] to perform source retrieval. The event occurred at 1630 [CST] and the source was retracted at 2400 [CST]. No over exposures occurred and no member of the general public received any additional exposure from this event. The guide tube has been removed from service for inspection. The dosimetry badges for the individuals involved in the event have been sent to the licensee's processor for reading. The licensee is investigating the event. Additional information will be provided as it is received in accordance with SA-300.

"On February 20, 2015, the licensee agreed to send the source involved in this event to the manufacturer for inspection."

Texas Incident: I-9281

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Power Reactor Event Number: 50852
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MICHAEL BROGAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/27/2015
Notification Time: 16:10 [ET]
Event Date: 02/27/2015
Event Time: 15:18 [EST]
Last Update Date: 02/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 87 Power Operation 87 Power Operation

Event Text

SHIPMENT OF CONTROL ROD MECHANISMS EXCEEDED EXTERNAL RADIATION LIMITS

"At 1518 EST on Feb 27, 2015, the Perry Shift Manager received notice from the Radiation Protection group that an Exclusive Use closed transport vehicle arrived on site exceeding the 10 CFR 71.47 radiation levels on contact with a box on the vehicle. The truck that arrived had two boxes containing four rebuilt control rod drive mechanisms to be used during the Perry refueling outage. One of the boxes had a contact dose reading of 1290 MR/HR. This is above the 1000 MR/HR limit as noted in 10 CFR 71.47. No other limits were exceeded on the exterior of the vehicle. Specifically, the cab of the truck was reading 0.1 MR/HR which is less than the 2 MR/HR limit. Also at 2 meters around the truck, the highest level reading was 1.2 MR/HR which is below the 10 MR/HR [limit]. Also on direct contact with the outside of the vehicle, the highest reading was 30 MR/HR, which is below the 200 MR/HR limit.

"The Site Radiation Protection Shipping Coordinator contacted the shipping organization of this finding at Perry. This was the Director of Operations of Energy Solutions in Memphis, Tennessee. The box was taken into the Perry Fuel Handling Building and is posted per the Perry Radiation Control Program. The vehicle is parked outside the Fuel Handling Building and is being controlled."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 50853
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM NAKAMINE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/27/2015
Notification Time: 17:04 [ET]
Event Date: 02/27/2015
Event Time: 13:05 [EST]
Last Update Date: 02/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (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

EMERGENCY NOTIFICATION SYSTEM AND HEALTH PHYSICS NETWORK TELEPHONE LINES OUT OF SERVICE

"On February 27, 2015, from 1305 to 1323 [EST], a loss of the ENS [Emergency Notification System] communication line, the HPN [Health Physics Network] line, and the other communication systems that the MCR [Main Control Room] operators use as part of the emergency plan occurred at TVA Sequoyah Units 1 and 2. A loss of these systems was experienced when transferring from a backup generator to an uninterruptible power supply (UPS) during fueling of the backup generator. Earlier in the day the normal power supply to the two (2) plant communications buildings was deenergized due to an unrelated electrical issue and backup diesel generators were supplying power to the buildings. While refueling one of the backup generators, the power supply was transferred to the UPS for personal safety reasons, however, the load on the UPS was greater than its capacity and its output [breaker] tripped.

"This loss of communications was corrected in approximately 18 minutes once the fuel tank was filled and the generator was started. Phone line capability has been restored and verified to be functional. Sequoyah is currently investigating why the load was greater than the UPS capacity. The radiological emergency plan (REP) was reviewed and other acceptable methods for communications were available. There were no personnel injuries as a result of this event and no impact on plant operations. Both units remain at 100% power. The NRC Resident Inspector has been notified.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of communications capability which includes events that would significantly impair the ability of the licensee to implement the functions of its emergency plans if an emergency were to occur."

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Power Reactor Event Number: 50854
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: RANDY KOUBA
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/28/2015
Notification Time: 01:20 [ET]
Event Date: 02/27/2015
Event Time: 17:56 [CST]
Last Update Date: 02/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GREG PICK (R4DO)

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

Event Text

UNANALYZED CONDITION CONCERNING CONTROL ROOM HABITABILITY ANALYSIS

"Cooper Nuclear Station became aware of the installation of two 12,000 gallon anhydrous ammonia tanks approximately 1.5 miles from the site. This amount of anhydrous ammonia at that distance exceeds the control room habitability hazardous chemical analysis previously evaluated for the nuclear station. The control room staff has been informed of the condition and have reviewed the appropriate abnormal procedures for actions to take in the case of a leak. This potentially represents an unanalyzed condition that significantly degrades plant safety and is reportable under 10 CFR 50.72(b)(3)(ii)(B)."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 50855
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DANIEL BOWERS
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2015
Notification Time: 05:24 [ET]
Event Date: 02/28/2015
Event Time: 00:00 [CST]
Last Update Date: 02/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GREG PICK (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 25 Power Operation 0 Hot Standby

Event Text

AUTOMATIC AUXILIARY FEEDWATER ACTUATION DUE TO PLANNED REACTOR TRIP

"Wolf Creek Generating Station performed a planned shutdown for the start of a refueling outage. As part of the procedure GEN 00-005, Minimum Load to Hot Standby, a planned manual reactor trip was initiated from 25 percent power level with the plant in Mode 1. As part of this planned shut down sequence, an anticipated automatic Auxiliary Feedwater [AFW] actuation signal was generated. This is a non-emergency event notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) due to preplanned manual actuation of the reactor protection system and auto-initiation of auxiliary feed water system.

"All systems and components operated as designed with the exception of the main generator output breakers. They did not open as designed. They were manually opened using the main control room hand switches as directed by EMG ES-02, Reactor Trip Response.

"The plant is stable in Mode 3 with AFW secured, with plans to cool down and enter Mode 5 for the planned refueling outage.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, March 02, 2015
Monday, March 02, 2015