Event Notification Report for June 25, 2015

TWO REACTOR VESSEL LEVEL CHANNELS FAILED HIGH

"At 2200 PDT during startup from refueling outage 22, it was discovered that both level instruments used in reactor protection system (RPS) trip system 'A' for initiation of a reactor scram on low reactor pressure vessel (RPV) level were observed to have failed high. This resulted in the inability to generate a full reactor scram on low level (+13 inches). All remaining RPV level indications demonstrated that level was being maintained within normal operating bands. This constitutes a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to shut down the reactor.

"The RPS trip logic at Columbia consists of two trip systems, RPS trip system 'A' and RPS trip system 'B'. There are two level instrument channels in each trip system. Columbia utilizes a 'one-out-of-two taken-twice' trip logic to generate a full scram signal. At least one channel in both trip systems must actuate to generate a full scram signal. With both level instruments in RPS system 'A' failed high, the RPS trip logic was unable to generate a full scram.

"At 2246 [PDT] and in accordance with TS LCO 3.3.1.1 Condition C, a half scram was generated on RPS trip system 'A' to restore full scram capability. The cause of the failure of the two level instruments associated with RPS Trip system 'A' is under investigation."

The level channels are being calibrated prior to changing to mode 1 (power operations). The licensee will notify the NRC Resident Inspector.

SECONDARY CONTAINMENT PRESSURE INCREASE DUE TO VOLTAGE TRANSIENT

"At approximately 0301 [CDT] on 6/25/15, the Main Control Room received numerous annunciators that indicated a trip of the Emergency Reserve Auxiliary Transformer (ERAT) Static VAR Compensator (SVC) caused by a voltage transient on the 138 kV feed due to thunderstorms in the area. The Division 1 Safety Bus was manually aligned from the reserve source to its normal source. As a result of the voltage transient, the Division 1 Fuel Building Ventilation (VF) system isolation dampers closed causing a trip of VF supply and exhaust fans. With no running VF fans, secondary containment differential pressure rose to slightly greater than 0 inches water gauge and which exceeded the Technical Specification requirement of greater than 0.25 inches vacuum water gauge. The Control Room entered EOP-8, Secondary Containment Control. This event is being reported as a condition that could have prevented fulfillment of a safety function under 10 CFR 50.72(b)(3)(v)(C). Secondary Containment differential pressure was restored within Technical Specification requirements at 0319 [CDT] by reopening the VF isolation dampers and restarting the VF supply and exhaust fans. The ERAT SVC was returned to service at 0457 [CDT].

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOST RADIOGRAPHY CAMERA DURING TRANSIT

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

"Event date and time: On 06/25/2015 [at 0930 CDT, the licensee Radiation Safety Officer] called the Radiation Section of LDEQ [Louisiana Department of Environmental Quality] to report a lost/missing radiography camera. The camera was to be loaded on a rig truck and [to] be transported to a temporary site. The crew and site RSO had been looking for the camera since it was discovered missing at 0830 [CDT].

"A radiography exposure device was left on the bumper of a rig truck and not secured in the vault/overpack on the truck. The crew left the yard on Highway LA #30 and headed to I-10 and then East on I-10. About 5 miles down I-10, the crew remembered that they had not secured the camera in the rig truck. They stopped and found the camera missing. They backed tracked I-10 to LA # 30 and back to the office. They did not locate the missing camera. The LA State Police was notified in addition to LDEQ.

"The Radiation Section [of LDEQ] was notifying the staff and dispatching a Radiation [Environmental Scientist] individual to respond. The media put out an alert of the missing camera. Homeland Security, QSA Global, and the Ascension Parish Sheriff responded and were aiding in locating the lost camera. They were combing the area on ATVs and utilizing sensitive radiation detection instruments.

"At about 1130 [CDT] the LDEQ was given an update by [the licensee Radiation Safety Officer] which only includes responding agencies and the Site RSO for contact. About 1150 [CDT] the NRC Region IV was notified of the incident (Latisha Hanson) and given a preliminary notification and told the [NRC Operations Center] was being notified.

"Event Location: A rig truck was dispatched from TIS at 37568 Hwy # 30, Gonzales, LA down LA #30 to Interstate-10. The rig went east on I-10 for about 5 miles when the crew remembered that the camera had not been secured in the rig. The crew check the back of the rig and backed tracked the I-10 to LA #30 route. The camera was not located. Notifications were made.

"Event type: Loss of control over an exposure device. A QSA 880 Delta exposure device S/N 4586. The exposure device was loaded with about 30 Ci of Ir-192, QSA source Model # 84-9. The Category II, Quantity of Concern was released or lost into the general public. The radioactive exposure device was released into the general public by the two individuals not following the TIS's [Team Industrial Services] Radiation Safety Procedures or the IC [Increased Controls] Security Procedures. The exposure device was released to the general public unsupervised and not in direct control of an authorized company representative.

"Event description: The equipment was a QSA 880 Delta exposure device S/N D4586. The source was about 30 Ci of Ir-192, model # 84-9. At this time LDEQ consider this incident still open and updates will be given when available.

"Transport Vehicle: This was a TIS company crew truck being dispatched to a temporary jobsite.

"Media attention: News Media was alerted and reporting agencies were notified."

Louisiana Event: LA150010

Notified DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, FDA(email), Nuclear SSA (email) FEMA National Watch Center (email), DNDO-JAC (email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


* * * UPDATE ON 06/29/2015 AT 1356 EDT FROM JOE NOBLE TO STEVEN VITTO * * *

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

"The exposure device was recovered at about 7:00pm [CDT] on 06/25/2015.

"Device QSA/AEA Technologies, Model Delta 880, S/N 4586 Source QSA/AEA Technologies, Model A424-9, S/N 166306; 48.2 Ci Ir-192

"Recovered [approximately] 1.5 [Miles] on LA 61 east of US I-10 east. It was on the side of the road in a wet-muddy ditch area. [The device was found] by backtracking the trucks GPS device.

"A health and safety survey was conducted and the shielding appeared to be intact.

"The exposure device was loaded on to another Team Industrial vehicle, blocked and braced, and returned to the vault at the highway LA-30 address.

"The device and source were leak tested and analysis was performed on the test. A QSA Global representative stated it appears the device (DU) and the Ir-192 source were not leaking or compromised.

"With the exception of corrective actions and enforcement issues the department, LDEQ [Louisiana Department of Environmental Quality], considers this incident closed."

Notified R4DO(O'Keefe), IRD MOC(Grant), ILTAB (Wray), and NMSS Events Resource (via email).

Notified DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, FDA(via email), Nuclear SSA (via email) FEMA National Watch Center (via email), DNDO-JAC (via email).

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

"A prostate brachytherapy implant using I-125 performed at Fauquier Hospital on 6/25/2015, resulted in a dose distribution having a D90 percent of 97Gy as measured on post implant CT done on 8/12/15. The written directive prescribed a D90 percent of 145Gy. The implanted dose of 97 Gy is 66.9 percent of the intended 145 Gy. The patient was notified and is being monitored to determine if additional treatment is required.

"The final determination was not made until 10/8/15 and Fauquier notified VRMP [Virginia Radioactive Materials Program] by email on 10/8/15. A telephone conversation was held on 10/13/15 regarding the 15 day written report. VRMP will review the report and determine whether an inspection will be performed."

Virginia Report ID: VA-15-14

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.