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Event Notification Report for July 15, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/14/2015 - 07/15/2015

** EVENT NUMBERS **


51200 51203 51204 51228 51231 51232

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Agreement State Event Number: 51200
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE BROAD SCOPE MEDICAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/06/2015
Notification Time: 15:52 [ET]
Event Date: 06/14/2013
Event Time: [CDT]
Last Update Date: 07/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY TONGUE LOW DOSE RATE IMPLANT RESULTED IN OVERDOSE TO SKIN

The following report was received from the Kentucky Department of Health via facsimile:

"Brachytherapy LDR [low dose rate] tongue implant was loaded with thirty 1.12 mCi lr-192 sources on 6/13/13 by attending radiation oncologist. On 6/14/13 at [0730] [CDT] another physician rounded on the patient and all catheters and sources were in the proper position. At [1000] nursing on 6 East changed bedding of patient. At [1230] attending radiation oncologist rounded on patient and discovered one of the strands of sources (5 sources total) was no longer in the catheter. Physician removed nursing personnel and himself from the room and notified Physics. A Geiger counter was used to survey the room and a hot area was found in the linen basket. The linens were surveyed individually and the source was found. At [1245] the sources were reinserted into the proper catheter. Dosimetry was done to compare the plans and the deviation was well below the 20% reportable levels and almost indiscernible on the DVH [Dose Volume Histogram].

"During an inspection of the medical broad scope license, RHB [Kentucky Radiation Health Branch] reviewed the above procedure and inquired as to the dose potentially received by healthy tissues, namely the skin, assuming worst the case scenario. Specifically, the lr-192 strand displaced from the catheter actually lay against the patient's skin in one location for the whole 2 hours and 15 minutes between the time the physician last saw the strand in place and the time the patient's bed linen were changed. Based on this unrecognized worst case scenario, the RSO performed a dose calculation to the patient's skin and determined the patient may have potentially received a dose of 51.75 rem to the skin at a location which was not anticipated to receive any appreciable dose had the strands remained in place. A dose of 51.75 rem exceeds the limit requiring the report and notification of the Medical Event. A dose to the skin or an organ or tissue other than the treatment site that exceeds by five-tenths (0.5) Sv (fifty (50) rem) to an organ or tissue and fifty (50) percent or more of the dose expected from the administration defined in the written directive. The RSO at U of L [University of Louisville] e-mailed RHB a copy of the Medical Event report on July 6, 2015 at [1446]. Upon receipt of an email to the Radiation office the required 24 hour notification is made to the NRC Headquarters Operations Officer.

"The physician was notified of this potential medical event at the time of the inspection. The patient had follow up visits during and after the course of 6/14/13 treatment and was not found to be necessary to notify them of this potential event since no effects to the patient were noted."

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: 51203
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ZILKHA BIOMASS CROCKETT
Region: 4
City: CROCKETT State: TX
County:
License #: 06381
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 07/07/2015
Notification Time: 16:20 [ET]
Event Date: 07/06/2015
Event Time: [CDT]
Last Update Date: 07/07/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On July 7, 2015, the Agency [Texas Department of State Health Services-Radiation Branch] was notified by the licensee's radiation safety officer (RSO) that the shutter on a Ronan GS-400 level gauge containing a 50 millicurie cesium - 137 source was stuck in the open position. The stuck shutter was discovered during the start up of a system component. Open is the normal position for the shutter. The gauge does not possess an exposure risk to any individuals. The manufacturer has been contacted and will replace the gauge. Additional information on this event will be provided as it is received in accordance with SA-300."

Texas Incident: I-9324

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Agreement State Event Number: 51204
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: MISSISSIPPI DEPARTMENT OF TRANSPORTATION
Region: 4
City: JACKSON State: MS
County:
License #: MS-261-01
Agreement: Y
Docket:
NRC Notified By: JEFF ALGEE
HQ OPS Officer: VINCE KLCO
Notification Date: 07/07/2015
Notification Time: 17:01 [ET]
Event Date: 07/03/2015
Event Time: 16:30 [CDT]
Last Update Date: 07/07/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the State of Mississippi by email:

"Location of Incident: Brandon, Mississippi, I-20 exit ramp 56 construction.

"Description of Incident: July 3, 2015 at approximately [1630 CDT], a Humboldt Model 5001 portable nuclear moisture density gauge, Serial Number 3339, was run over by a heavy equipment truck while on a jobsite. The gauge was severely damaged, but the sources remained intact and in shielded position. DRH [Mississippi Division of Radiological Health] was notified and provided with a survey measurement of 8mR/hr at the surface of the damaged gauge. The RSO was able to safely load the fragmented gauge back into its approved transport case and return it to the MDOT [Mississippi Department of Transportation] storage facility. DRH personnel visited the MDOT storage facility and observed an 8mR/hr surface survey reading with an NDS ND-2000 survey meter, serial number 24562, calibration date 7-1-2015. Leak test wipes were taken from both sources and sent for analysis by the licensee. The measured activity was well below the regulatory upper limit of .005 microcuries. Wipe analysis was received 7-7-2015. Gauge is being returned to the manufacturer for disposal."

Radioisotopes: Cs-137(11 mCi); Am-241/Be(44 mCi). Radiation measurements taken by the Mississippi Division of Radiological Health: 8 mR/hr at surface; Less than 1 mR/hr at 1 meter.

Mississippi Event: MS-15001

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Power Reactor Event Number: 51228
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: ZACKARY DUNHAM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/14/2015
Notification Time: 05:37 [ET]
Event Date: 07/13/2015
Event Time: 23:39 [PDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 64 Power Operation 64 Power Operation

Event Text

SECONDARY CONTAINMENT PRESSURE INCREASE ABOVE TECHNICAL SPECIFICATION LIMIT

"Reactor Building (Secondary Containment) pressure increased to above the Technical Specification Surveillance requirement of 0.25 inches vacuum water gauge for approximately 2 minutes during a planned surveillance test due to a subsequent failure of REA-FN-1A [Exhaust Fan] to manually start during restoration from the surveillance test. This event is reportable as an event that could have prevented fulfillment of a safety function needed to control the release of radiation and mitigate the consequences of an accident.

"Prior to taking test data the surveillance test directs declaring Secondary Containment inoperable in anticipation of potentially exceeding 0.25 inches vacuum water gauge reactor building pressure during the conduct of the surveillance. Consequently Technical Specification LCO 3.6.4.1.A was entered with a 4 hour completion time to restore Secondary Containment to an operable state.

"Upon failure of REA-FN-1A to start immediate actions were taken to close reactor building ventilation dampers and secure ROA-FN-1A [Supply Fan]. Following closure of ventilation dampers and stopping ROA-FN-1A reactor building pressure was quickly restored to less than 0.25 inches vacuum water gauge with Standby Gas Treatment that was already in operation as part of the surveillance test.

"There were no radiological releases associated with the event.

"No safety system actuations or isolations occurred.

"The licensee notified the NRC Resident Inspector."

Maximum Secondary Containment pressure noted was 0.1 inches positive water gage.

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Power Reactor Event Number: 51231
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MICHAEL BROOKS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/14/2015
Notification Time: 22:59 [ET]
Event Date: 07/14/2015
Event Time: 17:15 [CDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
GERALD MCCOY (R2DO)
SCOTT MORRIS (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 99 Power Operation
2 N Y 100 Power Operation 99 Power Operation
3 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"At 1810 (Central Daylight Time) on July 14, 2015, Browns Ferry Units 1, 2, and 3 initiated actions to commence a reactor shutdown to comply with TS [Technical Specifications] LCO 3.0.3. TS LCO 3.0.3 was entered at 1715 (Central Daylight Time) due to concurrent losses of the A and B Control Bay Chillers. This resulted in a loss of cooling to the U1 and U2 4kV Shutdown Board Rooms. Required actions for the loss of cooling to the U1 and U2 4kV Shutdown Board Rooms are to declare the electrical equipment in the 4kV Shutdown Board Rooms inoperable. The declaration of inoperability of the equipment supported by the U1 and U2 4kV Shutdown Boards resulted in TS LCO 3.0.3 for Units 1, 2, and 3. TS LCO 3.0.3 requires actions to be initiated within one hour to place the affected units in MODE 2 within 10 hours; MODE 3 within 13 hours; and MODE 4 within 37 hours.

"This event requires a 4-hour report in accordance with 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'

"The NRC Resident Inspector has been notified.

"Condition Report #1056829 has been initiated in the Corrective Action Program."

The 4kV shutdown electrical boards are required in all modes of operation.

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Power Reactor Event Number: 51232
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: PATRICK HAARHOSS
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2015
Notification Time: 01:04 [ET]
Event Date: 07/15/2015
Event Time: 00:04 [CDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3DO)

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

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"At 0004 [CST] on Wednesday, July 15, 2015, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system will be removed from service for planned maintenance activities. During the maintenance, the TSC Ventilation will be shut down. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed in approximately 24 hours.

"Contingency plans are in place so that if an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning (EP) procedures and checklists. If radiological or environmental conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will relocate the TSC staff in accordance with station procedures."

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, July 15, 2015
Wednesday, July 15, 2015