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Event Notification Report for August 18, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/17/2015 - 08/18/2015

** EVENT NUMBERS **


51297 51299 51304 51305 51323 51324

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Power Reactor Event Number: 51297
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TRAVIS ROHLFING
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/06/2015
Notification Time: 20:53 [ET]
Event Date: 08/06/2015
Event Time: 17:39 [CDT]
Last Update Date: 08/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY AZUA (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

TECHNICAL SUPPORT CENTER NON-FUNCTIONAL

"Technical Support Center (TSC) Air Conditioning [AC] unit is out of service. Due to expected high temperatures in the upcoming days, there exists the potential for the TSC to become nonfunctional. This could result in a reduction in Emergency Plan Response Capability. The Alternate TSC is available for use in the event of an emergency and would be staffed and activated using existing EP (Emergency Preparedness) procedures and checklists."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM P.C. MOORE TO STEVEN VITTO ON 08/17/2015 AT 1010 [EDT] * * *

"As of 0700 [CDT], 8/17/15, the TSC is fully functional, the HVAC system has been restored to 100 percent capacity.

"NRC Resident Inspector has been notified."

R4DO (HAGAR) has been notified.

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Agreement State Event Number: 51299
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WELLSTAR KENNESTONE HOSPITAL
Region: 1
City: MARIETTA State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/07/2015
Notification Time: 15:58 [ET]
Event Date: 08/05/2015
Event Time: [EDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

GEORGIA AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO OVEREXPOSURE

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

"The [Georgia] Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015.

"Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by [greater than] 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015.

"The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy."

* * * UPDATE AT 0808 EDT ON 8/11/2015 FROM TRAVIS CARTOSKI TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"First fraction delivered was 300 cGy
Second faction delivered was 300 cGy
Third fraction delivered was 900 cGy, should have been 300 cGy
Total dosed received 1500 cGy

"On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU [Authorized User] that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy).

"On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec.

"The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015."

Notified the R1DO (Powell) and NMSS Events Resource (via e-mail).

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: 51304
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ELEMENT MATERIALS TECHNOLOGY HOUSTON INC
Region: 4
City: HOUSTON State: TX
County:
License #: L06451
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/10/2015
Notification Time: 14:51 [ET]
Event Date: 08/10/2015
Event Time: [CDT]
Last Update Date: 08/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT

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

"On August 10, 2015, the licensee's radiation safety officer [RSO] reported to our Agency [State of Texas Department of State Health Services] that a source was not able to retract into a radiography camera [at a temporary job site in Houston]. The RSO responded to the job site and checked the equipment. The RSO found the drive cable had broken. The RSO replaced the crank out control mechanism and retracted the source. The new crank mechanism was checked and the source was easily extended and retracted as normal. The camera was placed back into service. The RSO will be providing a detailed report on the cause of the break. Camera specifics were QSA model: Delta 880, serial number: D8509 with source serial 17604G, model A424-9, Ir-192 at 44 curies. Updates to be provided in accordance with SA300."

Texas Incident #: I-9331

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Non-Agreement State Event Number: 51305
Rep Org: WEAVER CONSULTANTS GROUP
Licensee: WEAVER CONSULTANTS GROUP
Region: 3
City: GRAND RAPIDS State: MI
County:
License #: 21-32761-01
Agreement: N
Docket:
NRC Notified By: JEFF BLUM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/10/2015
Notification Time: 16:46 [ET]
Event Date: 08/10/2015
Event Time: [EDT]
Last Update Date: 08/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

DAMAGED TROXLER MOISTURE DENSITY GAUGE

"After completing 17 moisture density gauge readings on the southern half of the West Slope of Clinton County landfill, the Troxler (Model: 3440, Serial # 39264) portable nuclear density gauge owned by [the licensee] was placed on the ground behind a Ford F150 pick up truck owned by [the licensee]. [The gauge operator] sat at the back of the truck reviewing the field sheets of moisture density readings and preparing for the next group of readings. When it was clear that additional blank forms were needed, [the gauge operator] went to the cab of the truck to look for the additional forms. No forms were available so the truck was started and backed up to go to the field office to retrieve the forms.

"After backing and going forward a few feet, [the gauge operator] remembered the moisture density gauge behind the truck. The truck was backed up beside its original location and the damaged gauge was observed. [The gauge operator], got out of the truck to see the plastic casing of the gauge broken in several pieces. The source rod was still in the shielding but the guide rod was broken.

"[The gauge operator] was the only person on that portion of the jobsite at the time of the incident and received no exposure from the source as it was still contained in the shielding. The closest other person to the area was more than a thousand feet away at the time of the incident.

"The gauge and broken plastic housing was placed into its transportation box after confirmation of intact sources. The area of the incident was cordoned with orange paint for containment purposes. The licensee's radiation safety officer [RSO], was notified of the incident and the gauge was photographed and photos were sent to him.

"The RSO mobilized to the site with a SE International radiation meter to survey the cordoned area of the incident as well to verify that sources were intact in the portable nuclear density gauge. Survey results indicated that both sources, Cs-137 and Am-241:Be were intact and undamaged."

The gauge is a Model 3440 Troxler Moisture Density gauge, serial #39264, with Cs-137 8 mCi, serial #77-6741 and Am/Be 241 40 mCi sources, serial #78-4049.

The licensee has temporarily stored the gauge in a secure location and will transport the gauge back to the company office, in Michigan, for repair.

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Power Reactor Event Number: 51323
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KEN TIEFENTHAL
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/17/2015
Notification Time: 12:59 [ET]
Event Date: 08/17/2015
Event Time: 10:30 [EDT]
Last Update Date: 08/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)

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

OFFSITE NOTIFICATION DUE TO OIL SPILL

"At 0837 EDT on August 17, 2015, it was determined that Beaver Valley Unit 2 had experienced a small oil leak of approximately 1 liter from equipment located inside the Alternate Intake structure, some of which progressed to the Ohio River. Subsequent to confirmation of this discovery, notification was made to the following offsite agencies starting at 1030 EDT:

"National Response Center (Incident Report# 1125865), Pennsylvania (PA) Department of Environmental Protection, Beaver County Emergency Management, PA Emergency Management Agency, and downstream water authorities (Midland Water Authority, Allegheny Ludlum, East Liverpool Water Co.)

"This notification is a required 4-hour report per 10 CFR 50.72 (b)(2)(xi).

"The source of the oil leak has been stopped. Absorbent material has been placed to contain the oil that had leaked. No press release is planned.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51324
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: VERLE CASTLE
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/17/2015
Notification Time: 13:01 [ET]
Event Date: 08/17/2015
Event Time: 05:05 [CDT]
Last Update Date: 08/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KENNETH RIEMER (R3DO)

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

Event Text

LOSS OF ASSESSMENT CAPABILITY DUE TO PLANNED MAINTENANCE ON SEISMIC INSTRUMENTATION

"At 0505 CDT on August 17, 2015, Clinton Power Station's Seismic Instrumentation system was removed from service to support scheduled maintenance. During this time, the seismic instrumentation will not be able to generate Main Control Room annunciation or provide ground acceleration information necessary for Emergency Action Level (EAL) threshold determination until the seismic instrumentation is restored. Since the duration of the maintenance activity is expected to last greater than 24 hours, with no viable compensatory measure specified in the EAL's, this condition will result in a loss of emergency assessment capability while the Seismic Instrumentation is out of service and results in a reportable condition in accordance with 10 CFR 50.72(b)(3)(xiii).

"The licensee has notified the NRC Resident Inspector and the licensee has informed the State of Illinois Resident Engineer."

The licensee also notified the State of Illinois Emergency Management Agency.

Page Last Reviewed/Updated Tuesday, August 18, 2015
Tuesday, August 18, 2015