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Event Notification Report for August 28, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/27/2015 - 08/28/2015

** EVENT NUMBERS **


51212 51330 51331 51332 51341 51353 51355

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Power Reactor Event Number: 51212
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: RAYMOND MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/08/2015
Notification Time: 17:43 [ET]
Event Date: 07/07/2015
Event Time: 11:05 [EDT]
Last Update Date: 08/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GERALD MCCOY (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

Event Text

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility.

"A condition impacting functionality of the TSC Ventilation system was discovered on July 7, 2015 at 11:05 EDT. The issue involved a loss of cooling capability of the TSC Ventilation system due to failed ventilation system components. Maintenance started repairs immediately following the discovery of the component failures and completed repairs to restore functionality of the TSC Ventilation system on July 8, 2015 at 17:07 EDT. On July 8, 2015, at approximately 15:30 EDT, further review of the impact of this equipment failure determined that this condition was reportable as a loss of emergency assessment capability.

"If an emergency were declared requiring TSC activation during the non-functional period, the TSC would have been staffed and activated using existing emergency planning procedures unless the TSC became uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC became necessary, the Emergency Director would have relocated the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team was notified of the maintenance and the possible need to relocate during an emergency. This condition did not affect the health and safety of the public or station employees. The NRC Resident Inspector has been notified."

* * * UPDATE ON 8/27/15 AT 1445 EDT FROM INGRID NORDBY AND JOHN CAVES TO HOWIE CROUCH * * *

"An extent of condition review revealed three additional instances of loss of cooling capability of the Technical Support Center due to failed ventilation system components: January 7, 2015; June 20, 2015; and June 30, 2015. Functionality was restored after these conditions were identified. Each of these instances was determined to be reportable in accordance with 10 CFR 50.72(b)(3)(xiii). The NRC Resident Inspectors have been notified."

Notified R2DO (Rose).

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Non-Agreement State Event Number: 51330
Rep Org: ELEKTA, INC.
Licensee: ELEKTA, INC.
Region: 1
City: ATLANTA State: GA
County:
License #: 10-35096-01
Agreement: Y
Docket:
NRC Notified By: DEBRA BENSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/19/2015
Notification Time: 09:48 [ET]
Event Date: 08/18/2015
Event Time: 10:18 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

FLEXITRON SOURCE LODGED IN CHECK RULER

"On the morning of August 18, 2015, the Elekta Field Service Engineer (FSE) was called to the [Customer's facility, McLaren Cancer Institute Macomb, in Mt. Clemens, MI] to investigate an obstruction error involving a 10.2 Ci Ir-192 source and a Flexitron HDR. The facility was using a microSelectron source position check ruler to check the source positioning of the Flexitron source. The source became lodged in the check ruler. The system E-stop was unable to retract the source.

"The FSE placed the check ruler and stuck source assembly into the customer's microSelectron HDR (mHDR) Emergency Service container (ESC) in order to secure the radioactive material in a shielded container. He then tried to manually retract the source back into the Flexitron unit which was also unsuccessful.

"Elekta RSO [Radiation Safety Officer] and FSE engaged the assistance from Senior Technical Support in Veenendaal [Netherlands]. After several troubleshooting attempts, the final decision was to remove the source tail in its entirety from the Flexitron unit. During the whole process, the source cable, check ruler and transfer tube remained secured in the emergency service container.

"Currently, the customer's mHDR ESC, which contains the source cable assembly, is secured and being bunkered inside the facility's 'dog house.' The survey readings of the ESC obtained by the customer physics staff were 50 mR/hr at the surface hot spot and 18 mR/hr at 1 meter.

"The FSE has checked the mechanical condition of the Flexitron unit and has loaded a dummy source. The unit is functioning properly.

"Elekta has reached out to their source manufacturer for assistance in transporting the source assembly in its entirety out of the facility.

"Elekta has escalated this case to the complaint handling department at Elekta/Nucletron B.V. for investigation. Further information will be forwarded upon receipt."

There were no over exposures or contamination involved with this event.

* * * UPDATE AT 1331 EDT ON 08/19/15 FROM PRAVEEN DALMIA OF MT. CLEMENS REGIONAL MEDICAL CENTER TO JEFF HERRERA * * *

This event was reported by Mt. Clemens Regional Medical Center d/b/a McLaren McComb, Mt. Clemens, MI. NRC License No. 21-04080-01 - See EN # 51341

Notified R1DO (DeFrancisco), R3DO (Riemer) and NMSS Events Notification Group via email.

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Non-Agreement State Event Number: 51331
Rep Org: INTERNATIONAL ISOTOPES
Licensee: INTERNATIONAL ISOTOPES
Region: 4
City: IDAHO FALLS State: ID
County:
License #: 11-27680-01
Agreement: N
Docket:
NRC Notified By: STEVE LAFLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/20/2015
Notification Time: 13:04 [ET]
Event Date: 08/20/2015
Event Time: 09:00 [MDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(a)(1) - PERS OVEREXPOSURE/TEDE >= 25 REM
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PETER HABIGHORST (NMSS)
PATRICIA MILLIGAN (EMAI)
ANGELA MCINTOSH (NMSS)

Event Text

PERSONNEL OVEREXPOSURE

"At about 0900 MDT on Thursday August 20, 2015, [the CEO of International Isotopes] was informed by our area manager that one of our technicians had been exposed to a 'flash' of radiation while handling a Co-60 source drawer. They reported his electronic dosimeter was reading 5.62 Rem. [The CEO of International Isotopes] immediately went to the work area and verified the Co-60 source (approximately 4000 Curies of Co-60) was in a secure shielded position and interviewed the technicians involved. All of the other technicians in the area reported their pocket or electronic dosimeters were reading normally (e.g. doses in the range of 1 to 5 mRem). The initial investigation indicates there was only one technician performing the work and in the immediate vicinity of the cask and source drawer at the time of the exposure.

"The technicians were preparing to transfer the Co-60 source drawer into another shielded container (a therapy head). A special handling tool had been bolted to the end of the source drawer for positioning the source drawer within a therapy head. This special handling tool needed to be removed from the source drawer in order to transfer the source back into the therapy head. The technician attempted to move the source drawer just enough to expose the bolts on the special handling tool so it could be removed. The technician stated that the drawer was sticking and when he pulled harder on the drawer it slid out of the cask about 9 inches, bringing the source to within an estimated 2 inches of the cask external surface. The technician immediately pushed the source drawer back into the cask into a fully shielded position. The technician then noted that his electronic dosimeter was reading 5.62 [Rem] and he left the work area."

The electronic Dosimeter reading was at 26 inches from the source. The TLD was approximately 15 inches from the source and a dose calculation resulted in a whole body dose of 16.9 Rem. Dose calculations for the hand (extremity) is 237 to 950 Rem depending on various assumptions. The technician was not wearing any finger rings. His dosimetry is being sent off for emergency reading. The technician is being restricted from work on radioactive materials.

* * * UPDATE FROM STEVE LAFLIN TO JOHN SHOEMAKER AT 1135 EDT ON 8/22/15 * * *

"The follow-up investigation continues at INIS. We have completed several simulated walk-throughs of the event and compared to personnel statements and descriptions of the event.

"We have been able to retrieve security camera footage of the event as well from two different angles. The security video footage reveals that the technician did, in fact, momentarily completely remove the source drawer containing the cobalt source from the shield. This video is being used to carefully model estimated exposures to both the individuals extremity and whole body.

"Dosimetry results were obtained from Landauer and indicated whole body readings of 201.875 Rem. Blood sampling from the individual does not support this high of an exposure and a review of the security video indicates the individuals TLD (on a lanyard around his neck) swung out away from his body, very near the source drawer, and was not in a position to accurately represent whole body exposure. Additional modeling using the security camera footage and additional data obtained from the electronic dosimeter will be used to estimate a more accurate whole body dose to the individual.

"The exposed individual has been providing blood samples at the local hospital per the sampling protocol prescribed by the DOE Radiation Emergency Assistance and Training Center. All blood samples are normal with no indication of radiation exposure. This sampling will continue through today (August 22) until a 48 hour period of testing from the event has been completed.

"Closer modeling to more accurately determine the individuals extremity dose are still in progress. This modeling is using both security camera footage as well as video footage from the mock-up of the event. While this modeling is not complete it appears that extremity dose may be closer to 50 Rem or less rather than the 250 - 950 Rem initially estimated.

"Daily photographs are being taken of the individuals hands and lower extremities to monitor for the development of any edema or signs of radiation damage to tissues. At this time there are no indications of radiation effects to any extremity.

"Additional data was extracted from the electronic dosimeter worn by the individual. This dosimeter was the device that initially read 5.62 Rem after the event. Analysis of the dosimeter data indicates it was exposed to a peak dose rate of about 3,739 R/hr. This is significantly less than the 10,166 R/hr initially estimated to have caused the 5.62 Rem ED reading at an estimated 2 seconds of exposure time. Using dose and dose rate information from this ED it appears the actual exposure time was about 5.4 seconds and this correlates with the security camera video time stamp.

"Additional information will be reported as it becomes available."

Notified R4DO (Hay), NMSS EO (Habighorst), and NMSS (McIntosh), NSIR (Milligan), and NMSS_Events_Notification via email.

* * * UPDATE FROM STEVE LAFLIN TO JOHN SHOEMAKER AT 2129 EDT ON 8/22/15 * * *

The following update was received from International Isotopes via email:

"Blood testing for the technician involved in the exposure event has been completed and all results are normal. Complete documentation is to be provided to the company by the medical provider on Monday and an additional follow-up discussion will be held directly between the company and the physicians at REAC/TS [National Nuclear Security Administration - Radiation Emergency Assistance / Training Site] on Monday, 8/24 to see what additional, if any, testing is recommended."

Notified R4DO (Hay), NMSS EO (Habighorst), and NMSS (McIntosh), NSIR (Milligan), and NMSS_Events_Notification via email.

* * * UPDATE AT 1309 EDT ON 8/23/15 FROM STEVE LAFLIN TO MARK ABRAMOVITZ * * *

"Dose modeling of the technician's extremity (left hand) and whole body exposures have been completed. These models estimate 49.1 Rem to the left hand. The whole body dose has been calculated to be 7.245 Rem. Both models were completed using micro shield and based upon a 3664 curie source in a 5.5 second exposure period. The whole body model assumed 3 worker positions and all times and distances are based upon our observations of the security video and supplemented by the mock-up of the event. Additional modeling will be performed of the lower extremities to confirm whether the left hand was likely to have been the most exposed extremity. The whole body model will also be validated by repeating the calculations and assumptions used against the known position of the electronic dosimeter and comparing calculated results of this modeling to the 5.62 Rem indicated on that dosimeter after the event. Over the coming weeks the company plans to acquire an expert in this type of dose reconstruction and have them independently verify the company's models and exposure calculations.

"The completed report of all lab work on the exposed technician is expected to be obtained on Monday, August 23. The company also plans to contact DOE's REAC/TS on Monday and confer with them on all blood test results and discuss whether any additional precautionary sampling or testing is advised.

"Visual examination of the exposed technicians hands and lower extremities will continue to be performed daily at least through August 28 unless REAC/TS recommends a longer monitoring period. At this time there are still no indications of radiation effects to any extremity of the exposed technician."

Notified the R4DO (Hay), NMSS EO (Habighorst), IAEA Contact (Milligan & McIntosh via e-mail), and NMSS Events Resource (via e-mail).


* * * UPDATE AT 1220 EDT ON 08/24/15 FROM STEVE LAFLIN TO JEFF HERRERA * * *

"REAC/TS has been contacted to discuss and review the results of laboratory work of the exposed technician. [The] Associate Director, Radiation Emergency Assistance Center/Training Site confirms that all blood work appears normal. [The Associate Director REACTS/TS] recommended that we continue CBC once daily through Friday this week and continue to forward them the results. She also agreed with our plan for continued daily examination of extremities through 8-28 but recommended further that we continue this examination every other day for up to 3 weeks post event (Sept. 10).

"The company has contracted with [the] Associate Dean for Idaho State University, to perform an independent dose assessment of the event. This work is expected to begin this week with a goal of including this report with the formal 30 day report on this event."

Notified the R4DO (Campbell), NMSS EO (Habighorst), IAEA Contact (Milligan & McIntosh via e-mail) and NMSS Events Resource (via email).

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Non-Agreement State Event Number: 51332
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2015
Notification Time: 15:05 [ET]
Event Date: 08/19/2015
Event Time: 15:52 [EDT]
Last Update Date: 08/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LOST/STOLEN U.S. ARMY RADIOACTIVE CHEMICAL ALARMS FOR SALE OR SOLD ON EBAY

The U.S. Army TACOM Radiation Safety Program Manager in Warren, MI was notified via email of what appeared to be U.S. Army material containing radioactive sources were for sale on eBay. The program manager was not able to find the listing but the information received indicated that the material was already sold or the listing expired. When the program manager contacted eBay about the material and the seller, eBay was uncooperative, citing privacy of the individuals selling/buying the material.

The program manager contacted the U.S. Army Criminal Investigative Command in Troy, MI and provided them with all the information pertaining to the material. Since the material was not recovered, the U.S. Army considers the material lost/stolen.

The materials are two M8A1 Chemical Agent Alarms each containing nominally 300 microcuries of Am-241.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Non-Agreement State Event Number: 51341
Rep Org: MCLAREN MCCOMB
Licensee: MCLAREN MCCOMB
Region: 3
City: MT. CLEMENS State: MI
County:
License #: 21-04080-01
Agreement: N
Docket:
NRC Notified By: PRAVEEN DALMIA
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/19/2015
Notification Time: 13:31 [ET]
Event Date: 08/18/2015
Event Time: 10:35 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

FLEXITRON SOURCE LODGED IN CHECK RULER

On August 18, 2015, at 1035 EDT as a part of acceptance of a new Flexitron mHDR Unit, [Mt. Clemens Regional Medical Center d/b/a McLaren McComb] tested the source position accuracy using a position check ruler. Licensee programmed the source so that it would go to certain positions. The positions were initialized at 1034 EDT. The source was being watched with the room monitor camera and the camera was zoomed in on the position and not the entire ruler. The source was viewed moving out and passing the positions. The source was supposed to dwell two seconds in each position. After 10 seconds, the cable was seen retracting. At 1035 an error message was received from the machine. The camera was zoomed out and noticed the cable was stuck in the ruler and the source was lodged somewhere between the faceplate and the groove in the ruler. At this point the service engineer from Elekta was there and he looked at the situation and the door had been decided to be opened so the source could be retracted to resolve the situation. With the door open, the room monitor was showing radiation present so we closed the door. At this point, the service engineer engaged the emergency switch and tried to add additional force to the source to retract. This was unsuccessful. Contacted the Elekta Radiation Safety Officer (RSO) for advice. The Elekta RSO suggested to go into the room and retract the source manually. The service Engineer and the Director for Radiation Services then entered the room to secure the ruler with the source in it inside the lead pig sitting right next to the mHDR unit. The plan for securing the source and ruler was discussed and approved with the Elekta RSO.

The event was planned and timed. It took 11 seconds from opening the door to securing the source inside the pig. The source cable was secured to the pig. The pig was secured inside a cabinet and the room was secured to prevent unauthorized entry.

The exposure around the container was 50 mR/hr at the surface and 18 mR/hr at one meter away. Lead bricks were placed around the cabinet to reduce the exposure and the dose was measured at <1mR/hr at the lead bricks where the door is located.

The Device is an Elekta Nucletron Flexitron
Serial Number: 00225

Source: Ir-192, 12.21 Ci on 7/30/2015
Serial Number: D363E-0477
Model Number: 136.147

This event was also reported by the device manufacturer, ELEKTA, at 0948 EDT on 08/19/2015 NRC License No. 10-35096-01- SEE EN # 51330

* * * UPDATE PROVIDED BY MARK YUDELEV TO JEFF HERRERA AT 1519 EDT ON 08/24/2015 * * *

The following additional information summary was excerpted from a detailed time line provided by licensee via email:

"McLaren Macomb was in the middle of a project to replace a microSelectron v2 HDR unit with a Flexitron unit. The installation was scheduled to be completed on Friday, August 14, 2015, with training and commissioning to begin immediately. However, the dedicated camera for source position verification was pending shipment and installation by the vendor. In light of this missing camera, a Source Position Ruler was borrowed from our sister facility at Karmanos Cancer Institute in Detroit, MI to check the source position accuracy with Gafchromic film as part of acceptance procedures.

"On August 18, 2015, the source position check ruler was connected to the Flexitron channel five using matching transfer tubes. The plan was created for the source to dwell at positions 360 (most proximal), 370, 380, 390, 395, and 400mm (most distal) within the ruler for two seconds each. In the absence of dedicated Elekta camera, the CCTV camera for in-room patient monitoring was used. The camera was zoomed on the part of the ruler where the source was expected to dwell. The plan was executed successfully with the source position check ruler two times. On the third attempt, the source got wedged inside the ruler and could not be retracted into the HDR safe. No patient was involved in this incidence and the event did not result in any unplanned exposure to any personnel."

"[During source retrieval] , the total time from entering the room until the source was secured inside the emergency container was 11.16 seconds, which would result in total exposure of 140 mRem to the whole body. The survey around the lead container showed an exposure rate of 8 mR/hr at the top, 48 mR/hr at the side and 18 mR/hr 3 feet away. The background radiation recorded by the meter was 0.002 mR/hr. The power to the unit was removed. The radiation survey meter recorded background radiation at the console area and patient access hall about 20 feet away from HDR door.

"The door to the HDR room was secured. The automatic door switch to the HDR room was disabled, and the door knob inside the room turned so that the keypad to unlock the door was deactivated. The electrical door opener was also disengaged from inside the room. As such, one could only enter the room using a dedicated key. There are only two copies of the key which are in the possession of the Authorized Medical Physicists[AMP]. A 'Do Not Enter' sign, along with the AMPs name and mobile phone number, was placed on the door.

"The emergency container was placed inside the HDR cabinet into the back corner and the cabinet locked. The survey meter showed an exposure rate of 5 mR/hr at the cabinet door. A wall was built around the emergency container using 8 inch x 5 inch x 2inch steel bricks. This reduced the exposure rate at the cabinet door to about 1 mR/hr."

Notified R1DO(DeFrancisco), R3DO(Skokowski) and NMSS Events Notification (via email).

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Power Reactor Event Number: 51353
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEPHEN SPEIRS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/27/2015
Notification Time: 14:10 [ET]
Event Date: 08/27/2015
Event Time: 07:52 [CDT]
Last Update Date: 08/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

SECONDARY CONTAINMENT INOPERABLE

"At 0752 CDT on 8/27/2015, both doors of a Secondary Containment Airlock were reported to be open simultaneously for a period of approximately five seconds. The brief time that the doors were simultaneously open constituted an inoperable condition of Secondary Containment. The airlock interlock was verified to operate correctly, and Secondary Containment has been restored to an operable status."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 51355
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/27/2015
Notification Time: 20:39 [ET]
Event Date: 08/27/2015
Event Time: 13:47 [EDT]
Last Update Date: 08/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PAUL KROHN (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

BRIEF LOSS OF SECONDARY CONTAINMENT DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY

"On 8/27/2015 at 1347 [EDT], a cart and personnel were being traversed through an airlock in the Unit 2 reactor building and both airlock doors were inadvertently opened at the same time for a brief period of time (approximately one minute).

"Secondary Containment differential pressure was maintained throughout the time period that the doors were opened. The doors serve as a Secondary Containment boundary and at least one in series is required to be closed at all times for Secondary Containment Operability.

"This event is being reported under 10 CFR 50.72(b)(3)(v) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, August 28, 2015
Friday, August 28, 2015