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Event Notification Report for February 24, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/23/2016 - 02/24/2016

** EVENT NUMBERS **


51655 51735 51736 51737 51751

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 51655
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN CLIPPERTON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/14/2016
Notification Time: 18:10 [ET]
Event Date: 01/14/2016
Event Time: 14:43 [PST]
Last Update Date: 02/23/2016
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAY KELLAR (R4DO)
M DAPAS (RA)
SCOTT MORRIS (NRR)
M EVANS (NRR)
B HOLIAN (NSIR)
BERNARD STAPLETON (IRD)
DENNIS ALLSTON (ILTA)
J KOZAL (R4)

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

NOTIFICATION OF UNUSUAL EVENT - SECURITY CONDITION THAT DOES NOT INVOLVE HOSTILE ACTION

A security condition that does not involve a hostile action was reported by the Diablo Canyon security watch commander.

At 1443 PST on 1/14/16, Diablo Canyon declared an Unusual Event, due to an unauthorized person in the Owner Controlled Area. Site Security was dispatched and assistance was requested from the local Sheriff's Department. The individual was apprehended.

At 1602 PST on 1/14/16, Diablo Canyon terminated the Unusual Event after the individual was apprehended and placed in custody of local law enforcement. Diablo Canyon remained at 100 percent power for the duration of the event. No radiological release has occurred and all radiation levels are normal on both units. A press release is planned.

The licensee has notified the NRC Resident Inspector and state and local authorities.

Notified FEDS (DHS SWO, FEMA Ops, DHS NICC, and NuclearSSA via email.)

* * * UPDATE AT 1905 EST ON 02/23/16 FROM DOUG EVANS TO S. SANDIN * * *

"This Notification is being retracted.

"Upon further evaluation, Pacific Gas and Electric has determined that declaration of the Unusual Event was not required. The event did not constitute a threat or compromise to site security, did not involve a threat or risk to site personnel, did not represent a potential degradation to the level of safety of the plant, and did not affect the health and safety of the public.

"The licensee has notified the NRC Resident Inspector of the retraction."

Notified R4DO (Whitten), IRD (Stapleton) and NRR (Morris).

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Agreement State Event Number: 51735
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ST JOSEPH'S HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 296-6
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/15/2016
Notification Time: 08:47 [ET]
Event Date: 02/15/2016
Event Time: [EST]
Last Update Date: 02/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following report was received from the State of Georgia via email:

"The following was reported to the State of Georgia on February 15, 2016.

"The patient was prepped for the delivery of doses of 18 and 21 Gy to 14 subcentimeter brain metastases with Gamma Knife stereotactic radiosurgery. The frame adapter was placed on the patient's stereotactic head frame by a Gamma Knife trained registered nurse, supervised by Authorized Medical Physicist [AMP], and Authorized User [AU]. After five of the planned 14 lesions were treated, the patient was given a break in order to use the restroom and for additional medication. During this treatment break, the AU and AMP entered the room to release the patient from the restraining device and assist [the patient] to the rest room. It was at that point that it was discovered that the restraining device was locked, but not in the correct position. The displaced distance was measured and determined to be a maximum discrepancy of 2 cm in one plane. The AMP and AU applied the displacement to the treatment plan to determine which areas were treated and which were not. It was determined that a potential misadministration had occurred.

"The RSO [Radiation Safety Officer] was notified to discuss the course of action. Following discussions with the AMP, AU, the medical director, the prescribing physician and radiation safety officer, it was decided that there was a potential medical event or misadministration as defined in 391-3-17-.05(115)(a)3 or 391-3-17-.05(115)(b).

"The cause of the event is uncertain at this time. The head restraining device should not have been able to be secured unless it was in the proper position. An investigation is ongoing and additional information is being sought.

"The patient received an unintended radiation dose to normal brain tissue, however, it was determined by the authorized user in consult with the medical physicist that little clinical effect will be demonstrated due to this inadvertent exposure. The patient, the patient's family and the patient's referring physician were informed of the event. After extensive discussions, it was agreed by all parties that the treatment would be completed to ensure that the correct dose is delivered to the remaining target areas.

"This is all the data available at the moment. A reactive inspection is currently underway and updates are soon to follow."

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: 51736
Rep Org: DOMINION RESOURCES SERVICES
Licensee: DOMINION TRANSMISSION, INC.
Region: 1
City: JANE LEW State: WV
County:
License #:
Agreement: N
Docket:
NRC Notified By: RAY HUGO
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2016
Notification Time: 10:05 [ET]
Event Date: 02/15/2016
Event Time: [EST]
Last Update Date: 02/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

LOST TRITIUM EXIT SIGNS

"Pursuant to Federal Regulation 10 CFR 31.5(a), Dominion Transmission, Inc. is a general licensee of the NRC because it possesses and uses byproduct material in the form of tritium exit signs (TES). Consistent with Federal requirements, Dominion is providing the subject report regarding two (2) lost TES.

"Dominion has established a company-wide program to inventory TES. Inventory efforts have identified that the following TES which were present at the previous inventory cannot be located and are presumed lost:

"Serial Number: CO563528
Model Number: BX
Activity: 20 Curies

"Serial Number: CO563530
Model Number: BX
Activity: 20 Curies

"Dominion conducted this most recent inventory during a recent construction re-modeling project involving the building of a new addition at its Lightburn Station. Dominion has no information that these TES have been transferred. Accordingly, and in addition to physical searches for the TES conducted by Dominion, Dominion interviewed key on-site personnel, contractors and vendors who had worked on the site. Interviewed personnel include the Dominion project manager, site safety personnel and the lead contractor who performed the demolition. None of these interviewees recall disposing of the TES.

"Dominion also contacted the local trash removal services (C and D Dumpster) and they have confirmed that a dumpster was removed from the site during the remodeling project. Dominion therefore contacted S and S Landfill. S and S Landfill has no equipment available to monitor for radiation levels and consequently could not provide us with any relevant information as to the possible disposition of these TES.

"As a result of these investigative efforts, Dominion concluded that these TES are lost. We have also confirmed that all other TES are currently in place at the Lightburn Station facility."

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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Agreement State Event Number: 51737
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: JARDEN ZINC
Region: 1
City: GREENEVILLE State: TN
County:
License #: R-30012
Agreement: Y
Docket:
NRC Notified By: RUBIN CROSSLIN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/16/2016
Notification Time: 10:32 [ET]
Event Date: 02/16/2016
Event Time: [EST]
Last Update Date: 02/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED FIXED NUCLEAR GAUGE

The following report was received from the State of Tennessee via email:

"On February 16, 2016 the RSO [Radiation Safety Officer] of Jarden Zinc reported that one of their fixed nuclear gauges (make, model, serial number not reported) had been damaged. Details concerning the cause of the damage were unknown. Surveys of the damaged gauge indicate that the gauge shutter is in the closed position, no radiation beam is emanating from the gauge, and there do not appear to be any exposures to staff. The gauge has been moved into storage until the manufacturer can arrive to inspect the gauge. The RSO indicated that follow-up information to the Tennessee Division of Radiological Health would occur within 24 hours."

State Event Report ID NO.: TN-16-021

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Power Reactor Event Number: 51751
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY PATE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/23/2016
Notification Time: 20:45 [ET]
Event Date: 02/23/2016
Event Time: 17:00 [CST]
Last Update Date: 02/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JACK WHITTEN (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION INVOLVING NORMALLY OPEN BATTERY ROOM DOORS

"At CPNPP [Comanche Peak Nuclear Power Plant], eyewash stations are located just outside of the Class 1E battery rooms. The battery room doors are normally open and if a MELB [Moderate Energy Line Break] occurred on the demineralized water line connected to the eyewash station, the water could potentially spray onto the Class 1E safety related batteries. If this occurred, an electrical short could potentially cause a loss of both the batteries and the associated battery chargers.

"This condition has been conservatively determined to be reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. Currently, the demineralized water lines on the battery room eyewash stations for both Units 1 and 2 have been isolated, therefore, all safety related equipment is currently operable. Comanche Peak Engineering is performing a past operability review of this condition.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, February 24, 2016
Wednesday, February 24, 2016