Event Notification Report for May 13, 2016

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following information was received via E-mail:

"On May 14, 2016, the Agency [Texas Department of State Health Services] was informed by the licensee's radiation safety officer (RSO) that a radiography crew had experienced a source disconnect at a temporary field site on May 13, 2016. The RSO stated the crew was working on a pipeline and after 3-4 welds were completed the source could not be retracted into the Spec 150 camera containing a 90.4 Curie iridium-192 source. The RSO, who was authorized to perform source retrieval, responded. He determined that the source cable had parted right next to the ball connector and that the source would not slide out of the source tube since the frayed cable was catching on the inside of the tube. He cut the source tube in order to recover the source. The RSO received 1300 mRem on his pocket dosimeter and is sending in his film badge for emergency processing. No member of the general public received an exposure due to this event. The licensee is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9403

* * * UPDATE FROM ART TUCKER TO VINCE KLCO ON 5/24/16 AT 1643 EDT * * *

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

"On May 24, 2016, the licensee's radiation safety officer (RSO) contacted the Agency and reported they just received the results of his badge worn during the source recovery. The RSO stated his badge was reading 1,348 millirem. The RSO stated he had previously received 100 millirem while performing radiography work prior to retrieving the source. Therefore, the dose received from retrieving the source was 1,248 millirem. Additional information will be provided as it is received in accordance with SA 300."

Notified the R4DO (Werner) and NMSS Events via email.

AGREEMENT STATE - LOST BRACHYTHERAPY SOURCE

The following was reported verbally and via email from the Illinois Bureau of Radiation Safety:

"On Friday, May 13, 2016, the licensee's radiation safety officer (RSO) contacted the Agency [Illinois Bureau of Radiation Safety] to advise that one source from a Medi+Physics sealed source brachytherapy device [44 mCi, Cs-137, Model Number CDCT1, Serial Number GA301] was missing following the treatment of a patient. During the unloading of the applicator that afternoon, only 2 of the 3 sources were recovered. Surveys were immediately conducted of the patient, the patient's room, the trash, bed and linen that remained present as well as several potential paths to and from the hot lab where the sources are stored. The facility expanded its surveys to additionally include dumpsters, roll off containers of biohazard waste and soiled linen storage without retrieving the source. Interviews with attending nursing staff showed that the patient had been cooperative throughout the 3 day treatment, did not have any visitors and had no complications where she had been found out of bed or otherwise unattended. Agency representatives were sent to the facility the following Monday to conduct confirmatory measurements of the same areas and equipment and expanded the search again to other outlying areas of the facility with no unexpected elevated readings detected in any area. Waste processing facilities were contacted and advised of the potential of a missing radioactive source in their waste stream beginning on the previous Wednesday. All indicated that they had functioning portal detection units for incoming trash/waste and that no anomalous readings had been noted.

"The Agency is continuing its investigation at this time and conducting additional surveys at out lying waste facilities. Hospital staff have been made aware of the event and been given a description of the source and appropriate action to take should it be discovered. This item remains open at this time."


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

MANUAL REACTOR SCRAM DUE AFTER LOSS OF AN ESSENTIAL MOTOR CONTROL CENTER

"At approximately 0110 hours [EDT] on May 13, 2016, Susquehanna Steam Electric Station Unit Two reactor was manually scrammed by plant operators due to a sustained loss of AC power to essential plant loads. Power to MCC 2B246 was lost at 2355 on May 12, 2016, resulting in a loss of Drywell cooling. Drywell pressure increased to 1.3 psig when operators placed the mode switch to the shutdown position to manually SCRAM the reactor. All rods inserted as expected. Reactor water level lowered to -27 inches and was immediately restored by normal feedwater level control. Level 3 (+13 inch) PCIS isolations occurred, along with an initiation of the RCIC system (-30 inches). Once adequate level was verified, RCIC was overridden. Pressure was controlled with turbine bypass valves, and subsequently main steam line drains. All safety systems functioned as expected.

"The power loss also tripped Reactor Building HVAC, causing a loss of secondary containment differential pressure resulting in a loss of safety function.

"Due to the loss of drywell cooling, high drywell pressure actuations and a second reactor SCRAM signal, this signal was automatic, occurred at 0314 hours. HPCI [which automatically initiated on high drywell pressure] was subsequently overridden and declared inoperable, resulting in a loss of safety function. [HPCI did not inject into the vessel].

"The reactor is currently stable in Mode 3. Initial reports from the field indicate a phase to phase fault on the MCC 2B246 bus bars."

The licensee has notified the NRC Resident Inspector and will be issuing a press release.

EXISTING DESIGN INADEQUACY COULD PREVENT STANDBY GAS TREATMENT SYSTEM OPERABLITY

"At 1200 [CDT] May 13, 2016, while the plant was operating at 100% power, it was brought to the attention of the River Bend Station Main Control Room staff that an existing design inadequacy could prevent both trains of the Standby Gas Treatment System (GTS) from performing its design function. Under certain specific conditions, the installed Masterpact breakers may not close to allow energization of the filter train exhaust fans. A start signal (reactor level 2, drywell pressure 1.68 psid, annulus high radiation, annulus low flow) combined with a trip signal within a certain time differential, could result in a failure of the breakers to close. As a result of this condition, both Standby Gas Trains were declared inoperable, which required entry into LCO 3.6.4.3 Condition C (requires entering Mode 3 in 12 hours). Declaring both trains of Standby Gas Treatment System inoperable resulted in loss of the safety function since a system that has been declared inoperable is one in which the capability has degraded to the point where it cannot perform with reasonable expectation or reliability.

"The Standby Gas Treatment System (GTS) limits release to the environment of radioisotopes, which may leak from the primary containment, ECCS systems, and other potential radioactive sources to the secondary containment under accident conditions.

"At 1240 [CDT] May 13, 2016, one division of GTS, GTS 'A', was manually started from the Main Control Room. This action prevents the breaker failure mode, restored the operability of one train and restored the safety function of the GTS system. LCO 3.6.4.3 Condition A (restore Operability in 7 days) is currently entered for Standby Gas Train 'B'. During the 40 minutes of inoperability, both trains of Standby Gas remained available. At no time was the health or safety of the public impacted.

"This condition is being reported in accordance with 10CFR50.72(b)(3)(v)(C) as an event that could have caused a loss of safety function to control the release of radioactive material. The Senior NRC Resident was notified."

* * * UPDATED AT 1341 EDT ON 05/17/16 FROM DAN PIPKIN TO RICHARD SMITH * * *

"Further review has determined that the design inadequacy discussed in EN #51928 could adversely effect the ability of the main control building heating, ventilation, and air conditioning (HVAC) system to perform its design safety function, based upon a particular sequence of events occurring within a short window of time (approximately 75 milliseconds). River Bend has implemented compensatory actions to ensure operability of the main control building HVAC system."

The Resident Inspector has been notified by the licensee.

Notified the R4DO (Miller).