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Event Notification Report for May 25, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/24/2016 - 05/25/2016

** EVENT NUMBERS **


51930 51933 51937 51952 51953 51954 51955 51956

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Agreement State Event Number: 51930
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: QUALITY INSPECTION & TESTING INC.
Region: 4
City: HOUSTON State: TX
County: ORANGE
License #: L06371
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/15/2016
Notification Time: 09:24 [ET]
Event Date: 05/13/2016
Event Time: [CDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

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.

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Agreement State Event Number: 51933
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: SEADRIFT State: TX
County: CALHOUN
License #: 00051
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: RICHARD SMITH
Notification Date: 05/16/2016
Notification Time: 17:12 [ET]
Event Date: 05/16/2016
Event Time: [CDT]
Last Update Date: 05/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILED TO OPERATE

The following information was received via E-mail

"On May 16, 2016 the Agency [Texas Department of State Health Service] was notified by the licensee's radiation safety officer that the facility was unable to isolate a gauge for maintenance when the shutter failed to operate. The gauge is an Ohmart Vega model SHF2 containing a 200 millicurie cesium - 137 source, serial number 7548GK. The shutter was left in the normal operating, unshielded position. The source does not pose any additional risk of exposure to the workers or members of the general public. The RSO stated they have called TechStar to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."


Texas Incident #: I 9404

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Agreement State Event Number: 51937
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: JOHN STROGER HOSPITAL
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01768-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: KARL DIEDERICH
Notification Date: 05/17/2016
Notification Time: 11:54 [ET]
Event Date: 05/13/2016
Event Time: [CDT]
Last Update Date: 05/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JIM WHITNEY (EMAI)

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

Event Text

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

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Power Reactor Event Number: 51952
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN HARKINS
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/24/2016
Notification Time: 10:12 [ET]
Event Date: 03/28/2016
Event Time: 01:50 [EDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JON LILLIENDAHL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

INVALID ACTUATION OF INBOARD ISOLATION LOGIC

"On Monday, March 28, 2016, Unit 1 was in OPCON 5 (Refueling) conducting a refueling outage. A modification was being installed for an NSSSS [Nuclear Steam Supply Shutoff System] Test Box on Division 1A Group 1 NSSSS logic. At 0150 hours, a logic jumper was removed as directed by the work order and a logic fuse failed. The fuse failure caused an unplanned invalid actuation of the inboard isolation logic. The isolations were reset and the valves were restored to initial conditions at 0246 hours. On Sunday, April 3, 2016, at 0134 hours, one additional logic fuse opening event occurred during the testing which also caused an invalid actuation which was reset at 0405 hours. The fuse openings occurred during jumper manipulations as the modification was tested on the Division 1A and 1D logic during the refuel outage. The investigation determined the fuse openings were due to the testing process. The suspected devices that caused the condition are not permanent plant equipment and there is no degradation of the actual circuit. They were part of a temporary configuration that was installed to support modification installation and acceptance testing. The temporary devices have been removed.

"The portion of the primary containment isolation system that received an actuation signal functioned successfully. All of the affected open isolation valves automatically closed. The isolation was a partial actuation.

"This 60-day ENS report is being made per 10CFR 50.73(a)(2)(iv)(A) and 10CFR50.73(a)(1) to report invalid automatic actuations of systems listed in paragraph (a)(2)(iv)(B). The listed system that actuated was general containment isolation signals affecting containment isolation valves in more than one system. Primary containment isolation valves (PCIVs) closed on reactor water cleanup (RWCU), drywell chilled water (DWCW), primary containment instrument gas (PCIG), drywell sumps and the suppression pool cleanup systems."

The licensee has notified the NRC Resident Inspector.

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Non-Agreement State Event Number: 51953
Rep Org: DBI, INC.
Licensee: DBI, INC.
Region: 4
City: OVERLAND PARK State: KS
County:
License #: 15-29301-02
Agreement: Y
Docket:
NRC Notified By: MATT SLAYMAKER
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/24/2016
Notification Time: 14:57 [ET]
Event Date: 05/23/2016
Event Time: 13:15 [CDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

RADIOGRAPHY CAMERA SOURCE CABLE NOT ENGAGED TO SOURCE

"On May 23, 2016 DBI Inc. (Lic# 15-29301-02) had an Industrial radiography crew working outside of Elmer, MO (Approx. 3hrs from Overland Park, KS Office). At approximately 1315 [CDT] during the crews first source retraction it was determined that the source had become disconnected from the driver cable. The crew immediately recognized the situation though the use of their dosimetry equipment. The Corporate Radiation Safety
Officer [RSO], was immediately notified of the issue. [The RSO] informed the crew to establish the emergency barricades and to not attempt anything further with the exposure device. [The RSO] arrived at the job site at approximately [1620] to retrieve the source. The source was secured back into the exposure device by [1645].

"Dosimeter readings were taken immediately upon discovery of the disconnect and monitored throughout the end of the day. Total recorded dose for the individuals involved was as follows:
[Worker 1] 18mR
[Worker 2] 12mR
[RSO] 3mR

"Doses recorded fall within the normal expectations for the work that was performed.

"Listed below are the relevant materials & equipment involved:
QSA Global 880 Delta exposure device. (S/N D6707)
QSA Global model A424-9 lr-192 Source (S/N 27422G) 33 Curies
QSA Global extreme weather 35' cranks (S/N KC-009)
QSA Global extreme weather 7' source tube with a 4hvl collimator (S/N KC-009)"

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Power Reactor Event Number: 51954
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/24/2016
Notification Time: 15:28 [ET]
Event Date: 05/24/2016
Event Time: 12:50 [EDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE GUTHRIE (R2DO)
SHANA HELTON (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 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ONSITE FATALITY NOT RELATED TO WORK

"At approximately 1250 [EDT], a contract employee was found unresponsive in [their] personal vehicle located in the parking lot outside of the owner controlled area. The Fairfield County Coroner arrived on-site and declared the individual deceased at 1345. The fatality was due to an apparent personal medical issue and not work related."

The licensee has notified the NRC Resident Inspector.

The licensee has notified State of South Carolina Department of Labor - OSHA.

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Power Reactor Event Number: 51955
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: JEFF HERRERA
Notification Date: 05/24/2016
Notification Time: 17:48 [ET]
Event Date: 05/24/2016
Event Time: 10:22 [CDT]
Last Update Date: 05/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG WERNER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNPLANNED LOSS OF EMERGENCY ASSESSMENT CAPABILITY

"CPNPP [Comanche Peak Nuclear Power Plant] experienced an unplanned loss of the seismic monitoring instrument on May 24, 2016 at 1022 [CDT]. The unplanned loss of the seismic monitor resulted in a loss of assessment capability for the HA1.1 (seismic event greater than operating basis earthquake) Alert emergency classification. The seismic monitor was restored to service on May 24, 2016 at 1043.

"This loss of assessment capability is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 51956
Facility: VOGTLE
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT FRECK
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/25/2016
Notification Time: 04:54 [ET]
Event Date: 05/25/2016
Event Time: 02:06 [EDT]
Last Update Date: 05/25/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON LOWERING STEAM GENERATOR WATER LEVEL

"At 0206 EDT 5/25/16, Vogtle Unit 2 tripped from 100% when SG [Steam Generator] #1 Level began to lower for an unknown reason. Cause for level issue is under investigation. All control rods fully inserted and AFW [Auxiliary Feedwater] and FWI [Feedwater Isolation] actuated as expected.

"Unit 2 is in Mode 3 and stable with decay heat being removed by Aux Feedwater."

Prior to the trip, I & C [Instrumentation & Calibration] was performing a loop #1 narrow range instrument calibration. Unit 2 is in a normal post trip electrical lineup with all source of offsite power available.

The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 25, 2016
Wednesday, May 25, 2016