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Event Notification Report for July 19, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/18/2016 - 07/19/2016

** EVENT NUMBERS **


52075 52077 52078 52096 52097 52098 52099 52100 52101 52102 52103 52104

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Agreement State Event Number: 52075
Rep Org: CALIFORNIA DEPT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM
Region: 4
City: SACRAMENTO State: CA
County:
License #: 1334-57
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/08/2016
Notification Time: 20:53 [ET]
Event Date: 07/07/2016
Event Time: [PDT]
Last Update Date: 07/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - TOTAL DOSE DELIVERED DIFFERS FROM THE PRESCRIBED DOSE

The following report was received from the California Department of Public Health, Radiation Health Branch (RHB) via email:

"RHB North was informed by the Radiation Safety Officer of UC [University of California] Davis Medical Center, of a Medical Event that took place on July 7, 2016. The Medical Event involved a SirSphere case. The patient received 29 per cent more than the prescribed dose. The physicians working on the case as well as the referring physician and the patient have been notified. There are no expected negative impacts on the patient.

"Prescribed dosage: 13.5 mCi. Administered dosage: 17.4 mCi.

"The apparent reason of the misadministration is that the CNMT [Certified Nuclear Medicine Technologist] miscalculated the dosage required."

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: 52077
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: RRC POWER AND ENERGY LLC
Region: 4
City: ROUND ROCK State: TX
County:
License #: L06105
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/09/2016
Notification Time: 16:44 [ET]
Event Date: 07/08/2016
Event Time: 16:30 [CDT]
Last Update Date: 07/11/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

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

"On July 9, 2016, the licensee reported that on July 8, 2016, at approximately 1630 hours (CDT), one of its InstroTek 3500 Xplorer (SN: 1845) moisture/density gauges had been lost at a temporary job site. The licensee reported its technician had completed work for the day. The gauge was muddy so the technician placed it inside its transport case in the back of his pickup and left the case's lid up. He then got busy finishing up paperwork and talked to a site supervisor. The technician failed to close the case lid, secure the case in the vehicle, or raise the tailgate before leaving the site. When he got to the main road, he realized this and checked the gauge. It was not in the truck. He backtracked his route and checked at the work site but his search was unsuccessful. The source rod on the device is locked. The licensee stated there is a lot of oilfield traffic in the area the gauge was lost. The licensee's name and phone numbers are on the device and they are hopeful it may have been picked up and will be returned on Monday. More information will be provided as it is obtained in accordance with SA-300.

"Event Location: County Road 285, approximately 15 miles northwest of Mentone, Texas.

"Notifications: County Sheriff's Offices (both Loving and Reeves Counties)."

The State reported that the gauge contains 10 mCi of Cs-137 and 40 mCi of Am-241.

* * * UPDATE ON 7/11/16 AT 0919 EDT FROM KAREN BLANCHARD TO BETHANY CECERE * * *

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

"Texas has assigned its incident number I-9419 to this event.

"Also, correct spelling of gauge manufacturer is InstroTek."

R4DO (Gaddy), NMSS Events, and CNSNS (Mexico) have been notified by email.

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: 52078
Rep Org: PRIME NDT SERVICES
Licensee: PRIME NDT SERVICES
Region: 3
City: MARTINSVILLE State: IN
County:
License #: 37-23370-01
Agreement: N
Docket:
NRC Notified By: DON SCHUMWAY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/09/2016
Notification Time: 18:11 [ET]
Event Date: 07/08/2016
Event Time: 19:30 [EDT]
Last Update Date: 07/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
FRED BOWER (R1DO)
PATTY PELKE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

SOURCE FAILED TO RETRACT INTO RADIOGRAPHY CAMERA

While conducting radiography at a field location in Indiana, the radiographer determined that the source could not be retracted. He immediately contacted the company's radiation safety officer (RSO), located in Pennsylvania. The RSO, who is licensed to retrieve sources, directed the radiographer to establish a 2 mR/hr boundary and await his arrival. Additionally, another crew was dispatched to assist the original crew in maintaining the boundary secure.

Upon the RSO's arrival, the RSO and radiographers determined that the source was still in the collimator. They then used sandbags to reduce the work area dose rates. The RSO was able to retrieve the source and return it to the shielded position in the camera. The RSO conducted field testing and found no mechanical issues with the camera and could not replicate the problem. The RSO believes the problem was due to a source misconnect. The camera is currently enroute to the company's Ohio facility for additional testing prior to returning it to service. The RSO received 2 mR during the retrieval. The radiographer and assistant radiographer received 20 mR and 5 mR, respectively, during the retrieval.

The camera was a QSA 880 Delta containing a 55 Ci Ir-192 source.

No members of the public received any dose due to this event.

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Power Reactor Event Number: 52096
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JAMES REVELLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 14:48 [ET]
Event Date: 07/18/2016
Event Time: 07:30 [EDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARC FERDAS (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

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system).'

"On 07-18-2016 at 0730 [EDT], both Control Rooms were notified by the Emergency Preparedness Manager, that the Everbridge Emergency Response Organization [ERO] Notification System may not notify all ERO individuals within the required 10 minutes of system initiation. This constitutes a loss of offsite communications capability. The Everbridge vendor is working to resolve the issue. Compensatory measures are in place."

All ERO personnel received the page but not all received the notification within the required ten minutes.

The licensee notified the NRC Resident Inspector and the State.

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Power Reactor Event Number: 52097
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ERIC MASTHUCK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 21:41 [ET]
Event Date: 07/18/2016
Event Time: 16:00 [EDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARC FERDAS (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

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"At 1600 EDT, testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system was not able to notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue was reported resolved by the vendor and site testing has verified resolution as of 2130.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

Some of the ERO personnel did not receive a test page. The requirement is to have all ERO personnel receive the page within ten minutes. Compensatory measures were instituted while the system was not functional.

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Power Reactor Event Number: 52098
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DANIEL MILLER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 22:07 [ET]
Event Date: 07/18/2016
Event Time: 15:00 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified that the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. Compensatory measures (ERO phone lists) were put in place.

"The Everbridge system capability loss for Dresden Station was identified at 1500 CDT on July 18, 2016, due to an undetermined loss of system communications. Emergency Response Data System (EROS) capability was not lost.

"This event is reportable under 10 CFR 50.72(b)3(xiii) as a major loss of communication capability.

"On July 18, 2016 at 1957 CDT, an Everbridge ERO call in drill was initiated and verified successful at 2030 CDT.

"The NRC Resident Inspector has been notified."

Some of the ERO personnel did not receive a test page. The requirement is to have all ERO personnel receive the page within ten minutes and to be fully staffed within one hour.

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Power Reactor Event Number: 52099
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JAMES COX
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 22:21 [ET]
Event Date: 07/18/2016
Event Time: 14:50 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified that the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue has subsequently been reported resolved by the vendor and both site testing and common ERF [Emergency Response Facility] (EOF [Emergency Operations Facility] at Cantera) has verified resolution.

"The Everbridge system capability loss for Quad Cities was identified at approximately 1450 (CDT) hours on July 18, 2016, due to an undetermined loss of system communications, which is currently being investigated. Emergency Response Data System (ERDS) capability was not lost.

"The Everbridge system capability loss for the common ERF (EOF at Cantera) was identified at approximately 1500 (CDT) on July 18, 2016.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of EP offsite communications capability.

"The NRC Resident inspector has been notified."

The site was developing compensatory measures when the event was terminated.

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Power Reactor Event Number: 52100
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MACE DAVIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 22:26 [ET]
Event Date: 07/18/2016
Event Time: 15:00 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"During testing of the Everbridge Emergency Response Organization (ERO) notification system, it was found that the system may not have notified corporate ERO members within the required ten minutes from system initiation. This constitutes a loss of offsite communication capabilities. The Everbridge vendor has since restored and successfully tested the system. Additionally, the site successfully conducted an ERO call-in drill using the same Everbridge notification system.

"The Emergency Response Data System was not affected.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

The requirement is to have all ERO personnel receive the page within ten minutes. Compensatory measures were instituted while the system was not functional. The system was returned to service at 2100 CDT following repair and testing.

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Power Reactor Event Number: 52101
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN HARKINS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 22:43 [ET]
Event Date: 07/18/2016
Event Time: 16:00 [EDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARC FERDAS (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

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system was not able to notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue was subsequently reported resolved by the vendor and site testing has verified resolution at 2037.

"The Everbridge system capability loss for Limerick was identified at approximately 1600 EDT on July 18, 2016, due to a loss of system communications. Emergency Response Data System (ERDS) capability was not lost.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident inspector has been notified."

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Power Reactor Event Number: 52102
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: IAN KUENZLI
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/18/2016
Notification Time: 22:43 [ET]
Event Date: 07/18/2016
Event Time: 15:00 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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 OFFSITE COMMUNICATIONS CAPABILITY

"Testing of the Everbridge ERO [Emergency Response Organization] notification system identified the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability. The issue has subsequently been reported resolved by the vendor.

"Emergency Response Data System (ERDS) capability was not lost.

"The Everbridge system capability loss for the common ERF (EOF at Cantera) was identified at approximately 1500 CDT on July 18, 2016. Site and EOF testing verified resolution at 2029 CDT.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability."

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 52103
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RYAN CRAGG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/18/2016
Notification Time: 23:20 [ET]
Event Date: 07/18/2016
Event Time: 15:00 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"Loss of the Offsite Emergency Response Organization (ERO) notification system (Everbridge) identified the system cannot notify all ERO individuals. This constitutes a loss of offsite communications capability.

"The Offsite ERO notification system (Everbridge) capability loss of Braidwood was identified at approximately 1500 CDT on July 18, 2016, due to an undetermined loss of system communications, which is currently being investigated.

"The Offsite ERO notification system (Everbridge) capability loss for the common Emergency Response Facility (ERF) (Emergency Offsite Facility (EOF) at Cantera) was identified at approximately 1500 CDT on July 18, 2016.

"The issue has subsequently been reported resolved by the vendor at 1912 CDT and site testing has verified resolution at 2108 CDT.

"The onsite communication system was not affected.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a loss of communications capability.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52104
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MATTHEW TUTICH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/18/2016
Notification Time: 23:29 [ET]
Event Date: 07/18/2016
Event Time: 14:50 [CDT]
Last Update Date: 07/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF OFFSITE COMMUNICATIONS CAPABILITY

"This telephone notification is provided in accordance with the Exelon Reportability manual, 'Major Loss of Emergency Preparedness Capabilities', and 10 CFR 50.72(b)(3)(xiii).

"On July 18, 2016 at 1500 CDT, it was determined during testing of the Everbridge ERO [Emergency Response Organization] notification system that the system would not notify the corporate EOF [Emergency Operations Facility] individuals if the system had been activated. This constitutes a loss of offsite communication capability. Exelon and Everbridge have identified and corrected this issue. A follow-up test of the LaSalle Everbridge ERO notification system was completed satisfactorily on July 18, 2016 at 2100.

"The Emergency Response Data System (ERDS) capability was not lost.

"The licensee has notified the [NRC] Senior Resident Inspector of the issue."

Compensatory measures were in place during this event.

Page Last Reviewed/Updated Tuesday, July 19, 2016
Tuesday, July 19, 2016