United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > November 10

Event Notification Report for November 10, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/09/2016 - 11/10/2016

** EVENT NUMBERS **


52247 52338 52339 52341 52357 52359

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52247
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: ANDY MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/16/2016
Notification Time: 23:35 [ET]
Event Date: 09/16/2016
Event Time: 16:57 [EDT]
Last Update Date: 11/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ORTH (R3DO)

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

Event Text

ESSENTIAL BUSSES NOT ALIGNED TO POWER TRANSFORMERS DURING PLANT STARTUP

"At 1657 Eastern Daylight Time (EDT) the plant entered Mode 4 (from Mode 5), and subsequently, at 1710 EDT, it was discovered that 480V AC essential busses E1 and F1 were being supplied from the shutdown operations transformers. The essential busses E1 and F1 are required to be aligned to the power operations transformers in Mode 4 for operability in accordance with TS 3.8.9.

"With both E1 and F1 essential busses aligned to the shutdown operations transformers with the plant in Mode 4, both trains of the essential electrical power distribution system were inoperable, resulting in a loss of safety function. At 1733 EDT both E1 and F1 essential busses were aligned to the power operations transformers as required by TS 3.8.9.

"This issue is being reported as a loss of safety function of the essential electrical busses.

"The NRC Resident Inspector has been notified of the event."

* * * RETRACTION AT 1315 EST ON 11/09/2016 FROM ANDY MILLER TO JEFF HERRERA * * *

"Engineering reviewed the actual conditions during the approximate 36 minutes the 480V AC essential busses were being supplied from the shutdown operations transformers. Grid voltages were higher than assumed minimum voltages, and electrical loading during Mode 4 conditions were reduced from expected full power operation loading. As a result, Engineering determined that all equipment remained capable of performing its required functions while connected to the shutdown operations transformers.

"Because the equipment remained capable of satisfying the requirements for Operability, no condition existed that could have prevented the fulfillment of a safety function. Therefore, no loss of safety function existed for the 480V AC essential buses, and the notification made per 10 CFR 50.72(b)(3)(v)(A-D) by the Davis-Besse Nuclear Power Station on 9/16/2016 (EN# 52247) is being retracted.

"The NRC Resident Inspector has been briefed on the evaluation results and informed of this retraction."

Notified the R3DO (Jeffers).

To top of page
Agreement State Event Number: 52338
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: NORTHWEST INSPECTION
Region: 4
City: KENNEWICK State: WA
County:
License #: WN-IR065-1
Agreement: Y
Docket:
NRC Notified By: STEVE MATTHEWS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/01/2016
Notification Time: 14:07 [ET]
Event Date: 10/29/2016
Event Time: [PDT]
Last Update Date: 11/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER DOSIMETRY LEFT NEAR EXPOSURE DEVICE DURING RADIOGRAPHY SHOT

This report was received by the State of Washington via email:

"During preparation of a radiography exposure, the radiographer and another radiation worker from Bechtel, attempted to untangle their dosimetry from the camera apparatus. In doing so, they left their dosimetry next to the camera during a shot. The radiographer exposed his TLD [Thermo Luminescent Dosimetry] and pocket dosimeter, as well as a client's electronic dosimeter during the exposure. Their dosimetry minus the radiographer's rate alarm was left next to the camera during the exposure. The radiographer wears dosimetry issued by Northwest Inspection and their client, Bechtel, sub contractor of the US Department of Energy. The radiographer's pocket dosimeter was off scale. Bechtel's electronic dosimeter showed an exposure dose of 300 mrem. The radiographer reported the incident to the RSO [Radiation Safety Officer]. The radiographer's TLD was sent to the dosimetry processing facility. Additional training for the radiographer has already taken place. In view of the fact that no 'persons' were overexposed, a spare TLD will be issued to the radiographer and will be allowed to continue to work."

The radiography camera is a QSA Model Number A424-9, Serial Number 32886G, containing an Ir-192 34.5 Ci source.

Washington State Incident Number: WA-16-045

To top of page
Agreement State Event Number: 52339
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RMA GROUP
Region: 4
City: RANCHO CUCAMONGA State: CA
County:
License #: 2700-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/01/2016
Notification Time: 18:15 [ET]
Event Date: 11/01/2016
Event Time: [PDT]
Last Update Date: 11/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CNSNS (MEXICO) (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On November 1, 2016, the RSO [Radiation Safety Officer] of RMA Group, contacted RHB ICE [State of California, Radiation Health Branch, Inspection, Compliance, and Enforcement Section] to report the theft of a moisture density gauge from the gauge user's pickup truck while he was home for lunch [in Grand Terrance, CA]. The nuclear gauge was inside a Type A transportation box was reportedly chained and secured properly but the chains were found cut. Troxler Labs model 3430, # 24568, contains 0.3 GBq of Cs-137 and 1.48 GBq of Am-241/Be. A power generator and other assorted equipment was also stolen.

"[The RSO] will notify the local newspaper to place a Reward Notice for information leading to the safe return of the gauge. [The RSO] was asked to obtain a detailed report from the authorized gauge user.

"The gauge's theft was reported to San Bernardino Police Dept. as well as the local calibration facilities were alerted of anyone bringing the gauge to them for service. [The State of California] RHB requested a copy of the police report and newspaper notice."

California State Report 5010 Number: 110116

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

To top of page
Agreement State Event Number: 52341
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: NORTHSIDE HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 39-1. AMEN
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/02/2016
Notification Time: 11:38 [ET]
Event Date: 10/21/2016
Event Time: [EDT]
Last Update Date: 11/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION TO INCORRECT SITE

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

"Northside Hospital's Radiation Safety Officer called the Department [Georgia Radioactive Materials Program Environmental Protection Division] on 10/21/2016, informing us of a misadministration with the HDR [High Dose Rate] that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming."

Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci.

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.

To top of page
Power Reactor Event Number: 52357
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: MICHAEL S. MOORE
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/09/2016
Notification Time: 14:58 [ET]
Event Date: 11/09/2016
Event Time: 13:39 [EST]
Last Update Date: 11/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ROSE (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

OFFSITE NOTIFICATION DUE TO SANITARY SYSTEM DISCHARGE

"At approximately 1008 [EST] on 11/9/16, site personnel discovered a sanitary lift station overflowing in the protected area. The overflow entered a nearby storm drain that discharges into Outfall 13. The estimated release volume is approximately 10 gallons. The release has been stopped. At 1339 an initial notification was made to SCDHEC [South Carolina Department of Health and Environmental Control]. The cause of the overflow is still
under investigation. Functionality of the lift pump has been restored and cleanup is complete.

"The NRC Senior Resident has been notified."

To top of page
Part 21 Event Number: 52359
Rep Org: SOR
Licensee: SOR
Region: 4
City: LENEXA State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MELANIA DIRKS
HQ OPS Officer: VINCE KLCO
Notification Date: 11/09/2016
Notification Time: 17:50 [ET]
Event Date: 11/03/2016
Event Time: [CST]
Last Update Date: 11/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RAY MCKINLEY (R1DO)
STEVE ROSE (R2DO)
MARK JEFFERS (R3DO)
VIVIAN CAMPBELL (R4DO)
PART 21/50.55 REACT (EMAI)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

PART 21 - NOTIFICATION OF DEVIATION - SOR QUALIFICATION TEST REPORT 9058-102

The following information was excerpted from a facsimile received by SOR:

Pursuant to the requirements of 10CFR Part 21, this letter notifies the NRC of a Part 21 condition. Irradiation testing performed since 1984 did not take into account all of the uncertainties associated with reported doses of gamma radiation to nuclear test specimens for qualification testing.

SOR contracted services with lsomedix in 1992 for the radiation aging that was performed per SOR nuclear qualification report 9058-102 Revision 1. Although SOR imposed Part 21 reporting requirements, lsomedix did not include SOR as part of their Part 21 notification. The Part 21 was brought to SOR's attention through an inquiry by a nuclear power station.

SOR requested a conference with Steris lsomedix which occurred on November 3, 2016. The teleconference confirmed that the subject radiation aging test results report would be affected by the Steris lsomedix Part 21. As a result, corrections are underway per qualification test report 9058-102 regarding the uncertainty calculations.

SOR does not have the capability to perform further evaluations to determine if a safety hazard exists as the specific customer application is unknown. The end user must confirm for each application that the qualified life dose + accident dose + 10% of accident dose is less than or equal to the corrected values.

SOR is currently identifying all customers potentially affected by this deviation. At the conclusion of this activity, SOR will notify the customers and the U.S. Nuclear Regulatory Commission in accordance with the requirements of 10 CFR Part 21.

Page Last Reviewed/Updated Thursday, November 10, 2016
Thursday, November 10, 2016