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Event Notification Report for November 14, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/10/2016 - 11/14/2016

** EVENT NUMBERS **


52309 52341 52345 52346 52363

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52309
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ARMANDO AVILES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/20/2016
Notification Time: 00:09 [ET]
Event Date: 10/19/2016
Event Time: 18:30 [MST]
Last Update Date: 11/10/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN KRAMER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Defueled 0 Defueled

Event Text

SAFETY INJECTION PIPING WELD FLAW

"While performing a scheduled inservice inspection on a section of safety injection system piping, a flaw was identified in a circumferential weld on the 14 inch safety injection line from the 2A safety injection tank to the 2A reactor coolant loop. Examination results indicate that the flaw constitutes a welding defect that cannot be found acceptable under ASME Section XI, IWB-3600, or Table IWB-3410-1. Further analysis is being conducted.

"The unit had been shutdown for its 19th refueling outage (3R19) on October 8, 2016, at 0000.

"The NRC Resident Inspectors have been informed of this condition."

This piping is required to be operable in modes one through four.

* * * RETRACTION ON 11/10/16 AT 1640 EST FROM ROBERT CHU TO MARK ABRAMOVITZ * * *

"Subsequent engineering examination of the weld on the 14" safety injection line from the 2A safety injection tank to the 2A reactor coolant loop using enhanced examination techniques concluded the indication in the circumferential weld does not represent a flaw constituting a weld defect. The indication was the result of a metallurgical weld interface in the area of a previously documented weld repair. Therefore, the indication is acceptable under ASME Section XI with no further analysis required.

"Based on the above information, PVNGS has determined the indication does not represent a degraded condition of a principal safety barrier as defined by 10CFR 50.72(b)(3)(ii)(A) and event notification #52309 is retracted.

"The NRC Resident Inspectors have been notified."

Notified R4DO (Campbell).

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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.

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Agreement State Event Number: 52345
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTEK ASSET INTEGRITY MANAGEMENT INC
Region: 4
City: LONGVIEW State: TX
County:
License #: 06801
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/03/2016
Notification Time: 12:36 [ET]
Event Date: 11/02/2016
Event Time: [CDT]
Last Update Date: 11/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DID NOT RETRACT CAUSING DOSIMETER ALARM

The following report was received from the Texas Department of State Health Services via email:

"On November 3, 2016, the Agency [Texas Department of State Health Services] was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The camera had a 36 curie Ir-192 source. The crew could not hear the alarming rate meters due to excessive noise. The radiographers noticed the source had not retracted completely into the camera while trying to disconnect the guide tube to move the camera to another location. The radiographer reported to the RSO that the source was retracted immediately after finding the source extended. The time reported to the RSO with the source exposing the radiographer was less than 3 minutes. The pocket dosimeters were checked outside the area and found off scale. The RSO stopped all work, requested radiographers return to the shop and he checked the camera to find no defects. The RSO has sent the monitoring badges in for processing and is in the process of completing an investigation to determine exposure dose. A complete report will be provided by the RSO. Updates will be provided in accordance with SA 300 guidelines."

Texas Incident #: I 9437

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Agreement State Event Number: 52346
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: ONCOLOGY ASSOCIATED OF OREGON
Region: 4
City: Eugene State: OR
County:
License #: 90862
Agreement: Y
Docket:
NRC Notified By: TODD S CARPENTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/04/2016
Notification Time: 13:05 [ET]
Event Date: 11/01/2016
Event Time: [PDT]
Last Update Date: 11/04/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE ON NUCLETRON MICROSELECTRON

The following is an excerpt of a report received from the Oregon Department of Health via email:

[The Oregon Department of Health] had a teleconference with the Radiation Safety Officer (RSO). [The RSO] stated that during the morning QA check, the source would not retract. No patient was in the room and the QA check was performed with no one in the room. The RSO went inside the room just at the door and obtained an exposure [rate] reading of 2.6 mR/hr at approximately 15 feet from the HDR [high dose rate] unit, a Nucletron model microSelectron 106.990. The treatment room is secured at the current time until the Elekta FSE [Field Service Engineer] arrives. The RSO is working on treatment of another patient and will get more information as he gets time to do so.

During a phone call with the Elekta RSO, the Elekta RSO stated that the FSE found that the HDR unit [obstruction alarm] was being tested during QA by locking the HDR exit port [in order to block the source] and [cause an] alarm condition. The port was only partially locked so that the source was able to get out but not able to retract. The FSE was able to retract the source by opening the port fully and didn't have to manually do it. Total dose received was estimated at 10 mR maximum. The Elekta RSO mentioned that there could be shavings from the sealed source capsule around the port and that leak tests have been negative but that the entire HDR head, including source is now to be replaced.

Device: Nucletron
Model: microSelectron 106.990
Activity: Ir-192, 10 Ci.

Oregon Incident Number: OR160004

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Power Reactor Event Number: 52363
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DANNY BRADFORD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/13/2016
Notification Time: 17:39 [ET]
Event Date: 11/13/2016
Event Time: 10:12 [CST]
Last Update Date: 11/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VIVIAN CAMPBELL (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

Event Text

ONE MAIN STEAM LINE RADIATION MONITOR FAILED

"At 1012 [CST], Unit 1 Main Steam Line 1-01 Radiation Monitor (1-RE-2325) failed high. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 1-01 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii).

"Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity and there is a negligible safety significance to the current condition from a public health and safety perspective. Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator or fuel cladding.

"Until this radiation monitor can be restored, Operations has implemented compensatory measures to monitor the main steamline 1-01 N-16 [Nitrogen-16] radiation monitor for early signs of a steam generator tube leak/rupture and pre-brief radiation protection technicians on taking local readings with a Geiger-Muller tube on Main Steam Line 1-01 and reporting the reading to the Control Room. Corrective actions are being pursued to restore 1-RE-2325 to functional status.

"The NRC Resident Inspector has been notified."

Radiation monitor 1-RE-2325 is not in the plant technical specifications but is important to safety and the Emergency Plan.

Page Last Reviewed/Updated Monday, November 14, 2016
Monday, November 14, 2016