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Event Notification Report for November 15, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/14/2016 - 11/15/2016

** EVENT NUMBERS **


52244 52346 52348 52349 52350 52351 52364

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52244
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIMOTHY BENNETT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2016
Notification Time: 00:14 [ET]
Event Date: 09/15/2016
Event Time: 15:40 [CDT]
Last Update Date: 11/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY AZUA (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

POTENTIAL DEGRADATION OF ECCS PUMP PRESSURE INDICATORS

"During a review of commercial grade dedication records for a Unit 1 [Emergency Core Cooling System ECCS] Centrifugal Charging Pump discharge pressure gauge, it was identified that the process side of the diaphragm seal utilizes a Teflon (PTFE) gasket. Further review found Teflon (PTFE) to be installed in the pressure gauge seal assembly for all four of the Centrifugal Charging Pumps and both of the Positive Displacement Charging Pumps on Units 1 and 2.

"Teflon (PTFE) is a restricted material normally prohibited from use in contact with reactor coolant or in radiation environments. Teflon (PTFE) is not radiation tolerant and significantly degrades in a radiation environment. The Teflon (PTFE) used in these pressure gauges could fail during a LOCA [Loss of Coolant Accident] which could cause the [ECCS] Centrifugal Charging Pumps and both of the Positive Displacement Charging Pumps on Units 1 and 2 to be inoperable, and exceed system leakage limits. Excessive leakage from systems which would contain post-LOCA recirculation fluid would challenge onsite and offsite dose estimates and in-plant post-accident accessibility. This represents an unanalyzed condition.

"Currently, the pressure gauges for all four of the [ECCS] Centrifugal Charging Pumps and both of the Positive Displacement Charging Pumps on Units 1 and 2 have been isolated until this issue can be further evaluated. Luminant Power believes that the Teflon (PTFE) has existed in the pressure gauges since initial plant licensing. Luminant Power is currently investigating the extent of the condition and repair techniques.

"The NRC Resident Inspector has been notified."

* * * RETRACTION AT 1634 EST ON 11/14/16 FROM DANNY BRADFORD TO JEFF HERRERA * * *

"On 09/16/2016, Comanche Peak reported an ENS Report (no. 52244) related to the identification of teflon-containing pressure-seal assemblies installed on the suction and discharge sides of the centrifugal charging pumps and on the suction side of the positive displacement pump. The technical concern was the potential for the teflon-containing assemblies to leak if subjected to post-LOCA recirculation fluid and associated radiation levels.

"Subsequent investigations by Engineering have determined: (1) the centrifugal charging pumps were operable for all postulated non-LOCA design bases events which required their operation and (2) for postulated LOCA scenarios which would involve radiation levels sufficient as to call into question the ability of the teflon-containing assemblies to maintain system pressure boundary, the ECCS function would be fulfilled in the event one or all of the charging pumps had to be removed from service (due to system leakage) and limiting (control room) doses would have remained below applicable regulatory limits.

"Based on the above, the condition described in ENS report no. 52244 is not considered to be an un-analyzed condition as described in10 CFR 50.72(b)(3)(ii)(B), nor is it considered to be a condition which could have led to a potential uncontrolled radiation release per 10CFR 50.72(b)(3)(v)(C), nor is it considered to be a condition which could have prevented fulfillment of a safety function under 10 CFR 50.72.(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

Notified the R4DO (Azua).

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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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Agreement State Event Number: 52348
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CLARK DIETRICH BLDG SYSTEMS
Region: 3
City: ROCHELLE State: IL
County:
License #: 9223802
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 11/07/2016
Notification Time: 12:28 [ET]
Event Date: 10/06/2016
Event Time: [CDT]
Last Update Date: 11/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK JEFFERS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILED TO OPERATE AS DESIGNED

The following information was received by email:

"On November 2, [2016], the registrant's representative reported [to the State of Illinois] that a generally licensed gauge under their control had failed to operate as designed. A Gamma Instruments model GR100 device exhibited signs of the shutter not closing properly. A contractor was notified and repairs affected. The gauge was subsequently returned to service with no additional engineering issues noted. Procedures at the plant were modified such that the area around the gauge is now cleaned following each shift."

The fixed gauge serial number was 930706, and the sealed source was 37 GBq of Am-241.

Illinois Event: IL 16010

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Agreement State Event Number: 52349
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: TEAM INDUSTRIAL SERVICES
Region: 3
City: HAMMOND State: IN
County:
License #: IL-01136-01
Agreement: N
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/07/2016
Notification Time: 15:35 [ET]
Event Date: 11/03/2016
Event Time: [EDT]
Last Update Date: 11/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK JEFFERS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT TO SAFE POSITION

The following report was received from the Illinois Emergency Management Agency via email:

"On Thursday, November 3, [2016] the licensee's Corporate RSO [Radiation Safety Officer] called to advised that one of their crews experienced a source retraction problem while at a temporary jobsite. Radiography shots were being taken with a nominal 60 Ci Ir-192 source at the Wood River Refinery, Wood River, IL. During a shot around 1230 [EDT] that afternoon it became obvious that the source would not retract using normal means. The crew contacted the local facility radiation safety officer to advise him of the event. The local radiation safety officer responded to the site within 30 minutes to discover that a portion of the drive cable assembly had been laid across a bare spot on a pipe that was otherwise insulated. The heat from the uninsulated section of pipe had caused the return side, cable housing coating to melt, forming an obstruction that the return cable could not pass. The RSO, having retrieved a source from a similar predicament in the past was able to quickly and efficiently cut the return side cable guide tube creating an open path for the cable and bypass the obstruction. The source was then able to be returned to the safe position without undue effort. The matter was resolved within an hour. The drive cable equipment has been removed from service. The camera was inspected and tested and put back into service. The direct ion storage dosimeter for the facility RSO was immediately analyzed at the end of the event and a dose of 3 mR was noted. Doses for the crew members were similarly analyzed and both found to be less than 30 mR since the last read which was performed at the end of the previous month. As the area being radiographed was on an overhead scaffold, no other personnel were in the work area at any time during the event other than the radiographers who maintained vigilance over the scene. A preliminary report with supporting photos was received the next day. Based on that report, an immediate investigation was not conducted at that time."

Device: Radiography Exposure Device
Manufacture: QSA Global
Equipment Serial Number: D10972
Source Serial Number: 32867G
Model Number: 880-D
Radionuclide: IR-192
Activity: 2168.2 GBq

Illinois Item Number: IL16011

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Agreement State Event Number: 52350
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PETNET SOLUTIONS, INC.
Region: 4
City: PORTLAND State: OR
County:
License #: 90927
Agreement: Y
Docket:
NRC Notified By: TODD S CARPENTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/07/2016
Notification Time: 16:26 [ET]
Event Date: 10/19/2016
Event Time: [PDT]
Last Update Date: 11/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN COLLINS (NMSS)
PATRICIA MILLIGAN (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR PHARMACIST RECEIVES GREATER THAN 50 REM EFFECTIVE DOSE EQUIVALENT

The following report was received from the Oregon Department of Health via facsimile:

"Oregon Health Authority, Radiation Protection Services (RPS) has confirmed on 11/07/16 that a cumulative effective dose equivalent of 50 rem [received by] a pharmacist working in several facilities. This information is being reported by PETNET Solution's corporate office in Knoxville, TN.

"Oregon Health Authority, Radiation Protection Services (RPS) received a call on October 20, 2016 at 1348 [PDT] informing the office that a contract pharmacist may have received an exposure greater than 50 rem to [the] right ring dosimeter and is conducting an analysis to determine if the individual received a dose greater than 50 rem. [The] caller is [the], Corporate Radiation Safety Officer (CRSO), PETNET Solutions.

"It's suspected that the individual received multiple doses while working at PetNet's Phoenix, Arizona and Portland, Oregon pharmacies. Dosimetry rings from both sites demonstrate a possible cumulative dose greater than 50 rem. The individual has now been restricted from working with radiopharmaceuticals at this time.

"CRSO states that the incident was discovered on 10/19/2016 and as of 11/07/16, exposure levels of greater than 50 rem are confirmed. This notification involves two facilities in Arizona and Oregon and RPS is not sure if the HOO [NRC Headquarters Operations Officer] was contacted by other regulatory agencies.

"CRSO has commenced a root cause analysis of the incident with an estimated date for completion within approximately two weeks."

Oregon Incident Number: 16-0037

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Agreement State Event Number: 52351
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: PHILLIPS 66
Region: 1
City: LINDEN State: NJ
County:
License #: 506897
Agreement: Y
Docket:
NRC Notified By: ED TRUSKOWSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/07/2016
Notification Time: 16:50 [ET]
Event Date: 11/07/2016
Event Time: 13:45 [EST]
Last Update Date: 11/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER FAILURE TO CLOSE

The following was excerpted from information received from the State of New Jersey by email:

"Event Narrative: On November 7, 2016, during the six-month shutter checks, the pneumatically operated shutter on the Vega source holder Phillips 66-Bayway Tag # PBL002 (source capsule S/N 0321CG) failed to close when tested. Several attempts were made wherein the shutter position indicator seemed to move slightly. It was concluded that the issue was not a failure of the air system controlling the pneumatic shutter actuator. The manufacturer was contacted to assess the problem.

"Root cause(s) and contributing factors: The source remained in the holder attached to the vessel in its normal operating position. The integrity of the source holder remains intact so there should be no exposures.

"Source/Radioactive Material/Devices: radioactive level gauge

"Isotope and activity; manufacturer, model and serial number, leak test results as applicable: The source is a 50 mCi Cs-137 solid sealed source, S/N 0321CG. The last leak test was 10/19/15."

The equipment is an Ohmart/Vega model SH-F1A source holder mounted to a vessel.

New Jersey Case Number: 161107162023

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Power Reactor Event Number: 52364
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: DEREK ETUE
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/14/2016
Notification Time: 14:01 [ET]
Event Date: 11/14/2016
Event Time: 11:06 [EST]
Last Update Date: 11/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
HIRONORI PETERSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 63 Power Operation 63 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ON-SITE SEWAGE SPILL

"At 1106 EST on 11/14/16, Fermi 2 discovered a sewage leak from a temporary restroom trailer that had reached a permeable gravel surface. The majority of the spill was confined to the impermeable surface below the restroom trailer. lt was estimated that the quantity of the spill which reached the permeable gravel surface was less than approximately 5 gallons. None of the sewage entered the storm drain system. The source of the sewage leak was eliminated by 1126 EST. A local sanitary contractor will be contacted to respond to the site to clean the affected areas.

"Reports to the Michigan Department of Environment.al Quality, the local health department (Monroe County), and the local news media are in progress. Since these reports are in the process of being made, this is considered a News Release or Notification to Other Government Agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, November 15, 2016
Tuesday, November 15, 2016