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Event Notification Report for December 29, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/28/2016 - 12/29/2016

** EVENT NUMBERS **


52438 52446 52447 52448 52450 52453

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Power Reactor Event Number: 52438
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: DON TAYLOR
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/15/2016
Notification Time: 13:50 [ET]
Event Date: 12/15/2016
Event Time: 11:30 [EST]
Last Update Date: 12/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ERIC MICHEL (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION MADE FOR POTENTIAL FUEL OIL LEAKAGE

"On 12/14/16 at 1206 [EST], 0-PT-89.9K (underground fuel-oil piping pressure test), was performed UNSAT after a failed attempt to maintain pressure in the supply line to the Unit 2 'H' Emergency Diesel Generator (EDG) Day Tank. The exact source of the leakage is unknown at this time but is reasonable to believe some fuel oil was released underground. The associated Fuel Oil line is currently tagged out and isolated. This condition is reportable to the Virginia Department of Environmental Quality [VA DEQ] as part of the Underground Storage Tank Program. Pressure tasting of the other EDG fuel oil supply lines has been previously completed satisfactorily. The 2H EDG remains Operable as the redundant fuel oil transfer pump and its fuel oil piping are Operable and capable of maintaining adequate day tank level. The VA DEQ was notified of this condition
at 1130 [EST] on 12/15/16.

"This event is reportable in accordance with 10CFR50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'"

The licensee has notified the NRC Resident Inspector and will notify Louisa County.

* * * UPDATE ON 12/28/16 AT 1659 EST FROM JAY LEBERSTIEN TO DONG PARK * * *

"This is a follow-up report to Event Number 52438, made on 12/15/2016, regarding offsite notification to the Virginia Department of Environmental Quality for potential fuel oil leakage from the supply line to the Unit 2H Emergency Diesel Generator (EDG) Day Tank.

"During investigation of the potential fuel oil leak from the 2HB EDG Day Tank supply line (as previously reported in EN 52438), the 2HA fuel oil line, which runs close to the 2HB line, was disturbed and began to leak a mist of fuel oil. The fuel oil was contained in the area and was being cleaned via vacuum truck as it was leaking. Personnel at the scene noted the soil was not contaminated with fuel oil initially and saw the leak start on 2HA line. It has been estimated that less than one gallon of fuel oil was released to the surrounding soil during troubleshooting of the leak. The fuel oil was immediately vacuumed. The 2HA line was isolated and the leakage was stopped. The 2HA line is to be repaired and tested. The 2H EDG remains available, however, it is considered inoperable at this time. Investigation of the 2HB fuel oil line continues.

"The condition of the 2HA fuel oil line was reported to the Virginia Department of Environmental Quality [VA DEQ] as part of the Underground Storage Tank Program on 12/28/16. Therefore, this event is reportable in accordance with 10CFR50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'

"The licensee has notified the NRC Resident Inspector and will notify Louisa County."

Notified R2DO (Rose).

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Agreement State Event Number: 52446
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EAGLE NDT, LLC
Region: 4
City: POTH State: TX
County:
License #: 06176
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 12:49 [ET]
Event Date: 12/20/2016
Event Time: [CST]
Last Update Date: 12/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERAS DAMAGED IN BUILDING FIRE

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

"On December 20, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee's corporate radiation safety officer (CRSO) that a fire had occurred at their Poth, Texas location causing extensive damage to the building. The licensee reported that inside the building was its storage location for its radiography exposure devices. The storage location had ten QSA 880D cameras containing between 32.2 and 90.2 curies Ir-192. Dose rates five feet from the storage location after the fire was out were near normal.

"Once the licensee gained access to the storage location they discovered that at least two of the handles on the devices had been melted to some degree. The licensee removed all the cameras from the storage location and a radiation survey on each was completed. The licensee stated the measured dose rates were normal. It appears the integrity of the shielding was maintained, but could have been affected. The CRSO stated all cameras were being returned to the manufacturer for leak test and inspection.

"No licensee personnel or member of the general public were exposed to any significant levels of radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-9452

* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1049 EST ON 12/23/16 * * *

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

"On December 23, 2016, the Agency contacted the licensee to get an update on the status of the radiography exposure devices. The licensee stated ten exposure devices were involved in the event and all have been delivered to the manufacturers Houston, Texas location for leak test and inspection. The licensee stated the exposure device storage area has been surveyed and no contamination was found. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO(Hay) and NMSS_Events_Notification via email.

* * * UPDATE FROM TUCKER TO KLCO AT 1056 EST ON 12/28/16 * * *

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

"On December 28, 2016, the Agency was notified by the licensee that the state Fire Marshal determined the fire was an electrical short at a plug. Additional information will be provided as it is received IAW SA-300."

Notified R4DO (Drake) and NMSS_Events_Notification via email.

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Agreement State Event Number: 52447
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: MARY HITCHCOCK MEMORIAL HOSPITAL
Region: 1
City: LEBANON State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: AUGUSTINUS ONG
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 16:01 [ET]
Event Date: 11/23/2016
Event Time: [EST]
Last Update Date: 12/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING HIGH DOSE RATE THERAPY DOSE TO AN UNINTENDED LOCATION

The following information was obtained from the state of New Hampshire via facsimile:

"NH Radiological Health Section 'Agency' was notified on November 23 by Chief Physicist followed by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital on November 24, 2016, of the HDR [high dose rate therapy] dose to an unintended location. The patient and the Authorized User were notified of the error and the correct fraction was administered.

"The licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. Cause of incident was identified as equipment malfunction (a deformed transfer tube)."

New Hampshire Event Report ID No.: NH-16-001

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: 52448
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINEGENERAL MEDICAL CENTER
Region: 1
City: AUGUSTA State: ME
County:
License #: 11623 #30
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 16:36 [ET]
Event Date: 12/20/2016
Event Time: 13:00 [EST]
Last Update Date: 12/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING WRONG TREATMENT SITE

The following information was obtained from the state of Maine via facsimile:

"On 12/19/2016, patient was scheduled for initial verification and treatment with electrons of a right sided metastatic rib lesion of 5 fractions at 400cGy per fraction. Patient was also to be treated with photons to a spinal lesion. Patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment location tattoos were present for each of these sites. Failure to identify the correct treatment tattoo and confusion over the treatment note led to the patient being setup to the previous rib tattoo location and treated. A single fraction of 400 cGy was delivered to the previous treatment site. Following treatment, the physician suspected a setup error. Further review of treatment plan confirmed the error. The licensee has notified the patient.

"A review of causes of the event and corrective actions was initiated."

Maine Event Report ID No.: ME 16-002

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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Non-Agreement State Event Number: 52450
Rep Org: INDIANA MICHIGAN POWER
Licensee: INDIANA MICHIGAN POWER
Region: 3
City: ROCKPORT State: IN
County:
License #: GL704402-21
Agreement: N
Docket:
NRC Notified By: STEVEN PFEISTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/21/2016
Notification Time: 14:09 [ET]
Event Date: 12/20/2016
Event Time: 15:10 [CST]
Last Update Date: 12/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

SHUTTER AND SHUTTER MECHANISM SEPARATED FROM SOURCE HOLDER

"On December 20, 2016 [at approximately] 1510 CST, a [level detector] nuclear source holder was found fallen off of its mounting on the unit 2 economizer hopper #49. The shutter mechanism and the shutter appear to have separated from the source holder. This occurred at the Indiana Michigan Power Rockport plant in Rockport, Indiana. The source holder is a Vega Americas Model SHLD-1-45, serial number: 7185CP. It is a 20 millicurie Cesium 137 source. The plant's general license number is GL704402-21. The radiation around the fallen source holder was tested and found to be a maximum of 35 millirem/hr at 1 foot in the source beam path. The radiation was tested at the 20 foot boundary where danger tape has been placed around the source holder and readings of 0.08 to 0.12 millirem/hr were noted. A nuclear technician from Vega Americas is currently on his way to the plant and we are planning to attempt to repair the source holder this evening [December 21].

"If we are unable to repair the source holder it will be prepared for shipping and will be sent back to Vega Americas' office in Cincinnati, Ohio for repair."

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Non-Agreement State Event Number: 52453
Rep Org: TERRACON CONSULTANTS, INC.
Licensee: TERRACON CONSULTANTS, INC.
Region: 3
City: CONWAY State: MO
County:
License #: 15-27070-01
Agreement: N
Docket:
NRC Notified By: KATIE GILCHRIST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/21/2016
Notification Time: 16:55 [ET]
Event Date: 12/21/2016
Event Time: 10:47 [CST]
Last Update Date: 12/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

TROXLER MOISTURE DENSITY GAUGE DAMAGED

A Troxler moisture density gauge (Model 3440) was damaged when it was struck by an asphalt roller. The source rod was out at the time of the incident but the source was able to be retracted into the shielded position.

The licensee's radiation safety officer surveyed the meter and found no abnormal radiation readings. The gauge was transported back to the licensee's facility for storage awaiting results of the swipe test. Once the swipe test results are returned, the licensee intends to ship the gauge to the vendor for repair or replacement.

The gauge contains Am-241/Be and Cs-137 sources. No personnel overexposures occurred during this incident.

Page Last Reviewed/Updated Thursday, December 29, 2016
Thursday, December 29, 2016