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Event Notification Report for June 19, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/16/2017 - 06/19/2017

** EVENT NUMBERS **


52717 52793 52794 52799 52802 52810 52812

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Agreement State Event Number: 52717
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VERSA INTEGRITY
Region: 4
City: HOUSTON State: TX
County:
License #: L06669
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 19:27 [ET]
Event Date: 04/28/2017
Event Time: [CDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER TRAINEE BADGE READ GREATER THAN 5 REM

"On April 29, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that on April 28, 2017, one of its radiographer trainees had reported their self-reading dosimeter had gone off-scale. The licensee stopped all work and sent the trainee's OSL [Optically Stimulated Luminescence] dosimeter to be processed. The licensee received a verbal report from the processer on April 29, 2017, and the dose was reported as 5.392 REM. The licensee did not know if the dose was static or dynamic. The licensee stated that the trainee had not operated the exposure device and did not know how the trainee could have received the exposure. The licensee stated there was a chance that the dose was to the badge only. The licensee is conducting a formal investigation into the event. No other individual reported an unusual exposure. The exposure device was a QSA 880D camera containing a 51 Ci Ir-192 source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9482

* * * UPDATE AT 1121 EDT ON 06/08/17 FROM IRENE CASARES TO STEVE SANDIN VIA EMAIL * * *

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

"On May 30, 2017 a detailed report was received by the corporate RSO [Radiation Safety Officer] stating the details of this event. The amount of information was limited and an on-site investigation was conducted on June 7, 2017. By interviewing employees who were at the event, it was determined that the individual did receive the dose of 5.392 REM (whole body) on April 28, 2017 as indicated on his badge reading. He was wearing monitoring devices and an alarming rate meter. There was extreme noise in the area. The exposed employee was a trainee and did not operate the radiography device, although the trainee was experienced in rope repelling in this specific situation and positioned the camera 30 feet above the floor in a pipe rack and collected the film. He did not crank the source in or out. He mounted the camera in the pipes, repelled down the ropes out of the area while the weld was imaged. He returned to the area after the trainer cranked in the source, checked a survey meter on the floor level, 30 feet below the camera, and shielded (there were pipes containing fluids and concrete columns shielding the area), while the trainee climbed the distance to collect the film. The trainee did not take the survey meter with him to do a post exposure survey near the camera or film (the meter is routinely snapped on the harness or cow-tail lanyard, but not this time). He collected the film and lowered it by rope to the trainer. The trainee decided on his own to stay in the rope harness near the camera, unknown to him that the source was slightly exposed. His alarming rate meter may have alarmed although he wouldn't have heard it, nor did he check it. The trainer took the film to the developer in another trailer onsite. When he returned (about 20 minutes) to say, film good, the trainee tried to unhook the cable. When it failed to unhook, another trainer in the crew had seen him and turned the crank handle to fully retract the source (uncertain, about half a turn). The trainee immediately lowered himself to the ground and both went to the vehicle. It was found that his pocket dosimeter was off scale, alarming rate meter was not alarming at this point and trainer phoned the RSO to get advice. Work stopped and the employees stayed on site. The RSO collected badge and sent it for immediate processing and gathered as much information as possible. It is believed the trainee's dose, according to the trainers, was to his whole body and possibly a few seconds to his right hand while trying to disconnect the cable. Within days, the trainee was released from employment from the company and disciplinary action taken against the other trainers. In an attempt to contact the trainee, the trainee responded to a phone text message stating he has not had any redness or tingling in his hand. He also stated he did not touch the collimator. The hand dose is estimated to be less than 2.5 millirem for three seconds or less."

Notified R4DO (Rollins), NSIR (Milligan), NMSS (Rivera-Capella), and NMSS Events Notification via email.

* * * UPDATE FROM IRENE CASARES TO HOWIE CROUCH VIA EMAIL AT 1410 EDT ON 6/16/17 * * *

"The RSO has finally completed and provided a rough calculation of the extremity dose on June 16, 2017. The hand dose was difficult to calculate due to deficiencies in rationale of where the source was in position to the exit port on the camera. The company dose was initially rejected due to rationale that if the whole body dose was 5 rem; how could the extremity dose be smaller. The deficiency in knowing the time, distance and actual
source shielding was resulting in varied numbers for the extremity dose. After discussing the situation and calculations with the RSO, it was agreed that the dose be assigned 10 rem to the right hand which is below the 50 rem reportable limit."

Notified R4DO (Campbell) and NMSS Events Notification via email.

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Agreement State Event Number: 52793
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINE MEDICAL CENTER
Region: 1
City: PORTLAND State: ME
County:
License #: ME 05611 #27
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/08/2017
Notification Time: 12:41 [ET]
Event Date: 06/07/2017
Event Time: 11:40 [EDT]
Last Update Date: 06/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE TO PATIENT WAS LESS THAN PRESCRIBED DOSE

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

"The following is a brief description of the event that occurred today in the [Maine Medical Center] (MMC) Cath Lab during an lntravascular Brachytherapy (IVB) case.

"The source train was deployed to treat the 1st dwell position of the cardiac stent. Following delivery of the prescribed dose to the 1st dwell position the source train became stuck during return to the afterloader and could not be freed. This required complete removal of the catheter with the source train and placement of it in the bailout box.

"As a result, only 1 dwell position was treated causing the delivered dose to vary by more than 20 percent of the prescribed dose.

"The prescribed dose was 1840 REM. MMC does not have the exact delivered dose estimate, but it is approximately 50 percent of the prescribed [dose] because they had planned on 2 dwell positions.

"MMC will follow this up with a full written report as required by SMRRRP G.3045.D. The Licensee will be providing a full report to the State within 15 days as required."

Maine Event Report: ME 17-003

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: 52794
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PRESTON GEOTECHNICAL CONSULTANATS
Region: 1
City: MACON State: GA
County:
License #: GA 109-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2017
Notification Time: 15:22 [ET]
Event Date: 06/06/2017
Event Time: [EDT]
Last Update Date: 06/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MOISTURE/DENSITY GAUGE LOST IN TRANSIT

The following report was received via e-mail:

"Preston was sending a Troxler gauge to Troxler located in North Carolina for a repair of a faulty battery pack. Preston scheduled a package pick-up by [common carrier] on May 8, 2017 from Preston's Macon hub. The licensee stated the typical expected turn-around time for a gauge repair is 3 weeks. Troxler does not send the licensee a receipt confirmation when they receive the customer's gauge. On June 6, 2017, when the licensee had not received the gauge back from Troxler, they made a call to Troxler inquiring about the repair status of the gauge. Troxler informed the licensee they had not received the gauge. The licensee contacted [the common carrier] and asked them to track down the gauge. Based on the tracking information the licensee has, the gauge was last scanned on May 9, 2017 in TN. After some search, [the common carrier] scanned the package on either 5/18 or 5/19/17 at their International Bond Cage. According to [the common carrier], the package would have been scanned daily if it were shipped internationally. [The common carrier] will continue to search for the package. In the meantime, the licensee will follow-up with a written report."

Sources: 8 mCi Cs-137 S/N 750-1945 and 40 mCi Am-241:Be S/N 47-24708
Device: Troxler 3430, S/N 28005

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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Agreement State Event Number: 52799
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AMERICAN RED CROSS BLOOD SERVICES
Region: 3
City: MADISON State: WI
County:
License #: WI-170008
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/09/2017
Notification Time: 17:04 [ET]
Event Date: 06/09/2017
Event Time: [CDT]
Last Update Date: 06/09/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR DRAWER STUCK IN INTERMEDIATE POSITION

"On June 9, 2017 it was reported to the department that, following a routine irradiation of two samples, the drawer containing the irradiated material ground to a halt while being raised from the irradiation position. The drawer is currently stuck in an intermediate position. Following the halting of the device, the licensee immediately removed it from service and contacted the manufacturer to schedule servicing of the device. Area monitors indicate that there are no elevated radiation levels. The device is J.L. Shepherd Model 143-45-C irradiator. The department will dispatch inspectors to perform an investigation."

WI Event Report ID No.: WI-170008

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Power Reactor Event Number: 52802
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: BETHANY CECERE
Notification Date: 06/12/2017
Notification Time: 13:50 [ET]
Event Date: 06/12/2017
Event Time: 09:14 [CDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
OTHER UNSPEC REQMNT
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

OFFSITE NOTIFICATION FOR DISCHARGE OF CIRCULATING WATER

"On Sunday, June 11, 2017 at 1200 CDT, a Chemistry Technician reported water from the Circulating Water Blowdown (CW B/D) valve building had been pumped onto the ground outside the CW B/D building during a maintenance activity. The sump in the CW B/D building has a sump pump discharge hose that had been routed outside to the ground near the outfall canal rather than to the permitted outfall path. Water sample analysis results confirmed the presence of tritium. The sump pump discharge hose was rerouted to the required outfall on June 11th, 2017 at 1500 CDT. The discharge flow did not leave the site boundary before reaching the permitted discharge pathway.

"In accordance with the Braidwood Station Illinois Environmental Protection Agency (IEPA) Consent Order dated March 11, 2010, the IEPA was notified of the blowdown line release on June 12, 2017 at 0914 CDT; the Illinois Emergency Management Agency (IEMA) was subsequently notified. Local agencies in the Braidwood area will also be notified.

"Follow-up analyses are being performed to determine if additional IEPA or IEMA notifications will be required. The release tank values for other radionuclides (i.e., other than tritium) were interpolated based on tritium values for the release tank, dilution from the CW B/D, and sampled sump tritium values; and determined to be less than Minimum Detectable Activity (MDA).

"Within 4 hours of determination that state and local agencies notification will be made, the NRC Operations Center is required to be notified. There were no public health risks associated with the event. The NRC Resident Inspector was notified. Due to the notification of government agencies, this event is being reported under 10 CFR 50.72(b)(2)(xi)."

* * * UPDATE ON 6/14/17 AT 1650 EDT FROM JOHN LOGAN TO DONG PARK * * *

"The Illinois Environmental Protection Agency (IEPA) and the Illinois Emergency Management Agency (IEMA) were notified on Wednesday, June 14, 2017, at 1206 CDT and 1213 CDT, respectively, of the preliminary results of estimated quantity of curies of tritium release (approximately 0.009 curies of tritium) and the estimated volume of the release (approximately 35,000 gallons). The discharge flow did not leave the site boundary before reaching the permitted discharge pathway. The NRC Resident Inspector was notified of the update to IEPA and IEMA."

Notified R3DO (Stone).

* * * UPDATE FROM CRAIG FOBERT TO HOWIE CROUCH AT 1656 EDT ON 6/16/17 * * *

"The Illinois Environmental Protection Agency (IEPA) and the Illinois Emergency Management Agency (IEMA) were provided with a follow-up report on June 16, 2017, at 1528 CDT as required by 35 IAC 1010.204. The report includes the estimated quantity of curies of tritium released (approximately 0.009 curies), the estimated volume of the release (approximately 35,000 gallons), and actions taken in response to the on-site release (installation of groundwater monitoring wells, implementation of a sampling program to monitor the concentrations and migration, if any, of the tritium in the groundwater on-site, and the installation of a remediation system).

"The NRC Resident Inspectors have been notified of the update to IEPA and IEMA."

Notified R3DO (Stone).

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Part 21 Event Number: 52810
Rep Org: TE CONNECTIVITY
Licensee: TE CONNECTIVITY
Region: 1
City: FAIRVIEW State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TERRY DUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/16/2017
Notification Time: 12:04 [ET]
Event Date: 06/02/2017
Event Time: [EDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
MEL GRAY (R1DO)
OMAR LOPEZ (R2DO)
ANN MARIE STONE (R3DO)
VIVIAN CAMPBELL (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - POTENTIAL DEFECT IN ETR14 CLASS TE CONNECTIVITY RELAYS

TE Connectivity reported that one of their relays, TE Part Number 7-1423177-5, ETR141B3BNC2023004, failed at TVA Labs during normal continuously energized operation. An investigation conducted with TVA Labs identified that a mis-oriented capacitor may have caused the failure. Although the failure occurred with only one part number, all relays in the ETR14 family with date codes from 1604 to 1650 contain the suspect capacitor. A root cause analysis is underway by the vendor.

If you have any questions or require any additional information, please contact me by email or telephone:

Terry Ducker
Quality Manager
TE Connectivity
Aerospace, Defense and Marine Division
1396 Charlotte Highway
Fairview, NC 28730

E-mail: duckert@te.com
Telephone: 828-338-1063
Fax: 828-338-1101


Quantity Supplied - Customer:

41 - Alabama Power
5 - ATC Nuclear
3 - Curtiss-Wright Nuclear
10 - Curtiss-Wright/QualTech NP
2 - Duke Energy Progress/Harris
16 - Energy Northwest/Columbia
4 - Engine Systems Inc
2 - Entergy/Pilgrim
39 - Entergy/River Bend
25 - Exelon/Limerick
2 - Exelon/Oyster Creek
12 - Exelon/Peach Bottom
2 - GE Hitachi Nuclear Energy
2 - Georgia Power/Hatch
2 - Nextera Energy Point Beach
5 - Talen Energy/Susquehanna
2 - TE/Germany
4 - TE/UK
6 - TVA/Browns Ferry
4 - TVA/Sequoyah
2 - TVA/Watts Bar Unit 1
9 - Xcel Energy/Monticello

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Power Reactor Event Number: 52812
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: JEREMY GALLOWAY
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/17/2017
Notification Time: 00:32 [ET]
Event Date: 06/16/2017
Event Time: 16:35 [EDT]
Last Update Date: 06/17/2017
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):
OMAR LOPEZ (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF SAFETY FUNCTION DUE TO KEOWEE DAM UNITS BEING DECLARED INOPERABLE

"Keowee Hydro Units [KHU] 1 and 2 were both declared inoperable at 1635 [EDT] on 6-16-17 due to discovery of breaker 1GSC-1 (KHU-1) in the intermediate position, and breaker 2GSC-1 (KHU-2) in the open position. Keowee Hydro Units are required to be operable per TS [Technical Specification] 3.8.1 (AC Sources - Operating), TS 3.8.2 (AC Sources - Shutdown), and TS 3.7.10 (Protected Service Water, applies only to KHU aligned to the Overhead Power Path). All Tech Spec required conditions were entered, and all required actions completed. Both Standby Buses were energized from a Lee Combustion Turbine via an isolated power path at 1715 [EDT] on 6-16-17 in accordance with TS 3.8.1 Condition (I), Required Action (I.1).

"It has been determined by station personnel that a loss of safety function did occur between 1635 [EDT] (when the Keowee Hydro Units were declared inoperable) and 1715 [EDT] (when the Standby Buses were energized from a Lee Combustion Turbine via an isolated power path).

"Investigation has determined the cause of breakers 1GSC-1 and 2GSC-1 being out of their required closed position to be inadvertent bumping while performing station work activities. Breakers 1GSC-1 and 2GSC-1 have been reclosed, and both Keowee Hydro Units have been declared operable as of 2351 [EDT] on 6-16-17."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, June 19, 2017
Monday, June 19, 2017