Event Notification Report for September 28, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/27/2017 - 09/28/2017

** EVENT NUMBERS **


52888 52977 52979 52981 52982 52995

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52888
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: WILLIAM ROBERTS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/04/2017
Notification Time: 17:25 [ET]
Event Date: 08/04/2017
Event Time: 15:11 [EDT]
Last Update Date: 09/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
BINOY DESAI (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

SECONDARY CONTAINMENT INOPERABLE DUE TO OPENING IN SERVICE WATER PIPING

"On August 4, 2017, at 1511 EDT, Unit 1 Secondary Containment was declared inoperable due to a small (i.e., approximately 0.75 inch diameter) hole in Service Water system piping which was found during ultrasonic testing activities. The affected portion of piping penetrates Secondary Containment and flow in the piping creates a vacuum condition; thus bypassing Secondary Containment. The identified hole is being evaluated with respect to its impact on operability of the Service Water system.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.

"This event did not result in any adverse impact to the health and safety of the public.

"Initial Safety Significance Evaluation: The initial safety significance of this event is minimal. At the time of discovery, Unit 1 was at 100% steady state conditions. Reactor Building Ventilation was in service in a normal alignment. No abnormal radioactivity conditions existed within Secondary Containment.

"Corrective Actions: Temporary repair of the affected Unit 1 Service Water piping has been completed. This repair was evaluated by Engineering and it has been determined that the repair meets the requirements to maintain Secondary Containment operable. Unit 1 Secondary Containment operability was restored at 1704 EDT on August 4, 2017."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM MIKE BRADEN TO RICHARD SMITH AT 1447 EDT ON 9/27/17 * * *

"Based upon further evaluation, Duke Energy is retracting Event Notification 52888. The safety objective of Secondary Containment is to limit the release of radioactivity to the environment after an accident so that the resulting exposures are kept to a practical minimum and are within regulatory limits. A bounding engineering evaluation was performed which demonstrates that potential releases from Secondary Containment could not have resulted in offsite or control room doses exceeding regulatory limits. Furthermore, the condition did not impact Technical Specification operability of Secondary Containment in that the ability of Secondary Containment to maintain the required vacuum was not impacted. Therefore, this condition does not represent an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material and is not reportable in accordance with 10 CFR 50.72(b)(3)(v)(C), and the event notification is being retracted."

The NRC Senior Resident was notified of this retraction.

Notified R2DO (A. Masters).

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Agreement State Event Number: 52977
Rep Org: ALABAMA RADIATION CONTROL
Licensee: SCHLUMBERGER
Region:
City:  State:
County:
License #:
Agreement: N
Docket:
NRC Notified By: MYRON K. RILEY
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/19/2017
Notification Time: 13:16 [ET]
Event Date: 09/19/2017
Event Time: [EST]
Last Update Date: 09/26/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - WELL LOGGING SOURCES STUCK DOWN HOLE

The following information was received via fax:

"On September 19, 2017, the [Alabama Department of Public Health] received a phone call from Schlumberger, stating that they had failed to notify the Agency [Alabama Department of Public Health] upon entering the State, to perform a job on September 13, 2017, and that two sources (Cf-252 - 18.3 mCi and Cs-137 - 1.78 Ci) are stuck down hole.

"Schlumberger stated that the first fishing attempt had failed to recover the sources, and the second attempt is now underway. Gathering information is continuing."

Alabama Incident: #17-26


* * * UPDATE FROM MYRON RILEY TO VINCE KLCO AT 1148 EDT ON 9/26/2017 Via Fax * * *

"On September 24, 2017, after several days of fishing for the logging tools, all recovery attempts had been unsuccessful and the sources were cemented in place down hole.

"The licensee will follow up with a written report and a picture of the plaque to be placed on the well head."

Notified R1DO (Bower) and NMSS Events Notification via email.

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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Agreement State Event Number: 52979
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/19/2017
Notification Time: 10:38 [ET]
Event Date: 08/24/2017
Event Time: [EDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED 20% GREATER THAN PRESCRIBED AND GREATER THAN 50 REM TO THE TARGETED AREA

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

"Emory University had new software installed for their HDR on 2/2/2016. During the time span of 3/2016 through 6/2017 [five] 5 patients received doses that were greater than 20% [percent] and greater than 50 rem to the targeted area. The misadministration was due to a software defect with Elekta's Oncentra Brachy Software version 4.5.2. using the ring applicator. The licensee was only aware of the defect on Aug 22, 2017 when Elekta notified all of their customers of the defect. Emory unofficially notified the State of Georgia on Aug 24, 2017 of a possibility that several of their patients may have been involved in a medical event. The medical event was confirmed on Sept 19, 2017 that [five] 5 patients were involved in a medical event.

"Cause and Corrective Actions: The events were due to a software issue utilizing the Oncentra Brachy Software version 4.5.2. A misadministration occurred due to an inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size.

"Device/Associated Equipment: Oncentra Brachy Software version 4.5.2. in a Elekta Nucleotron MicroSelection v3 HDR using a ring applicator."

The targeted area that received the greater than 50 rem was the tissue of the upper vaginal wall.

The defect in the equipment is identified and described in EN #52922.

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: 52981
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: WELDING TESTING X-RAY, INC.
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-3266-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/20/2017
Notification Time: 16:39 [ET]
Event Date: 09/20/2017
Event Time: [CDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GRETCHEN RIVERA-CAPE (NMSS)

Event Text

AGREEMENT STATE REPORT - POTENTIAL TEDE EXPOSURE IN EXCESS OF 25 REM

Louisiana Department of Environmental Quality called to report a potential overexposure.

Welding Testing X-Ray, Inc., contacted Louisiana Department of Environmental Quality to report an irregular excessive whole body badge exposure for a radiographer. The badge was for August 2017 reporting period of August 1 through 31, 2017. The whole body badge exposure reflected 754 rem.

This individual worked as part of a two man crew at various jobsites. All of the other crew members readings were within the expected range for typical trained radiographers. The individual was advised to contact REAC/TS [Radiological Emergency Assistance Center / Training Site] in Oak Ridge, TN for blood testing and cytogenetic testing. The individual did not exhibit any skin irritations or other signs of radiation sickness.

The licensee is investigating the exposure. Louisiana State advised the licensee to remove the individual from radiation work until the issue is resolved.

Event Report ID No.: LA-2017-0015

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Agreement State Event Number: 52982
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GPD GEOTECHNICAL SERVICE, LLC
Region: 3
City: AKRON State: OH
County:
License #: 31210780024
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/20/2017
Notification Time: 16:03 [ET]
Event Date: 09/15/2017
Event Time: [EDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following information was received via e-mail from the state of Ohio:

"On 9/15/17 at approximately 11:15 AM, the Ohio Department of Health (ODH) was notified by GPD Geotechnical Service, LLC. that a portable gauging device (CPN Model MC-1-DRP which contained a 10 mCi Cesium-137 source and 50 mCi Americium-241:Be source) had been run over and that the device had sustained heavy damage to the casing and the source handle was broken off. The gauging device was run over by a piece of construction equipment at their jobsite located at 225 Elyria Street, Lodi, OH 44254.

"An ODH inspector, responded to the location of the incident and was met by the licensee's RSO. The inspector was lead to the gauging device which had been surveyed and had been determined to have no abnormal radiation readings and that both radioactive sources were intact and properly secured with in the device. The device was secured in its transportation case and placed in the field technician's vehicle. The inspector also conducted a wipe test with no abnormal readings observed.

"In an interview with the field technician the inspector determined that the technician was approximately 10 to 15 feet away from the device but did not have direct line of site to the device as it was partially obstructed due to the construction equipment. It was also observed by the inspector that the equipment operator's view of the gauging device was obstructed due to the configuration of the equipment and the proximity in which the device was placed on the ground in front of the equipment.

"Licensee's leak test showed no removable contamination and the device has been sent to a service provider for repair."

Item Number: OH170005.

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Power Reactor Event Number: 52995
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TIMOTHY GATES
HQ OPS Officer: RICHARD SMITH
Notification Date: 09/27/2017
Notification Time: 14:26 [ET]
Event Date: 09/27/2017
Event Time: 10:00 [CDT]
Last Update Date: 09/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID PROULX (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation

Event Text

ACCIDENT MITIGATION - LOSS OF SECONDARY CONTAINMENT

"Security personnel reported to the Main Control Room that at time 1000 CDT [on 9/27/2017], an alarm indicated that a secondary containment door was open beyond the normal delay time allowed for entry and exit. Security personnel responded and found the door open and unattended with the dogs extended meaning that the door was unable to be closed. Security personnel secured the door at time 1004 CDT. No deficiencies were found with the door. The fact the door was open and unattended beyond the time allowed for normal entry and exit results in Technical Specification 3.6.4.1 'Secondary Containment-Operating,' not being met because surveillance requirement SR 3.6.4.1.3 is not met. This surveillance requires that doors be closed except during normal entry and exit. By definition in NUREG-1022, when Secondary Containment is inoperable, it is not capable of performing its specified safety function which in turn makes this condition reportable in accordance with 10 CFR 50.72(b)(3)(v)(D)."

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Thursday, March 25, 2021