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Event Notification Report for December 13, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/12/2017 - 12/13/2017

** EVENT NUMBERS **


52263 53097 53102 53103 53115 53116 53117 53118

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Agreement State Event Number: 52263
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: BRYCE CORPORATION
Region: 4
City: SEARCY State: AR
County:
License #: ARK-0819-0312
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: VINCE KLCO
Notification Date: 09/26/2016
Notification Time: 16:14 [ET]
Event Date: 09/22/2016
Event Time: [CDT]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON DENSITY GAUGE

The following information was provided by the State of Arkansas via email:

"On September 23, 2016 at 1300 CDT, the licensee contacted the Department [Arkansas Department of Health] reporting that during operations on September 22, 2016, the licensee discovered that the shutter on a Vega Americas Model BAL density gauge would not open. The gauge contains 300 milliCuries of Krypton-85.

"The gauge was replaced with a spare gauge and has been placed in a secure storage area and radiation exposure is maintained at less than 2 mR/hr.

"The licensee is contacting the manufacturer to request repair or disposal of the gauge.

"In accordance with RH-1502.f.2 (10 CFR 30.50(b)(2)) the malfunctioning shutter is reportable within 24 hours.

"The State of Arkansas is awaiting a written report from the licensee. The State's event number is AR-2016-011."

* * * UPDATE AT 1021 EST ON 12/12/2017 FROM STEVE MACK TO MARK ABRAMOVITZ * * *

The following update was received via e-mail:

"The licensee stated that the shutter solenoid was 24 years old and had been in continuous service over that time. The shutter failed to open on September 22, 2016 and the gauge was removed from service and placed in storage. On November 28, 2017, the manufacturer took possession of the gauge for disposal.

"The Department considers this event to be CLOSED."

Notified the R4DO (Deese) and NMSS Events Notification (E-mail).

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Agreement State Event Number: 53097
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTECK ASSET INTEGRITY MANAGEMENT, INC.
Region: 4
City: LONGVIEW State: TX
County:
License #: 06801
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/30/2017
Notification Time: 08:49 [ET]
Event Date: 11/28/2017
Event Time: [CST]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY TRAINEE OVEREXPOSURE

The following report was received via e-mail:

"On November 28, 2017, the Agency [Texas Department of State Health Services] was contacted by the licensee's Radiation Safety Officer (RSO) who reported that on November 28, 2017, they were notified by their dosimetry processor that one of their radiographer trainee's exposure badges was reported to read 62 Rem. The RSO stated the trainee was returning to the Longview office from West Texas to be interviewed. The badge reading was for the month of October 2017. The RSO stated the trainee had operated the radiography camera crank out device, but had not changed out any film. It is believed the dose is to the badge only. The RSO stated they had not observed any adverse health effects in the trainee. On November 29, 2017, the Agency contacted the RSO and requested additional information. The RSO stated the trainee stated that they had not dropped their dosimeter and accidently exposed it. The trainee had stated that they had been wearing an alarming rate meter and it had never alarmed. The trainee's daily exposure record did not indicate any abnormal exposures. The radiographer supervising the trainee did not recall any abnormal operations while supervising the trainee. The RSO stated the trainee had not received any type of medical treatments during the exposure period. The RSO stated they were considering sending blood samples to REAC/TS for analysis. The RSO stated the dosimetry processor reported the exposure to the badge was angular. The RSO stated the trainee has been assigned duties that would not give them any additional exposure.

"The licensee will provide the Agency [Texas Department of State Health Services] any information gathered in the interview with the trainee. The RSO cannot state with certainty that the exposure is not real, therefore the Agency is providing this report to the Nuclear Regulatory Commission. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9523


* * * UPDATE ON 12/12/2017 AT 0955 EST FROM ART TUCKER TO STEVEN VITTO * * *

The following report was received via e-mail:

"On November 28, 2017, the Agency was contacted by the licensee's RSO who reported that the OSL [Optically stimulated luminescence] badge reading for one of their radiographer trainees was reported to read 62 rem. On December 8, 2017, the Agency interviewed the individual with the high badge reading and the licensee's radiation safety officer (RSO). The interviews did not provide any additional information that would explain the high badge reading. The RSO stated a blood sample from the individual was submitted to Radiation Emergency Assistance Center/Training Site (REAC/TS) on December 5, 2017. Additional information will be provided as it is received in accordance with SA-300."

R4DO (Deese), INES Officer (Milligan), and NMSS Events Group have been notified.

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Agreement State Event Number: 53102
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MCNDT LEASING
Region: 3
City: CHANNAHON State: IL
County:
License #: IL-01875-01
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/04/2017
Notification Time: 16:07 [ET]
Event Date: 12/01/2016
Event Time: [CST]
Last Update Date: 12/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE CONNECTION

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

"Illinois Emergency Management Agency discovered a radiography incident involving McNDT Leasing, which had not been properly reported. The incident involved an exposure device (QSA Global model 880 Delta, serial #D13616) and a 3.7 TBq (100 Ci) Ir-192 source. A radiography team arrived at a job site on 12/1/2016 and, during equipment set up, noticed the drive cable connector was bent. Upon obtaining a new crank assembly, the team could not successfully crank out the source. The reel of the crank assembly did not move. After another failed attempt, they detached the crank assembly from the exposure device and noticed that place where the connector attaches to the source pigtail was worn and bent. The team returned to their facility and exchanged exposure devices. Preliminary investigation indicated that either the exposure device was damaged in previous work and had not been reported, or daily inspection and maintenance checks were inadequate or not performed prior to 10/11/2017. Corrective actions included obtaining new equipment.

"No exposures occurred since the source was not able to be cranked out of the device."

"Device/Equipment: Camera/ Radiography
Manufacture: QSA Global, Inc.
Model Number: 880 Delta
Equipment Serial Number: D13616

"Radionuclide: Ir-192
Activity: 100 Ci"

Illinois Item Number: 170517

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Agreement State Event Number: 53103
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CARE SOUTHERN LAKES, INC
Region: 3
City: KENOSHA State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: DAVID REINDL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/04/2017
Notification Time: 16:52 [ET]
Event Date: 12/04/2017
Event Time: 11:00 [CST]
Last Update Date: 12/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED Y-90 DOSE

The following was received from the State of Wisconsin via email:

"On December 4, 2017, the department [State of Wisconsin Department of Health Services] received a telephone call and email from the licensee's lead nuclear medicine technologist about a Y-90 TheraSphere dose that was not delivered as prescribed to the patient. The procedure occurred at 11:00 AM on December 4, 2017. The written directive stated that the dose delivered should be 120 Gy. The estimated dose delivered to the liver was 17.7 Gy. The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment. The licensee is suspecting that there was an issue with the administration kit. The licensee has contacted the manufacturer and the manufacturer is planning a site visit. The licensee has removed the contaminated administration kit and placed it in a waste bag for decay in storage. The room where the administration occurred has also been cleaned. The department [State of Wisconsin Department of Health Services] will follow up with a site visit to investigate the incident.

"Event Report ID No.: WI170019"

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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Power Reactor Event Number: 53115
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RYAN MEYER
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/12/2017
Notification Time: 17:40 [ET]
Event Date: 12/12/2017
Event Time: 09:18 [CST]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 16 Power Operation 16 Power Operation

Event Text

AUTOMATIC START OF EDG DUE TO LOSS OF ESF TRANSFORMER

"At approximately 0918 CST on Tuesday, December 12, 2017, the Grand Gulf Nuclear Station experienced a loss of the Engineered Safety Features (ESF) Transformer 11 which was powering the Division 1 ESF bus. Subsequently, the station experienced an automatic start of the Division 1 Emergency Diesel Generator [EDG], partial isolation of the primary and secondary containment buildings and the isolation of the Reactor Core Isolation Cooling System [RCIC].

"It is not currently understood why the RCIC system isolated during this event. A team is investigating this issue separately from the loss of the ESF 11 transformer.

"The cause of the event is under investigation at this time.

"No other issues or unexpected events occurred.

"The NRC Resident Inspector has been notified of the event."

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Power Reactor Event Number: 53116
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/12/2017
Notification Time: 17:52 [ET]
Event Date: 12/12/2017
Event Time: 15:19 [CST]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICK DEESE (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

OFFSITE NOTIFICATION DUE TO INADVERTENT ACTUATION OF EMERGENCY NOTIFICATION SIREN

"A South Texas Project [STP] Offsite Emergency Notification Siren (#7) was inadvertently going off. A resident who lived near the siren notified the Matagorda County Sheriff's Office at 0905 CST of the event and subsequently left a message with the STP Emergency Response staff. The Emergency Response staff dispatched maintenance to repair the siren and then later notified the Control Room at 1519 CST that the Sheriff's department was notified. The siren was inspected and reset. No issues were found with the siren.

"The Matagorda County Sheriff's Office was the only offsite agency that has been notified.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 53117
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: WESLEY MARSHALL
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/12/2017
Notification Time: 20:34 [ET]
Event Date: 12/12/2017
Event Time: 13:30 [CST]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 15 Power Operation 15 Power Operation

Event Text

HIGH PRESSURE CORE SPRAY DECLARED INOPERABLE

"At approximately 1330 CST on Tuesday, December 12, 2017, Grand Gulf Nuclear Station declared Division 3 'C' Battery inoperable due to questions concerning battery terminal connection continuity. Technical Specification 3.8.4, DC Sources - Operating, Condition E, Required Action E.1, requires the station to declare the High Pressure Core Spray System inoperable immediately. The Division 3 'C' Battery and High Pressure Core Spray System was declared operable and the LCOs [Limiting condition of operation] were declared met at 1731CST on Tuesday, December 12, 2017. Based on field measurements of terminal torque and resistance, the as-found and as-left terminal resistance micro-ohm readings indicated satisfactorily all times. Formal evaluation of the as-found condition of the battery is in progress.

"This report is to notify the NRC of a loss of safety function on the High Pressure Core Spray System."

The NRC Resident Inspector was notified.

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Power Reactor Event Number: 53118
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT TATRO
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/12/2017
Notification Time: 23:04 [ET]
Event Date: 12/12/2017
Event Time: 17:57 [CST]
Last Update Date: 12/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICK DEESE (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

UNPLANNED LOSS OF EMERGENCY RESPONSE EQUIPMENT

"At 1757 CST on December 12, 2017, South Texas Project Electric Generating Station (STPEGS) Unit 1 and Unit 2 experienced an unplanned partial loss of the Integrated Computer System (ICS). The partial loss of Unit 1 and Unit 2 ICS resulted in a major loss of emergency assessment capability to STPEGS Unit 1 and Unit 2 Technical Support Center (TSC) for greater than 75 minutes. Assessment capability has been verified to be available in the Emergency Operations Facility (EOF).

"This report is being made pursuant to 10 CFR 50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability, off site response capability, or off site communications ability.

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Thursday, December 14, 2017
Thursday, December 14, 2017