United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for September 24, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/21/2012 - 09/24/2012

** EVENT NUMBERS **


48303 48307 48308 48328 48332 48333 48334

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Agreement State Event Number: 48303
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOSEPH M. MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/13/2012
Notification Time: 12:05 [ET]
Event Date: 09/11/2012
Event Time: [EDT]
Last Update Date: 09/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDEREXPOSURE USING YTTRIUM-90 SIR-SPHERES TREATMENT

The following event was received from the Commonwealth of Pennsylvania via facsimile:

"Event type: A medical event (ME) involving the administration of yttrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).

"Notifications: On September 12, 2012, an inspector was performing a reactive inspection for a recent event (PA120026) that occurred on August 23, 2012. During the inspection the licensee reported another similar Sir-Sphere event.

"Event Description: A patient was being treated for disease of the liver with 33.04 millicuries (mCi) of Y-90 and received 25.6 mCi resulting in 77.5% of the intended dose. The treating physician, who also is the referring physician, notified the patient.

"Cause of the Event: Currently under investigation and unknown at this time.

"Actions: No harm to the patient is expected. The Department's reactive inspection occurring on September 11, 2012 incorporated this new event and therefore no new inspection is planned."

PA Report Number: 120030

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: 48307
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA DEPARTMENT OF TRANSPORTATION
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-031
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 13:22 [ET]
Event Date: 09/13/2012
Event Time: 09:00 [MST]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENT RESOURCES (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN HUMBOLDT NUCLEAR GAUGE

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

"At approximately 9:00 AM September 13, 2012, the [Arizona Radiation Regulatory] Agency was informed that the Licensee had a Humboldt Model 5001, SN 3920, portable gauge stolen from the back of a truck. The theft occurred between 9:00 PM September 12, 2012, and 6:00 AM September 13, 2012. The gauge was locked in a 16 gauge steel box bolted to the bed of the truck which was parked unattended at an employee's resident. The gauge contains 370 MBq (10 mCi) of Cesium-137 and 1.62 GBq (44 mCi) of Am:Be-241.

"El Mirage PD is investigating and has issued report number 12-09000902.

"The Agency continues to investigate this event.

"The Governor's Office, the States of CA, NV, CO, UT and NM and Mexico and U.S. NRC and U.S. FBI are being notified of this event."

Arizona Event Number: 12-020

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

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Agreement State Event Number: 48308
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: ANDERSON REGIONAL MEDICAL CENTER
Region: 4
City: MERIDIAN State: MS
County:
License #: MS-267-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 16:57 [ET]
Event Date: 09/10/2012
Event Time: [CDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - A PATIENT RECEIVING AN INCORRECT DOSAGE OF I-131

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

"On 9-10-2012, the licensee administered 163 mCi of I-131 from an admission order dated 9-6-2012, instead of the prescribed 100 mCi of I-131 from the written directive dated 9-5-2012. The licensee's investigation revealed a misinterpretation of an admission order as a written directive by the nuclear medicine technologist due to inclusion of the authorized user's name and 150 mCi of a radionuclide activity on the admission order. The written directive was never received by the Nuclear Medicine Department. The licensee determined the root cause of the error stemmed from a new communication process by which written directives are conveyed from the authorized user to Central Scheduling and then to the Nuclear Medicine Department.

"The administered dose is described as not out of line with doses typically prescribed for patients with similar disease and the authorized user indicates an expectation of no adverse effect for the patient. The referring physician and patient were both notified on 9-10-2012 by the authorized user.

"The licensee is correcting its procedure for written directives and how they are communicated to the Hospital's Nuclear Medicine Department and will submit them for review to DRH."

Mississippi Event Report No.: MS-267-01

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: 48328
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN LOGAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/21/2012
Notification Time: 01:20 [ET]
Event Date: 09/20/2012
Event Time: 20:35 [CDT]
Last Update Date: 09/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (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

TECHNICAL SUPPORT CENTER VENTILATION INOPERABLE

"At 2035 CDT on 9/20/2012 power was removed from the Technical Support Center ventilation for planned maintenance on the supply breaker and the supply breaker cubicle. At 2109 CDTduring restoration, it was discovered that the breaker for the Technical Support Center ventilation could not be closed.

"The cause for not being able to close the supply breaker is unknown. Troubleshooting is currently in progress and the Technical Support Center ventilation is expected to be returned to service on 09/21/2012.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev.2 since this work activity affects an emergency response facility."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48332
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: ANDREW MITCHELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/21/2012
Notification Time: 18:48 [ET]
Event Date: 09/21/2012
Event Time: 14:49 [CDT]
Last Update Date: 09/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MARK RING (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

DRYWELL RADIATION MONITOR INOPERABLE

"At 1449 CDT on September 21, 2012, the 2B Drywell Radiation Monitor was found downscale during control room panel monitoring. This monitor provides the input into one division of the primary containment isolation logic for a Group II isolation. As a result, the channel was placed in a tripped condition at 1515 hours in accordance with Technical Specification 3.3.6.1, Condition B.

"Initial troubleshooting indicates that one of the two divisions of the isolation logic was inoperable. Given both divisions are required to complete the Group II isolation logic, this condition is reportable in accordance with 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.

"The station is currently taking action to restore the 2B Drywell Radiation Monitor to an operable condition.

"The NRC Senior Resident Inspector has been notified.

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Power Reactor Event Number: 48333
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: REX REISSNER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/21/2012
Notification Time: 20:28 [ET]
Event Date: 09/21/2012
Event Time: 14:00 [EDT]
Last Update Date: 09/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

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

UNANALYZED CONDITION IDENTIFIED IN APPENDIX R FIRE SCENARIO

"On September 21, 2012, a condition was identified where hydrogen may become entrained in the charging pump suction after the credited pump is restarted as part of the alternate shutdown procedure for the Auxiliary Building basement and mezzanine levels.

"An air operated valve separates the Volume Control Tank (VCT) from the charging pump suction and this valve fails open on loss of air or power caused by the postulated fire. The alternate flow path from the Refueling Water Storage Tank (RWST) fails closed on a loss of air or power. A manual valve is provided to bypass this closed valve. However, due to hydrogen pressure in the VCT and the potential for significant pressure losses in the piping from the RWST to the charging pump suction, insufficient elevation head exists in the RWST to ensure that hydrogen will not become entrained. If this condition is left unmitigated, the credited charging pump is assumed to fail.

"Due to the location of the postulated fire and its impact on equipment and cables, no other inventory makeup sources are credited.

"Compensatory Measures have been implemented as follows:
1. All fire detection and suppression systems in the Appendix R fire zones have been verified functional.
2. All Hot Work in the area has been suspended.
3. Continuous Fire Watch has been posted in the Appendix R fire zone.
4. Combustion engine powered vehicles are restricted from entering the Auxiliary Building.
5. Within 24 hours remove all non-attended transient combustible materials from Appendix R fire zones.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48334
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAN WILLIAMSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/21/2012
Notification Time: 21:29 [ET]
Event Date: 09/21/2012
Event Time: 16:00 [EDT]
Last Update Date: 09/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

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

ISOLATION VALVES COULD FAIL TO FULLY CLOSE

"A review of load sequencing during a design basis loss of coolant accident (LOCA) with offsite power available has identified an issue with 24 motor operated valves (MOVs - 12 per unit). These valves all use limit switch 8 (LS-8) as an isolation permissive and may indicate closed if they are in a dead band zone when stroking closed from a containment isolation signal at the time of the load shed. The valves will then not resume movement to full isolation when power is restored potentially impacting containment leakage. This condition could occur during specific LOCA conditions, dependent on several variables.

"The systems affected by this issue are:
- RWCU
- DWCW
- PCIG
- CAC
- Suppression Pool Cleanup

"Actions are in progress to resolve the LS-8 issue with a modification to remove this vulnerability. Appropriate testing will be done to prove that all valves perform their required safety function after the modifications are complete for each valve.

"All affected valves are either closed and de-energized, or have been modified at this time."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, September 24, 2012
Monday, September 24, 2012