United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for December 4, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/03/2012 - 12/04/2012

** EVENT NUMBERS **


47719 48535 48552

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Non-Agreement State Event Number: 47719
Rep Org: CAMDEN CLARK MEMORIAL HOSPITAL
Licensee: CAMDEN CLARK MEMORIAL HOSPITAL
Region: 1
City: PARKERSBURG State: WV
County: WOOD
License #: 47-09772-02
Agreement: N
Docket:
NRC Notified By: DAN BERKLEY
HQ OPS Officer: ERIC SIMPSON
Notification Date: 03/05/2012
Notification Time: 16:17 [ET]
Event Date: 02/25/2011
Event Time: 12:00 [EST]
Last Update Date: 12/03/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
KEVIN O'SULLIVAN (FSME)

Event Text

DOSE RECEIVED BY PROSTATE LESS THAN PRESCRIBED

At the request of NRC Region I, Camden-Clark Memorial Hospital reassessed records from a prostate radioactive seed implantation procedure that had been performed on February 25, 2011. The record review indicated that the patient had received roughly 80 percent of the prescribed dose.

"The effect on the patient has been minimal as the desired response was achieved. The long term effect will be under constant follow-up.

"The entire implant process will be reviewed with special attention to real time seed placement and subsequent thirty day image evaluation with respect to NRC regulatory guidelines.

"The attending physician, based on medical judgment, felt that notifying the patient would be harmful. The patient is under the care of oncologic physicians and will be followed appropriately as per his disease type."

* * * UPDATE AT 1636 EST ON 12/03/12 FROM DAN BERKLEY TO S. SANDIN * * *

The licensee is updating the report with the following information:

"That (1) the dose received by the target was less than 80% of the prescribed dose and (2) a small volume of tissue outside of, and adjacent to, the treatment site received a dose that was greater than 10 Gy and more than 50% greater than the prescribed dose to that location."

The licensee discussed this update with R1 (Weidner). Notified R1DO (Jackson) and FSME Events Resource via email.

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: 48535
Rep Org: DOW CORNING
Licensee: DOW CORNING, MIDLAND PLANT
Region: 3
City: MIDLAND State: MI
County:
License #: 21-08362-12
Agreement: N
Docket:
NRC Notified By: DAVID DILLON
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/26/2012
Notification Time: 12:50 [ET]
Event Date: 11/26/2012
Event Time: 09:30 [EST]
Last Update Date: 11/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ANN MARIE STONE (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

PROCESS INSTRUMENT SHUTTER FAILURE

During a routine semiannual periodic inspection, a process gauge with a 15 milliCurie Cs-137 source was identified to have a stuck shutter. The gauge was an Ohmart Model SHF1-A45, S/N 0923GK. The instrument is permanently installed on a distillation column about 30 - 35 ft. from the ground. The integrity of the gauge is fine. Surveys indicated that radiation levels surrounding the gauge were less than 1 millirem per hour.

The same issue involving this specific gauge was reported previously in EN #46913.

The licensee plans on having the gauge repaired by the manufacturer.

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Power Reactor Event Number: 48552
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JORGE L. O'FARRILL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/03/2012
Notification Time: 11:18 [ET]
Event Date: 10/02/2012
Event Time: 09:37 [EST]
Last Update Date: 12/03/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

INVALID ACTUATION SIGNAL OF THE PRIMARY CONTAINMENT ISOLATION LEVEL TRANSMITTER

"This 60-day telephone notification is being made in accordance with the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation signal of the primary containment isolation level transmitter (02-3LT-101A).

"Status of SSC's that were inoperable and contributed to the event:

"The B Reactor Protection System (RPS) was inoperable due to performance of Emergency Diesel Generator (EDG) B & D Load Sequencing test and 4KV Emergency Power System voltage relay instrument functional test. Therefore, the B RPS was deenergized and associated B RPS channels were tripped.

"Narrative:

"On 10/2/2012 at 09:37 hours, James A. Fitzpatrick Nuclear Station received a full reactor scram actuation from reactor vessel level transmitter 02-3LT-101A, containment Isolation. The full scram was due to an equipment malfunction, no low level condition was actually present at the time.

"It was determined that the replacement of refueling water level transmitter 02-3LT-61 on 09/30/12 was incorrectly performed by not properly venting the sensing line after installation. The common sensing line contains a local high point inside the drywell. The mechanism is air displaces the water in the line causing pressure to momentarily drop which causes the instrument to trip as if reactor water level had actually dropped. Air propagation in one sensing line can have an impact on all of the instruments attached to the common sensing line.

"Corrective Actions:

"A back flush was performed for instrument rack 25-5. Applicable I&C Post maintenance testing procedures will be updated to include a back flush or forward flush to ensure that instrument lines are properly vented prior to returning the instrument lines to service.

"The following additional information is provided:

"On 10/2/2012 at 09:45 hours, shift performed OP-18 to reset the scram that occurred at 0937 EST. The procedure provided guidance to install jumpers to allow the scram discharge instrument volume (SDIV) high level scram signal to be bypassed. The jumpers were required since one channel of the RPS was inoperable due to performance of EDG B & D Load Sequencing test and 4KV Emergency Power System voltage relay instrument functional test.

"On 10/2/2012 at 10:07 hours, James A. Fitzpatrick Nuclear Station received another full reactor SCRAM actuation of the SDIV B hi-level trip. The safety function of the actuation had already been completed as a result of the previous scram due to the RPS B bus being de-energized, the SDIV B could not be drained. The SDIV A was also not yet drained, and the high level signal was still technically a valid signal that was present. AOP-1 contained steps to verify that the SDIV A or B 'not drained' annunciators are clear before placing the SDIV by-pass switch to normal position. This step was not performed. It was therefore determined to be an invalid signal based on NUREG-1022 guidance: 'actuations initiated for reasons other than to mitigate an event need not be reported.' The signal was actuated during an attempt to reset the previous SCRAM per OP-18, the occurrence of the signal was due to inadequate work planning, and a procedural deficiency which caused the jumpers to be removed prior to draining the SDIV A. Therefore this event did not meet the criteria for being a valid actuation.

"Additional Corrective Actions:

"Revise OP-18 to provide adequate guidance how to reset a SCRAM with one RPS bus de-energized."

The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, December 04, 2012
Tuesday, December 04, 2012