United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 19, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/18/2013 - 03/19/2013

** EVENT NUMBERS **


48813 48827 48828

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Agreement State Event Number: 48813
Rep Org: NJ DEQ RADIOACTIVE MATERIALS PRGM
Licensee: UNIVERSITY OF MEDICINE AND DENTISTRY
Region: 1
City: NEWARK State: NJ
County:
License #: NJ PI ID #450
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/08/2013
Notification Time: 12:54 [ET]
Event Date: 03/07/2013
Event Time: [EST]
Last Update Date: 03/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME RESOURCES ()

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE DUE TO EQUIPMENT FAILURE

"A patient was treated with a Varian GammaMed plus iX HDR unit on March 7, 2013. The prescription dose was 700 cGy per fraction for 2 fractions, with a prescription dose of 800 cGy for a third fraction. The first two fractions were delivered to the patient as planned, the first fraction on February 26, 2013 and the second on February 28, 2013. The third fraction was to be delivered via tandem and ovoid. The planned tandem dose of 613 cGy was successfully delivered, and the source returned to its shielded position. However, prior to delivery of the ovoid dose of 187 cGy, the HDR unit displayed an error message of 'Electronics Defective error.'

"The staff could not correct the error. The manufacturer was notified and a service technician arrived later in the day to correct the problem. The remaining portion of the fraction was cancelled for the day and re-scheduled. The fractionated dose delivered differed from the prescribed fraction by 23.37%.

"The Varian service technician arrived later in the day and replaced the unit's indexer board, cleaned the indexer belt, tested a spring for tightness and re-set the wheel on the belt. The unit then functioned properly."


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: 48827
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNY HUNTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/18/2013
Notification Time: 16:50 [ET]
Event Date: 03/18/2013
Event Time: 09:10 [EDT]
Last Update Date: 03/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 2 Startup 2 Startup

Event Text

HIGH PRESSURE COOLANT INJECTION INOPERABLE FOLLOWING REFUELING OUTAGE

"On 3/18/2013, with the Unit 2 reactor at approximately 165 psig while in Mode 2 (Startup) following a refueling outage, the high pressure coolant injection (HPCI) system was undergoing post-maintenance testing to demonstrate operability of the system following the performance of major system maintenance. The provision allowed by the Technical Specifications was being used to increase reactor pressure above 150 psig for the purpose of performing operability testing and there was reasonable assurance that the HPCI system had been restored to support successful test results. [However, the HPCI system failed to pass operability testing and] as a result of the inability of the HPCI system to function as required during this testing while above 150 psig, HPCI was not capable of performing its safety function. Reactor pressure was decreased below the Technical Specification 3.5.1 LCO Applicability Requirement of 150 psig and work is in progress to make the needed repairs to support returning HPCI to an operable condition."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48828
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANNY WILLIAMSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/18/2013
Notification Time: 18:00 [ET]
Event Date: 03/18/2013
Event Time: 16:05 [CDT]
Last Update Date: 03/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG WERNER (R4DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO RADIOACTIVE RELEASE ONSITE

"On March 18, 2013, at approximately 1605 CDT, the station commenced notification of the Louisiana Department of Environmental Quality and other offsite governmental agencies that traces of radioactive contaminants were found at the site of an underground pipe leak on station property. This leak could potentially contain tritium and cobalt-60, and is believed to have been contained on the plant site. The leakage path has been isolated. The station is currently starting up following a refueling outage.

"In October 2012, water was found leaking from the ground and accumulating in a ditch near the station's sewage treatment plant. The initial investigation concluded that the source of the leak was domestic water, based on pH sample results, known buried piping in the area, and the fact that the sewage treatment plant operates intermittently. During the recent refueling outage, which started on February 16, it was noted that the leak had stopped. Testing of the potentially affected piping found that the leak was not domestic water, but was actually coming from the sewage treatment plant effluent line. It was determined that the constant leakage seen in October 2012 was due to a failed check valve in the effluent line. This check valve is designed to prevent backflow from the main condenser circulating water system blow-down line. The failed check valve was allowing water from the blow-down line to flow backwards into the sewage plant effluent line and out of the breach. The leak had stopped because the circulating water system blow-down line was shut down at the start of the refueling outage.

"Discharges from the liquid radwaste system also flow into the blow-down line at a point upstream of the connection to the sewage plant effluent line. During planned discharge of liquid radwaste, some of the diluted radioactive water was thus able to leak out on the ground. Samples of the dirt in the area of the leak obtained on March 17 found detectable levels of cobalt 60. No water is available to perform tritium analysis.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi) as a condition requiring notifications to local and state governmental agencies in accordance with the NEI 07-07 Industry Ground Water Protection Initiative."

The leak path has been isolated.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, March 19, 2013
Tuesday, March 19, 2013