United States Nuclear Regulatory Commission - Protecting People and the Environment

Current Event Notification Report for August 28, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/27/2014 - 08/28/2014

** EVENT NUMBERS **


50379 50405 50406 50407 50410

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Agreement State Event Number: 50379
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAYLOR ALL SAINTS MEDICAL CENTER
Region: 4
City: FORT WORTH State: TX
County:
License #: L-02212
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/19/2014
Notification Time: 10:08 [ET]
Event Date: 08/15/2014
Event Time: [CDT]
Last Update Date: 08/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - IODINE-125 SEEDS POSITIONED INCORRECTLY DURING IMPLANTATION

The following information was received via E-mail:

"On August 18, 2014, the licensee notified the Agency [Texas Department of State Health Services] that on August 15, 2014, it discovered that a medical event had occurred. One of the licensee's patients had iodine-125 seed implantation in July 2014 and on August 7, 2014, a post-plan computed tomography scan was performed. During the post-plan evaluation, the licensee discovered that the seeds had not been positioned in the target tissue as prescribed during implantation. The licensee believes that approximately 30 percent of the prescribed dose was delivered to the target tissue. The licensee is evaluating the data to determine actual dosimetrics and will report its calculated dose to the intended and other tissue to the Agency upon completion. The Agency will provide further information in accordance with SA-300."

This event occurred at the Baylor All Saints Medical Center in Fort Worth, Texas.

Texas Incident #: I-9221

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.

* * * UPDATE FROM KAREN BLANCHARD TO CHARLES TEAL AT 1706 EDT ON 8/25/14 * * *

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

"The licensee for this event was initially reported as Texas Oncology, license L-05545. It has been determined that Baylor All Saints Medical Center Radiology Department, license L-02212, is the actual licensee the implantation procedure in this event was licensed under. The licensees are continuing their investigation and will submit a written report within the required 15 days."

Notified R4DO (Pick) and FSME Events Resource via email.

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Power Reactor Event Number: 50405
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN OSBORNE
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/27/2014
Notification Time: 09:13 [ET]
Event Date: 08/27/2014
Event Time: 02:48 [EDT]
Last Update Date: 08/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KEVIN MANGAN (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

SAFETY INJECTION PUMP FAILED TO START

"At 0243 [EDT on 8/27/14] the '11' Safety Injection pump breaker was tagged for scheduled maintenance on the 11SJ34, and the control room entered TSAS 3.5.2.b, action 'A' - a 72 hr LCO. The control room recognized the time line for the repair would require filling the '14' SI Accumulator prior to work completion. The CRS [Control Room Supervisor] decided to perform the '14' SI Accumulator makeup prior to commencing work on the 11SJ34, and directed the NCOs [Nuclear Control Operators] to start the '12' SI pump and make up to the '14' SI Accumulator in accordance with procedure SI.OP-SO.SJ-0002. At 0248, TSAS 3.0.3 was entered when the '12' Safety Injection pump failed to start on demand. At 0301, the '11' Safety Injection pump was restored to service and declared operable and TSAS 3.0.3 was exited. TSAS 3.5.2.b, action 'A' remains in effect due to the '12' Safety Injection pump being inoperable.

"This event is being reported under the requirements of 10 CFR 50.72(b)(3)(v) as 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of systems that are needed to perform mitigation of the consequences of an accident.'''

"Licensee has notified the NRC Resident Inspector. No one was injured as a result of the failure of the '12' Safety Injection pump breaker."

The licensee will notify the Lower Alloways Creek Township.

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Power Reactor Event Number: 50406
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: STEVE LAMBERT
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/27/2014
Notification Time: 09:56 [ET]
Event Date: 08/27/2014
Event Time: 08:39 [EDT]
Last Update Date: 08/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KEVIN MANGAN (R1DO)

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

Event Text

PROCESS RADIATION MONITORS REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"Loss of assessment capability due to preplanned maintenance affecting radiation monitors. Normal ventilation and 'HI' range process radiation monitors (3HVR & RE10A/10B) will be out of service. This condition is reportable per 10 CFR 50.72(b)(3)(xiii). The equipment is expected to be restored within 9 hours."

The NRC Resident Inspector has been notified. The licensee will notify the state and local governments.

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Power Reactor Event Number: 50407
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: FRED SCHWINGHAMER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/27/2014
Notification Time: 12:24 [ET]
Event Date: 08/27/2014
Event Time: 08:05 [CDT]
Last Update Date: 08/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG PICK (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

Event Text

LOSS OF COMMUNICATIONS DUE TO POWER SUPPLY FAILURE

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a loss of communications capability. On August 27, 2014 at 0805 hours CDT the internal phone system, Emergency Notification System (ENS), and Emergency Response Data System (ERDS) became nonfunctional because of a power supply failure.

"The ERDS has been restored to service and work is currently in progress to restore the internal phone system and ENS. It has not been determined at the time of this notification as to when the internal phones system and ENS will be restored to a fully functional status."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 50410
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN STRICKLAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/27/2014
Notification Time: 13:35 [ET]
Event Date: 08/27/2014
Event Time: 05:30 [CDT]
Last Update Date: 08/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

26 OF 40 EP SIRENS COULD NOT BE VERIFIED FUNCTIONAL

"At 0645 CDT on August 27, 2014, Exelon was notified that during the daily test at 0530 CDT of the offsite sirens, the vendor received an alarm on Clinton Power Station siren communications. This Emergency Preparedness (EP) siren communications issue results in 26 of the 40 EP sirens not being verified as functional, which affects 84.4% of the EPZ population. The loss of communications represents more than 25% of the EPZ population for greater than 1 hour and is therefore reportable under 10 CFR 50.72(b)(3)(xiii).

"The cause of issue has been isolated to a microwave link at Clinton Power Station that communicates via radio frequency to each siren. The siren vendor is currently investigating to repair the issue.

"The DeWitt County Emergency Manager has been notified. DeWitt County has implemented the Emergency Message System through 'Code Red' notification in lieu of siren communications.

"The NRC Senior Resident has been notified."

* * * UPDATE FROM RICH CHAMPLEY TO CHARLES TEAL AT 1755 EDT ON 8/27/14 * * *

"The DeWitt County Emergency Manager has been notified. DeWitt County has implemented the backup means of notification called 'Route Alerting' in lieu of siren communications. Route Alerting consists of vehicles and public address systems.

"At 1400 CDT only 2 sirens remain not fully functional. These 2 sirens represent 0.7% of EPZ population. Work continues to restore these 2 sirens.

"The NRC Senior Resident has been informed."

Notified R3DO (Stone).

Page Last Reviewed/Updated Thursday, August 28, 2014
Thursday, August 28, 2014