Event Notification Report for March 27, 2013

SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE EXCEEDING NRC REPORTING LIMITS

"Per 10 CFR 20.1906(d)(1), [the Veterans Health Administration (VHA) is] reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.

"The package was received today (March 27, 2013) around 12:48 PM CDT by South Texas Veterans Health Care System, San Antonio, Texas. This medical center holds permit number 42-15881-01 under the VHA master materials license.

"Wipe tests performed on the external surface of the package indicated a removable contamination level of 993 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters.

"The package contained one 30-millicurie dosage of Technetium-99m and was shipped and delivered by Cardinal Health in San Antonio, Texas. The inner packaging materials were slightly contaminated but the dosage itself was not impacted and was able to be used.

"The VA facility Nuclear Medicine Technologist immediately notified, by telephone, the Radiation Safety Officer at Cardinal Health about the contaminated package.

"As corrective actions: the packaging materials were bagged and set aside in a restricted area at the medical center for decay; staff with access to the area were notified about the contaminated packaging materials; and surveys were performed in the package receipt area to ensure that contamination was not spread beyond the area.

"[Veterans Health Administration] notified NRC Region III (K. Null) by telephone of this event."

PART 21 REPORT - FOXBORO POWER SUPPLY POTENTIAL FAILURES DUE TO DEFECTIVE TIE WRAPS AND HOLDERS

Mr. John F. Brosemer, President of Integrated Resources, Inc., reported discovery of repeated defects in Foxboro Meter Company's N-2ARPS-A6, Style D power supplies. When manufactured, the power supplies utilized Thomas and Betts TC105A aluminum wire tie holders in random numbers and placements. As the power supplies age, the tie wrap holder adhesive degrades and the tie wraps embrittle resulting in the separation of the tie wraps and loss of holder adhesion to the power supply enclosure. This causes the wraps and holders to fall to the bottom of the enclosure which could result in shorts when the aluminum comes in contact with electronic components. In one particular power supply, all tie wrap holders in use failed and separated from the enclosure.

The power supplies are used in Foxboro SPEC-200 cabinetry that are used throughout the industry. At the time of this notification, Integrated Resources has one power supply from Three Mile Island and two power supplies from Ft. Calhoun undergoing refurbishment. Integrated Resources will be following up this telephonic notification with a written report once their internal investigation is done.

Recommended corrective actions are for affected facilities to open and inspect all power supplies and remove the aluminum tie wrap holders and replace the tie wraps and holders with Teflon types.

* * * UPDATE FROM BROSEMER TO SNYDER AT 1530 EDT ON 4/1/13 * * *

"Suspecting this to be a common mode failure IRI [Integrated Resources, Inc.] opened and inspected two Foxboro N-2ARPS-A6 power supplies which were sent to IRI for refurbishment by Fort Calhoun Nuclear Station. Examination revealed that both of the power supplies have the same failures of the tie wrap aluminum mounting plates adhesive with the majority of the plates being held on the wire bundles by age embrittled nylon wire ties.

"Confirmation of the common mode failure by inspection of the Fort Calhoun Nuclear Stations was on or about 1530 CDT on March 27, 2013.

"IRI is not the OEM or Original supplier for this power supply and cannot provide the number nor locations of these components. However, by searching the RAPID database IRI has found the power supplies at the following:

"Arizona Public Service - Palo Verde Nuclear Generating Station; Constellation Energy - Nine Mile Point Nuclear Power Plant; Detroit Edison - Fermi 2 Nuclear Power Plant; Dominion Nuclear - Millstone Nuclear Power Plant; Dominion Nuclear - Kewaunee Nuclear Power Plant; Eletronnuclear - Angra Nuclear Power Plant; Entergy Nuclear - Arkansas Nuclear One; Entergy Nuclear - Indian Point Energy Center; Entergy Nuclear - Pilgrim Nuclear Power Plant; Entergy Nuclear - J. A. Fitzpatrick Nuclear Power Plant; Exelon Corporation - Three Mile Island Nuclear Plant; Exelon Corporation - Peach Bottom Atomic Power Station; NextEra Energy - Point Beach Nuclear Power Plant; Progress Energy Florida - Crystal River Nuclear Power Plant; Southern California Edison - San Onofre Nuclear Generating Station.

"IRI suspects several other utilities and units are affected by this report.

Corrective action taken: "IRI's preliminary suggestion is inspection and removal of failed tie wrap mounting plates which are being held on to wire bundles by aging nylon tie wraps. IRI also suggests replacement of age embrittled nylon tie wraps with Tefzel tie wraps."

Contact Information:
John F. Brosemer; President
Integrated Resources, Inc.
113 South 9th Street
Nebraska City, NE 68410

Notified R1DO (Dwyer), R2DO (Seymour), R3DO (Daley), R4DO (Kellar) and Part 21 Reactors (Email).

* * * UPDATE FROM JOHN BROSEMER (VIA EMAIL) ON 8/21/13 AT 1628 EDT * * *

"IRI's final recommendations are to remove all Thomas and Betts Co. model TC105A wire tie holders and to replace any embrittled wire ties with TEFZEL wire ties in all of the affected Foxboro Co. power supplies.

"IRI also discovered during the course of the investigation that Thomas and Betts Co. supplied these wire tie holders through normal distribution to all of the manufacturers. IRI recommends that the industry, during normal inspections, inspect for the these types of wire tie holders in all other installed equipment and to remove the failed wire tie holders."

Notified R1DO (Schmidt), R2DO (Haag), R3DO (Kozak), R4DO (Werner) and Part 21 Reactors (via email).

AGREEMENT STATE REPORT - UNDER DOSE IN BRACHYTHERAPY TREATMENT DUE TO USE OF WRONG LENGTH GUIDE WIRE

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

"On March 28, 2013, the Agency [Texas Department of Health] was notified by the licensee that a medical event occurred on March 27, 2013. The licensee stated that the wrong length guide wire was used during 3 of 4 HDR [High-Dose Rate Brachytherapy] treatments. The error was discovered after the third treatment. The Radiation Safety Officer (RSO) stated the desired area of treatment was under dosed by more than 50 percent. The treatment plan prescribed 2400 cGy over 4 treatments. He stated that the patient and their physician were notified as soon as the error was discovered. The RSO is not at the facility and is trying to gather the information on the event over his phone. The licensee has suspended all HDR treatments until their process and procedures have been reviewed. Additional information will be provided as it is received in accordance with SA - 300.

"Texas Incident #: I-9059"

* * * UPDATE ON 4/11/13 AT 2126 EDT FROM ART TUCKER TO DONG PARK * * *

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

"On April, 9, 2013, the licensee provided the following information: The Physicist of record retrieved tube connectors from the HDR supplies on shelves in the dosimetry area. The tube/connectors were stored, coiled in Ziploc bags. The Physicist selected green tubes when he saw the black tubes used previously were not on the shelf. He was unaware that there were two sets, each a different length when he selected the green set. The black tubes measure 120cm in length and the green tubes measure 132cm. The Senior Physicist, who was on vacation during the first two out of the four treatments, stored the black tube set in a drawer across the room. Physicist selected tubes which attached to the patient's treatment device. The Physicist planned the patient's treatment with the treatment lengths (119.9 cm) stated in our facility's HDR tandem and ring treatment planning procedure and forms but used the 132cm tube for the treatment delivery for three out of four fractions. Only the black tubes were used historically in tandem and ring HDR procedures and since their given length were known, they were not measured at the time of treatment delivery. The green tubes were also not measured prior to treatment delivery. The Physician of record saw the green tubes and believed their use was intentional. This medical event meant the patient's tissue to be treated (cervix) received less total radiation dose than that prescribed: 1,390 cGy (mean dose delivered) vs. the 5,139 cGy the cervix would have received over the four treatments. This is more than a 50 cGy (50 rem) effective dose equivalent difference to the cervix. In addition, the mean total dose delivered to the cervix over the four treatments differed from the prescribed dose by more than 20% (42.1% is the actual variance) and the delivered dose for at least one of the fractions differed by more than 50% from the prescribed dose (fraction #1 cervix mean dose delivered was 42.5 cGy vs. the 1,192.4 cGy expected) (fraction #2 cervix mean dose delivered was 34.6 cGy vs. the 1,416.3 cGy expected) and (fraction #3 cervix mean dose delivered was 45.2 cGy vs. the 1,262.2 cGy expected). The patient's urethra received a mean dose of 1,607 cGy for the four fractions. The maximum dose to 1 cc of the urethra for the four fractions was 1,849 cGy. The patient's anterior vagina received a mean dose from the four fractions of 1,549 cGy. The maximum dose to 1 cc of the anterior vagina for the four fractions was 3,049 cGy. The Agency [Texas Department of Health] has requested additional information from the licensee. Additional information will be provided in accordance with SA 300."

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

* * * UPDATE AT 1107 EDT ON 5/17/2013 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The reference to a guide "wire" in the initial report was incorrect. An incorrect guide "tube" was used. Additionally, the title should have stated "GUIDE TUBE."

Notified the R4DO (Walker).

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.

ONE EMERGENCY WARNING SIREN ENERGIZED FOR A SHORT TIME

"At 2245 [EDT] on 3/27/2013, Surry Power Station (SPS) Operations Department received a report from Virginia State Emergency Operations Center (VEOC) that a concerned citizen had called James City County (JCC) law enforcement to report that an Early Warning System (EWS) siren, #62 in James City County NW side of Route 682, was sounding. VEOC reported JCC police received call at 2240 [EDT] from a concerned citizen that an EWS siren was sounding. SPS Security contacted JCC police and subsequently reported that JCC police responded approximately 10 minutes later to the site of the siren, but the siren was no longer sounding. Maintenance will investigate in the morning. All plant conditions/parameters are normal and no releases to the environment have occurred.

"The site NRC Resident Inspectors have been notified.

"This notification is being transmitted due to notification of other Government Agencies in accordance with 10CFR50.72(b)(2)(xi)."

The licensee also notified the state and local governments.

* * * UPDATE FROM JASON SWEATMAN TO STEVE SANDIN ON 4/2/2013 AT 1710 HOURS * * *

"This report is being retracted based upon the following:

"On 3/28/13, an activation verification test was performed. The results of the test indicated EWS siren #62 did not activate. In addition, when a siren activates, the battery voltage decreases. A review of the battery voltage trend for siren #62 found no such decrease, verifying no activation occurred. Maintenance staff reported to the siren location and confirmed the siren did not activate. They also found no indication of tampering or intrusion. Three local homeowners were interviewed and stated they did not hear any siren activation.

"By all available indications, EWS siren #62 was functional and did not activate on 03/27/13.

"NRC Site Resident Inspectors have been notified of the retraction."

Notified R2DO (McCoy).

REACTOR PRESSURE BOUNDARY LEAKAGE

"On March 26, 2013, at 1635 [CDT], with Unit 1 shutdown for refueling, leakage was identified from the 2-inch reactor head vent line during a Reactor Pressure Vessel (RPV) pressure test. The leakage was approximately 20 drops per minute. The RPV pressure test was stopped and the reactor vessel depressurized to facilitate examination of the piping and associated flange connections. At 0245 hours on March 27, 2013, the leak was confirmed to be through-wall originating from a socket weld (i.e., pipe elbow). The cause and resolution are under evaluation. The condition is being reported under 50.72(b)(3)(ii)(A) given the defect was associated with the primary coolant system pressure boundary."

The licensee notified the NRC Resident Inspector

SAFETY INJECTION ACTUATION DURING TESTING

"On March 27, 2013 at 0601 EDT, the Safety Injection System automatically actuated while in Mode 3 during performance of I&C [Instrument and Control] testing due to faulty test equipment. All plant equipment responded normally to the safety injection. This is reportable under 10 CFR 50.72(b)(2)(iv)(A). The plant is stable in Mode 3 at this time.

"The Auxiliary Feedwater System actuated following the safety injection signal as expected. This is reportable under 10 CFR 50.72(b)(3)(iv)(A). The unit remains on offsite power and all electrical loads are stable. No primary or secondary relief valves lifted. The plant is in Hot Standby at 1140 psig and 395 degrees F with decay heat removal using auxiliary feedwater to the steam generators and normal heat removal through the atmospheric steam dumps. There was no radiation released.

"Indian Point Unit Two was not affected by this event and remains at 100% power.

"Notified NRC Resident Inspector. Notified NRC Emergency Operations Center Duty Officer."

The Safety Injection was reset and all plant equipment was restored to normal alignment. Pressurizer level remained in the indication range during the Safety Injection. The cause of the Safety Injection is still under investigation, but appears to be related to a faulty jumper necessary for the test.


* * * UPDATE FROM MICHAEL McCARTHY TO DONALD NORWOOD AT 1335 EDT ON 3/27/2013 * * *

"The event reported above resulted in additional reportable actuations under 10 CFR 50.72(b)(3)(iv)(A). These were: 1) RPS actuation, 2) Phase A containment isolation, 3) Containment fan cooler unit actuation, and 4) Emergency Diesel Generator actuation (start but did not load).

"The licensee notified the NRC Resident Inspector of the 1335 EDT update."

Notified R1DO (Krohn).

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE FOR MAINTENANCE

"This is a non-emergency eight hour notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the work activity affects the functionality of a emergency response facility.

"Planned maintenance activities are being performed today (March 27, 2013) to the Technical Support Center (TSC) HVAC. The work includes both corrective and preventive maintenance to the TSC HVAC system. This work activity is planned to be performed and completed expeditiously within about 14 hours.

"If an emergency condition occurs that requires activation of the TSC, plans are to utilize the TSC concurrent with this work activity as long as habitability conditions allow. Additionally, plans are in place to expedite the return of the system should an emergency condition occur. The emergency response organization duty team members will be relocated to an alternate location if required by habitability conditions in accordance with emergency implementing procedures.

"The licensee notified the NRC Resident Inspector."

* * * UPDATE FROM DAVE LEWIS TO HOWIE CROUCH AT 1511 EDT ON 3/27/13 * * *

The Technical Support Center has been returned to service. The licensee has notified the NRC Resident Inspector.

Notified R1DO (Krohn).