Event Notification Report for February 27, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/26/2014 - 02/27/2014
EVENT NUMBERS
4985949860498614988749917
Power Reactor
Event Number: 49859
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL CRAWFORD
HQ OPS Officer: JEFF ROTTON
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL CRAWFORD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2014
Notification Time: 03:37 [ET]
Event Date: 02/27/2014
Event Time: 03:30 [EST]
Last Update Date: 02/27/2014
Notification Time: 03:37 [ET]
Event Date: 02/27/2014
Event Time: 03:30 [EST]
Last Update Date: 02/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)
ANNE DeFRANCISCO (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE CORE SPRAY (HPCS) SYSTEM DECLARED INOPERABLE
"On February 24th at 0400 [EST], the Division 3 diesel (HPCS diesel) was declared inoperable for planned maintenance. Technical Specification (TS) 3.8.1 condition B was entered with a required action to restore the diesel to operable status within 72 hours. Shortly after starting the diesel for post maintenance testing, operations observed erratic voltage regulator operation. The diesel was secured at 1621 on 2/24/14 before completing the required post maintenance operability test and troubleshooting is ongoing.
"At 0330 on 2/27/14, the High Pressure Core Spray System (HPCS) was declared inoperable and TS 3.5.1 condition B was entered. With the HPCS system declared inoperable, TS 3.8.1 condition B was exited in accordance with the following note modifying TS 3.8.1: 'Division 3 AC electrical power sources are not required to be OPERABLE when High Pressure Core Spray (HPCS) System is inoperable.'
"The HPCS system is a single train system that is discussed in Chapters 6 and 15 of the Final Safety Analysis Report. The unplanned inoperability of the HPCS system is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D) as, 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (D) Mitigate the consequences of an accident.'
"The condition has been entered into the NMP corrective action program as CR-2014-001623.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM RODGER ORZELL TO JOHN SHOEMAKER AT 1210 EST ON 2/27/14 * * *
The NMP Unit 2 Division 3 diesel testing was completed satisfactorily. The licensee declared the Division 3 diesel and HPCS systems operable at 1013 EST on 2/27/14 and exited TS 3.8.1 and 3.5.1.
The licensee has notified the NRC Resident Inspector.
Notified the R1DO (DeFrancisco).
"On February 24th at 0400 [EST], the Division 3 diesel (HPCS diesel) was declared inoperable for planned maintenance. Technical Specification (TS) 3.8.1 condition B was entered with a required action to restore the diesel to operable status within 72 hours. Shortly after starting the diesel for post maintenance testing, operations observed erratic voltage regulator operation. The diesel was secured at 1621 on 2/24/14 before completing the required post maintenance operability test and troubleshooting is ongoing.
"At 0330 on 2/27/14, the High Pressure Core Spray System (HPCS) was declared inoperable and TS 3.5.1 condition B was entered. With the HPCS system declared inoperable, TS 3.8.1 condition B was exited in accordance with the following note modifying TS 3.8.1: 'Division 3 AC electrical power sources are not required to be OPERABLE when High Pressure Core Spray (HPCS) System is inoperable.'
"The HPCS system is a single train system that is discussed in Chapters 6 and 15 of the Final Safety Analysis Report. The unplanned inoperability of the HPCS system is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D) as, 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (D) Mitigate the consequences of an accident.'
"The condition has been entered into the NMP corrective action program as CR-2014-001623.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM RODGER ORZELL TO JOHN SHOEMAKER AT 1210 EST ON 2/27/14 * * *
The NMP Unit 2 Division 3 diesel testing was completed satisfactorily. The licensee declared the Division 3 diesel and HPCS systems operable at 1013 EST on 2/27/14 and exited TS 3.8.1 and 3.5.1.
The licensee has notified the NRC Resident Inspector.
Notified the R1DO (DeFrancisco).
Power Reactor
Event Number: 49860
Facility: MILLSTONE
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JASON ASHBURN
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: CT
Unit: [] [2] []
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JASON ASHBURN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/27/2014
Notification Time: 09:06 [ET]
Event Date: 02/27/2014
Event Time: 08:09 [EST]
Last Update Date: 02/27/2014
Notification Time: 09:06 [ET]
Event Date: 02/27/2014
Event Time: 08:09 [EST]
Last Update Date: 02/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
ANNE DeFRANCISCO (R1DO)
ANNE DeFRANCISCO (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 74 | Power Operation |
PLANT SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATION
"SYSTEM AFFECTED: Battery 201B inoperable at 1040 EST on 2/26/14
"ACTUATIONS & THEIR INITIATION SIGNALS: None
"CAUSES (IF KNOWN): Low cell voltage on cell 27
"EFFECT OF EVENT ON PLANT: Inoperable DC Bus
"ACTIONS TAKEN OR PLANNED: Commence shutdown and cooldown to Mode 5
"ADDITIONAL INFORMATION: None"
Plant shutdown was initiated by failure to meet the action statement of Technical Specification (TS) 3.8.2.3; restore cell 27 to operable within 2 hours. The failure to meet the action statement placed the plant in a 36 hr. to cold shutdown time clock. At 0809 on 2/27/14, the licensee commenced down powering the unit to meet the TS requirement. If the cell is not recovered, the licensee expects to achieve cold shutdown by 2300 on 2/27/14. Their 36 hr. clock expires at 0040 on 2/28/14.
The plant is stable with all other safety busses available via onsite and offsite power.
The licensee notified the State of Connecticut, Waterford dispatch and the NRC Resident Inspector.
* * * UPDATE FROM THOMAS CLEARY TO CHARLES TEAL AT 1600 EST ON 2/27/14 * * *
"At 1347 [EST] on February 27, 2014, Millstone Power Station Unit 2 exited the shutdown action statement for Technical Specification (TS) 3.8.2.3 'D.C. Distribution-Operating'. The 125-volt DC bus train has been restored to operable status. Operators had reduced plant power to approximately 16%. The plant is increasing power and is presently at approximately 27% power.
"The NRC Resident Inspector has been notified."
Notified R1DO (DeFrancisco).
"SYSTEM AFFECTED: Battery 201B inoperable at 1040 EST on 2/26/14
"ACTUATIONS & THEIR INITIATION SIGNALS: None
"CAUSES (IF KNOWN): Low cell voltage on cell 27
"EFFECT OF EVENT ON PLANT: Inoperable DC Bus
"ACTIONS TAKEN OR PLANNED: Commence shutdown and cooldown to Mode 5
"ADDITIONAL INFORMATION: None"
Plant shutdown was initiated by failure to meet the action statement of Technical Specification (TS) 3.8.2.3; restore cell 27 to operable within 2 hours. The failure to meet the action statement placed the plant in a 36 hr. to cold shutdown time clock. At 0809 on 2/27/14, the licensee commenced down powering the unit to meet the TS requirement. If the cell is not recovered, the licensee expects to achieve cold shutdown by 2300 on 2/27/14. Their 36 hr. clock expires at 0040 on 2/28/14.
The plant is stable with all other safety busses available via onsite and offsite power.
The licensee notified the State of Connecticut, Waterford dispatch and the NRC Resident Inspector.
* * * UPDATE FROM THOMAS CLEARY TO CHARLES TEAL AT 1600 EST ON 2/27/14 * * *
"At 1347 [EST] on February 27, 2014, Millstone Power Station Unit 2 exited the shutdown action statement for Technical Specification (TS) 3.8.2.3 'D.C. Distribution-Operating'. The 125-volt DC bus train has been restored to operable status. Operators had reduced plant power to approximately 16%. The plant is increasing power and is presently at approximately 27% power.
"The NRC Resident Inspector has been notified."
Notified R1DO (DeFrancisco).
Power Reactor
Event Number: 49861
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JAMES HOUGH
HQ OPS Officer: JOHN SHOEMAKER
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JAMES HOUGH
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/27/2014
Notification Time: 18:56 [ET]
Event Date: 02/27/2014
Event Time: 12:22 [EST]
Last Update Date: 03/06/2014
Notification Time: 18:56 [ET]
Event Date: 02/27/2014
Event Time: 12:22 [EST]
Last Update Date: 03/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DANIEL RICH (R2DO)
DANIEL RICH (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 4 | N | Y | 100 | Power Operation | 100 | Power Operation |
DEGRADATION OF THE TECHNICAL SUPPORT CENTER VENTILATION SYSTEM
"At approximately 1222 EST on February 27, 2014, the site discovered degradation of the Technical Support Center (TSC) ventilation air handling unit. Maintenance is in progress. The functionality of the TSC ventilation system is in question.
"The emergency assessment function could have been performed in the Control Room as addressed in emergency response procedures.
"This event is reported in accordance with 10 CFR 50.72 (b)(3)(xiii)."
A TSC ventilation fan was vibrating because of a thrown fan blade.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE AT 1105 EST ON 3/6/2014 FROM CHRIS TRENT TO JEFF ROTTON * * *
"Turkey Point Nuclear Station declared the TSC functional but degraded due to its normal power supply breaker tripping unexpectedly. The TSC is capable of going on emergency recirculation on its alternate power supply. The TSC is currently in its normal standby alignment with its power being supplied from its alternate source breaker. Compensatory measures are in place IAW 0-ADM-117, Equipment Important to Emergency Response, and will remain in place until the cause of the normal power supply breaker tripping is identified and corrected. Emergency Preparedness department will be making a notification to ERO members to report to the TSC as their primary notification again."
Notified R2DO (Rose).
"At approximately 1222 EST on February 27, 2014, the site discovered degradation of the Technical Support Center (TSC) ventilation air handling unit. Maintenance is in progress. The functionality of the TSC ventilation system is in question.
"The emergency assessment function could have been performed in the Control Room as addressed in emergency response procedures.
"This event is reported in accordance with 10 CFR 50.72 (b)(3)(xiii)."
A TSC ventilation fan was vibrating because of a thrown fan blade.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE AT 1105 EST ON 3/6/2014 FROM CHRIS TRENT TO JEFF ROTTON * * *
"Turkey Point Nuclear Station declared the TSC functional but degraded due to its normal power supply breaker tripping unexpectedly. The TSC is capable of going on emergency recirculation on its alternate power supply. The TSC is currently in its normal standby alignment with its power being supplied from its alternate source breaker. Compensatory measures are in place IAW 0-ADM-117, Equipment Important to Emergency Response, and will remain in place until the cause of the normal power supply breaker tripping is identified and corrected. Emergency Preparedness department will be making a notification to ERO members to report to the TSC as their primary notification again."
Notified R2DO (Rose).
Agreement State
Event Number: 49887
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2885
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: CHARLES TEAL
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2885
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/10/2014
Notification Time: 12:21 [ET]
Event Date: 02/27/2014
Event Time: 00:00 [EDT]
Last Update Date: 03/10/2014
Notification Time: 12:21 [ET]
Event Date: 02/27/2014
Event Time: 00:00 [EDT]
Last Update Date: 03/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARC FERDAS (R1DO)
FSME EVENT RESOURCE (EMAI)
MARC FERDAS (R1DO)
FSME EVENT RESOURCE (EMAI)
AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 ADMINISTRATION TO LIVER
The following was received from New York City Bureau of Rad Health via email:
"[A] patient was receiving treatment of left lobe of liver with Y-90 Sir Spheres. Half way through the procedure the catheter became clogged. 30 mCi of Y-90 was prescribed, only 22.5 mCi was delivered. 7.5 mCi remained in the catheter. [The] initial report stated that treatment of right lobe of liver had been scheduled for April. [The] initial report stated that Physician decided to treat left lobe of liver with makeup dose of 7.5 mCi Y-90 at that time.
"[The] ORH [Office of Radiological Health] inspector stated that multiple attempts were made to flush the catheter without success. The catheter was removed and the remainder of the dose was administered at the date of the initial clog with a micro-catheter.
"[The] physician spoke to the vendor rep (company SureFire). [The] company stated that cause of the clog would be investigated when the Y-90 had decayed.
"[The] referring physician was notified.
"[This] incident is considered a reportable medical event because the administered dose differed from the prescribed dose by >20%.
"[The] hospital states that if any future incidents such as this equipment malfunction occurs, they will keep the patient in treatment position to determine by measurement if proper dosage was delivered. If measurements indicate that inadequate dosage was delivered, they will draw another dose to supplement the original administration until the appropriate dose is administered to the patient."
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.
The following was received from New York City Bureau of Rad Health via email:
"[A] patient was receiving treatment of left lobe of liver with Y-90 Sir Spheres. Half way through the procedure the catheter became clogged. 30 mCi of Y-90 was prescribed, only 22.5 mCi was delivered. 7.5 mCi remained in the catheter. [The] initial report stated that treatment of right lobe of liver had been scheduled for April. [The] initial report stated that Physician decided to treat left lobe of liver with makeup dose of 7.5 mCi Y-90 at that time.
"[The] ORH [Office of Radiological Health] inspector stated that multiple attempts were made to flush the catheter without success. The catheter was removed and the remainder of the dose was administered at the date of the initial clog with a micro-catheter.
"[The] physician spoke to the vendor rep (company SureFire). [The] company stated that cause of the clog would be investigated when the Y-90 had decayed.
"[The] referring physician was notified.
"[This] incident is considered a reportable medical event because the administered dose differed from the prescribed dose by >20%.
"[The] hospital states that if any future incidents such as this equipment malfunction occurs, they will keep the patient in treatment position to determine by measurement if proper dosage was delivered. If measurements indicate that inadequate dosage was delivered, they will draw another dose to supplement the original administration until the appropriate dose is administered to the patient."
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.
Agreement State
Event Number: 49917
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DONG HWA PARK
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/14/2014
Notification Time: 16:48 [ET]
Event Date: 02/27/2014
Event Time: 00:00 [EDT]
Last Update Date: 03/14/2014
Notification Time: 16:48 [ET]
Event Date: 02/27/2014
Event Time: 00:00 [EDT]
Last Update Date: 03/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARC FERDAS (R1DO)
FSME EVENTS RESOURCE (EMAI)
MARC FERDAS (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - YTTRIUM 90 MEDICAL EVENT
The following information was received from the State of Georgia via email:
"Event Narrative: A patient was treated with Y-90 microspheres for cholangiocarcinoma. This was a bilateral disease that would require the treatment of both lobes of the liver. Significant tumor burden was in the central (segment IV) and medial sections. The medical team decided to treat the left lobe first as a result.
"For the first treatment, 54.05 mCi was to be delivered to the left lobe. It had an expected dose of 69.0 Gy to the liver. Due to issues with hepatic arterial anatomy not previously anticipated, the medical team could not properly position the catheter. Because it was a bilateral disease that would eventually require the treatment of both lobes, they decided to move forward with the procedure.
"Of the calibrated activity of 52.6 mCi, a post-therapy survey of the vial showed 88% of the dose or 46.3 mCi was delivered. A post-delivery Bremsstrahlung scan showed excellent coverage of Segment IV, with some minor coverage in the right lobe due to the arterial anatomy. 21.8 mCi was localized to Segment IV, and the approximate remainder, 24.5 mCi, ended up in the right lobe. There was no significant extrahepatic activity seen.
"The medical team considered the treatment to be successful due to the patient's bilateral disease. The authorized user intended to treat the right lobe next, and the team reports that the treatment plan will be adjusted to take into account the diseased areas which were treated. There should be no adverse reaction from this initial treatment.
"Cause and Corrective Actions: Occurred due to an arterial aberration causing a the interventional radiologist to be unable to canulate the artery. The hepatic arterial anatomy was different the day of treatment than the initial shunt study suggested on 5 February 2014. The patient's medical team decided to proceed with the catheter orifice just at the origin of the segment IV hepatic artery. The shunt fractions then resulted differently from the intended treatment for that day.
"The medical team and RSO are continuing to discuss if any preventative actions can be achieved. Treatment with Y-90 microspheres is reported to be complicated by the degree that the disease and prior treatments have affected liver vasculature. This makes it hard to plan for these scenarios pre-treatment.
"Generic Implications: Post treatment scans for Y-90 were reported by the licensee not to be a common practice, but they seem vital for determining if a treatment meets reportable limits.
"Procedure Administered: Bilateral radioembolization of liver with Y-90 microspheres.
"Intended Dose: 54.05 mCi (69.0 Gy) to left lobe of liver.
"Actual Dose: 21.8 mCi to Segment IV of left lobe and 24.5 mCi to the right lobe.
"Patient and Referring Physician Notified: Informed following the procedure's post-delivery Bremsstrahlung scan."
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.
The following information was received from the State of Georgia via email:
"Event Narrative: A patient was treated with Y-90 microspheres for cholangiocarcinoma. This was a bilateral disease that would require the treatment of both lobes of the liver. Significant tumor burden was in the central (segment IV) and medial sections. The medical team decided to treat the left lobe first as a result.
"For the first treatment, 54.05 mCi was to be delivered to the left lobe. It had an expected dose of 69.0 Gy to the liver. Due to issues with hepatic arterial anatomy not previously anticipated, the medical team could not properly position the catheter. Because it was a bilateral disease that would eventually require the treatment of both lobes, they decided to move forward with the procedure.
"Of the calibrated activity of 52.6 mCi, a post-therapy survey of the vial showed 88% of the dose or 46.3 mCi was delivered. A post-delivery Bremsstrahlung scan showed excellent coverage of Segment IV, with some minor coverage in the right lobe due to the arterial anatomy. 21.8 mCi was localized to Segment IV, and the approximate remainder, 24.5 mCi, ended up in the right lobe. There was no significant extrahepatic activity seen.
"The medical team considered the treatment to be successful due to the patient's bilateral disease. The authorized user intended to treat the right lobe next, and the team reports that the treatment plan will be adjusted to take into account the diseased areas which were treated. There should be no adverse reaction from this initial treatment.
"Cause and Corrective Actions: Occurred due to an arterial aberration causing a the interventional radiologist to be unable to canulate the artery. The hepatic arterial anatomy was different the day of treatment than the initial shunt study suggested on 5 February 2014. The patient's medical team decided to proceed with the catheter orifice just at the origin of the segment IV hepatic artery. The shunt fractions then resulted differently from the intended treatment for that day.
"The medical team and RSO are continuing to discuss if any preventative actions can be achieved. Treatment with Y-90 microspheres is reported to be complicated by the degree that the disease and prior treatments have affected liver vasculature. This makes it hard to plan for these scenarios pre-treatment.
"Generic Implications: Post treatment scans for Y-90 were reported by the licensee not to be a common practice, but they seem vital for determining if a treatment meets reportable limits.
"Procedure Administered: Bilateral radioembolization of liver with Y-90 microspheres.
"Intended Dose: 54.05 mCi (69.0 Gy) to left lobe of liver.
"Actual Dose: 21.8 mCi to Segment IV of left lobe and 24.5 mCi to the right lobe.
"Patient and Referring Physician Notified: Informed following the procedure's post-delivery Bremsstrahlung scan."
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.