Event Notification Report for April 30, 2014

AGREEMENT STATE REPORT - INCORRECT DOSAGE ADMINISTERED TO PATIENT

"I am reporting a Medical Event and Abnormal Occurrence. The event resulted from incorrect dosage administered to the patient for the second phase of the yttrium-90 SirSperes for treatment of the liver. The patient was administered 43 millicuries of Y-90 for the second phase instead of 12 to 12.5 mCi as intended. The event occurred at Cedars Sinai Medical Center (California Radioactive Materials License number 0404-19) in Los Angeles, CA, on April 30, 2014. Los Angeles County Public Health, Radiation Management was notified on May 1, 2014. During the original report date, the licensee did not have any information regarding the radiation dose to the patient and was working with their Medical Physicists. On May 6, 2014, Cedars Sinai Medical Center reported that the patient received 363 Gray instead of the intended dose within the range of 53-102 Gray. Per the licensee, both the patient and referring physicians have been notified. The patient has not reported any side effects that were unanticipated and the patient will continue to be medically monitored."

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 REPORT - MISDELIVERY OF A RADIOACTIVE SOURCE

The following information was received from the State of Nevada by email:

[A Common Carrier] misdelivered an Ir-192 source for 645 North Arlington Avenue, Suite 120, Reno, NV 89503. The address was correct, but the source was inadvertently delivered to the Main Hospital receiving at 235 West Sixth Street, Reno, NV 89503. The source bucket was then delivered to the Radiation Safety Officer (RSO) - at the correct address. Once received by the RSO, the delivering employee was contacted and questioned
about length of contact and it was estimated that 2 mrem of dose was received for 10 minutes of contact. The employee as well as the Director for the receiving department were contacted and told to refuse shipment of anything with a radioactive label and to call the RSO immediately. The shipper (Varian) was contacted and they filed a formal complaint with [the Common Carrier].

Nevada Event: NV140011

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

POSTULATED HOT SHORT FIRE EVENT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"Based on a review of industry operating experience, it was identified that each unit has two un-fused DC control circuits for non safety-related DC motors which are routed from the turbine building through other separate fire areas including the Control Room. The DC breakers used to protect the motor power conductors are insufficient to protect the control conductors for these circuits. It is postulated that a fire induced short in one fire area could adversely impact safe shutdown equipment by overheating the cable and causing a secondary fire in other fire areas where the cable is routed. At Unit 1, cables for the affected circuits are routed in the Turbine Building, Cable Spreading Area and Control Room. At Unit 2, cables for the affected circuits are routed in the Turbine Building, Normal Switchgear, Service Building Cable Tray Area, Cable Vault, Instrument Relay Room, Control Building West Communication Room, Control Building Cable Spreading Area and Control Room.

"The postulated secondary fires or cable failures are outside the assumptions of each unit's fire protection analysis. A preliminary investigation of the issue indicates that existing fire protection safe shutdown procedures could be used to safely shut down the plant if needed. This condition is reportable as an 8-hour report in accordance with 10 CFR 50.72(b)(3)(ii)(B). Interim compensatory measures will be implemented for affected areas of the plant.

"The NRC Resident Inspector has been notified."

MOMENTARY LOSS OF SECONDARY CONTAINMENT DUE TO AIRLOCK INTERLOCK MALFUNCTION

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(C), Event or Condition that could have prevented fulfillment of a Safety Function needed to Control the Release of Radioactive Material and 10CFR50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to Mitigate the Consequences of an Accident. Unit 1 was in mode 1 and in a condition of moving irradiated fuel in the secondary containment. Unit 2 was in mode 5 and in the condition of moving irradiated fuel in the secondary containment, core alterations, and operations with the potential to drain the reactor vessel. An employee entered a secondary containment interlock [Unit 2] and identified that both doors of the interlock opened simultaneously when the door on the auxiliary building side was opened. The employee immediately secured both doors in the interlock and notified the Main Control Room Supervisor. Both doors in the interlock were open for approximately 5 seconds. With both doors open, TS SR 3.6.4.1.2 [Technical Specification Surveillance Requirement] was not met. This rendered secondary containment inoperable per TS 3.6.4.1. Reactor Building differential pressure, as observed in the Main Control Room, has remained less that -0.25 inches of water column at all times. Initial investigation determined that the interlock for the doors was malfunctioning. Administrative controls have been put in place to ensure the doors remain closed pending repairs to the interlock."

The licensee has notified the NRC Resident Inspector.

TSC OUT OF SERVICE DUE TO MAINTENANCE

"On April 30, 2014, at 0800 EDT, the Technical Support Center (TSC) will be unavailable due to pre-planned maintenance on a motor control center associated with the TSC. The TSC is expected to be restored to a functional status in approximately 13 hours.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures, and the TSC staff will relocate to an alternate TSC location in accordance with the Hatch emergency plan and applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72 (b)(3)(xiii) due to the planned loss of an emergency response facility (ERF). An update will be provided once the TSC has been restored to normal operation. The NRC Resident Inspector has been notified."

* * * UPDATE PROVIDED BY JOHN SELLERS TO JEFF ROTTON AT 2011 EDT ON 04/30/2014 * * *

"The planned maintenance activities have been completed. The power was restored to the TSC at 1802 EDT on 4/30/14. Ventilation has been confirmed to be functional. The TSC was fully functional at 1802 EDT on 04/30/14."

The licensee has notified the NRC Resident Inspector. Notified R2DO (Ayres).

ON-SITE MEDICAL TREATMENT OF A CONTAMINATED INDIVIDUAL

"An employee with low blood sugar reported to the on-site dispensary this morning. The plant nurse administered first aid and then sent the employee to an off-site medical facility for further evaluation. A whole body survey of the employee in her plant clothing was performed. The maximum amount of contamination present was on the employee's right boot (7,887 dpm/100cm2). Prior to leaving the Restricted Area, the employee removed all plant clothing, changed into her personal clothing, and was whole body frisked out of the plant. The employee was free of contamination upon release."

The licensee notified the NRC Fuel Facility Inspector.