Event Notification Report for January 08, 2015

PATIENT RECEIVED WRONG FORMULATION OF TECHNETIUM RADIOPHARMACEUTICAL

A patient who was to be given a myocardial stress profusion exam was incorrectly given a 160 mCi dose of technetium pertechnetate [instead of prescribed Tc-99m sestamibi]. The cause of the incident was the medical technologist deviated from established procedures. There is no expected adverse impact on the patient as a result.

The patient and physician have been informed.

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.

OFFSITE NOTIFICATION DUE TO LOW LEVEL TRITIUM SPILL

"On January 7, 2015, at approximately 0700 CST, a leak to the environment was identified. Tritium was present at a concentration of 7.52E-3 uCi/mL, which is above the US Environmental Protection Agency (EPA) drinking water standard of 20,000 picocuries per liter. No other radioactive isotopes were identified. The leak rate was estimated at approximately 0.5 gpm and determined to be from the condensate head tank. Water was accumulating on the concrete-lined reactor/refuel air zone air intake plenum with some accumulation of water on the ground in the area. The intake plenum contains three floor drains. Actions were immediately taken to terminate the leak once the flowpath was identified. The flowpath was terminated two hours and 45 minutes after identification. Based on system review and analysis, any tritiated water that would have made it to the floor drains would then be mixed with incoming raw water at two million gallons per minute. This mixed volume of water would then be circulated through the plant and discharged to the river with a resultant tritium concentration that is much less than detectable levels and well below US EPA drinking water standards. The station has established increased monitoring of groundwater at designated sample wells.

On January 8, 2015, at approximately 1645 CST in accordance with TVA procedures and the guidance of NEI 07-07 [Nuclear Energy Institute] for the Groundwater Protection Initiative, the licensee notified the Alabama Radiological Protection Department and Alabama Department of Environmental Management. The Limestone County Emergency Management Department will be notified."

The licensee notified the NRC Resident Inspector.

POTENTIAL FAILURE OF SBM TYPE SWITCHES

The following is a summary of information that was provided by the reporting organization via facsimile:

"Pursuant to 10 CFR 21.21 (b), AZZ - NLI [AZZ - Nuclear Logistics Inc.] has provided written notification to the affected licensees of the potential failure of GEH SBM type switches manufactured (by GEH) [General Electric - Hitachi] in the period from January 2012 to December 2014.

"This condition has been reported in GEH document SC 14-19 (dated Dec. 11, 2014) in which GEH notified their affected licensees of the potential failure of SBM type switches, manufactured and shipped January 2012 through December 2014, due to incorrect installation of a conical spring. AZZ - NLI procured and dedicated commercial grade SBM type switches, manufactured during this time-frame, and subsequently provided to: Exelon - Peach Bottom; OPPD - Fort Calhoun; TVA- Watts Bar; KHNP [Korea Hydro & Nuclear Power].

"On the basis of our evaluation, it is determined that AZZ - NLI does not have sufficient information to determine if the subject condition would, or has, created a Substantial Safety Hazard or would have created a Technical Specification Safety Limit violation as it relates to the subject plant applications.

"Therefore, purchasers are being advised to perform a visual inspection of the switches at the earliest opportunity to determine if the condition exists.

"The following information is provided per 10 CFR 21.21(d) (4). Name and address of the individual or individuals informing the Commission: Tracy Bolt, Director of Quality Assurance, AZZ - Nuclear Logistics Inc., 7410 Pebble Drive, Ft. Worth, TX 76118"

AGREEMENT STATE REPORT - GAUGE FAILED TO FUNCTION AS REQUIRED

The following information was provided by the Commonwealth of Pennsylvania via email:

"During a daily routine maintenance inspection [at the Edgar Thomson Plant in Braddock, PA], the licensee observed that the Berthold moisture analyzer gauge was at an odd angle when compared to the chute that it was attached. A mounting bracket had broken causing the gauge to become dislodged. An area survey check was performed and determined no elevated radiation readings. The shutter was placed into the closed position and a service provider was notified. The gauge was then removed by the service provider and transported to their warehouse to determine the repair method. The licensee is also awaiting a response from the manufacturer.

"Manufacturer: Berthold Technologies, Isotope: Am-241, Activity: 300 mCi

"CAUSE OF THE EVENT: The bracket had broken allowing the device to shift. The device was still in place but not completely flush with the chute.

"ACTIONS: The device was removed from the site without incident and transported to the service provider's warehouse for repair. The Department plans a follow-up inspection with the licensee. More information will be provided when received."

PA Event Report ID NO: PA150001

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF BOTH CHANNELS OF REFUELING WATER STORAGE TANK INSTRUMENTATION

"At 0400 [EST], Indian Point Unit 3 entered LCO 3.5.4 Condition C due to both Refueling Water Storage Tank (RWST) Low Low Level Alarm channels failing. The failure was a result of freezing in the instrument lines. LCO 3.5.4 Condition C requires at least one channel of RWST Low Low Level Alarm be restored to Operable within 1 hour. At 0500, Unit 3 entered Condition D due to the required action and completion time of Condition C not being met. This requires the unit be placed in Mode 3 in 6 hours and Mode 4 in 12 hours. This failure also has resulted in a loss of safety function. Operators rely upon the RWST Low Low Level Alarms during an accident to alert them of the need to transfer injection from the RWST as a source of water to the containment sump. At 0700, Indian Point Unit 3 commenced a shutdown to be in compliance with the requirements of LCO 3.5.4 Condition D. Investigation and repair efforts were immediately put in place to correct the failure and return the function to operable. At 1000, one Channel of RWST Low Low Level Alarm was returned to operable. LCO 3.5.4 Conditions C & D were exited. The shutdown was stopped and safety function was restored. Unit 3 remains in a 7-day shutdown [LCO action statement] for one RWST Low Low Level Alarm Channel inoperable as per LCO 3.5.4 Condition B.

"Unit 2 is unaffected and remains at 100% power."

The State of New York and the NRC Resident Inspector were notified.