Event Notification Report for February 24, 2015

INCORRECT DOSE RECORDED ON PRESCRIPTION DIRECTIVE

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Salt Lake City Health Care System, Salt Lake City, Utah.

"On February 24, 2015, a dosage of 30.8 millicuries of I-131 sodium iodide (capsule form) was administered to a patient for a thyroid ablation. The prescribed dosage on the written directive was incorrectly annotated as 3 millicuries.

"The basis for identifying this as a medical event is the administered dosage differed from the prescribed dosage, as annotated on the written directive, by more than 20 percent.

"The medical event was discovered today (May 13, 2015) during an inspection, conducted by the National Health Physics Program (NHPP).

"Interview of the Radiation Safety Officer revealed the standard dosage for a thyroid ablation is 30 millicuries of I-131 sodium iodide (capsule form). Interview of the authorized user (a physician) revealed the intended prescription was for 32 millicuries of I-131 sodium iodide (capsule form).

"No biological harm to the patient is expected since the thyroid ablation was successfully performed. The patient and attending physician were not informed of the incorrect annotation on the written directive since the thyroid ablation was successfully performed, as clinically intended, with a dosage of I-131 sodium iodide (capsule form) within an acceptable range of the authorized user's intent.

"The inspection is ongoing with causal factors and corrective actions being developed. Additional information will be provided in a 15-day written report, to be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone.

"The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 43-03299-01. National Health Physics Program makes required notifications to NRC. "

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.

60-DAY OPTIONAL TELEPHONE NOTIFICATION OF INVALID SYSTEM ACTUATION DUE TO MOTOR GENERATOR OUTPUT BREAKER TRIP

"On February 24, 2015, at approximately 1702 CDT, while the plant was in cold shutdown, power was lost on the Division 1 reactor protection system (RPS) bus. This event resulted in the automatic closure of the Division 1 primary containment isolation valves in the residual heat removal (RHR) and reactor water cleanup systems. Additionally, the primary containment atmospheric monitoring system automatically actuated, and ventilation systems in the fuel building, auxiliary building, and control building shifted to emergency mode. The closure of the isolation valves in the residual heat removal system caused an automatic trip of the 'A' RHR pump, which had been in the shutdown cooling alignment. The equipment response to the isolation signal was as expected. This event is being reported in accordance with 10 CFR 50.73(a)(1) as an invalid actuation of the Division 1 primary containment isolation system.

"The isolation was promptly diagnosed as having resulted from a trip of the output breaker of the RPS motor generator (MG) set 'A,' and not from a valid signal. Operators implemented the appropriate response procedures to align power to the bus via the alternate source, and began restoring the affected systems. The 'A' RHR pump was re-started within twelve minutes, during which time coolant temperature increased approximately seven degrees to a maximum of approximately 100F. Other affected systems were restored over the next few hours.

"The causal analysis concluded that the MG set output breaker tripped due to an overly conservative setpoint on the overvoltage trip relay. The low trip setpoint was a latent condition that had existed since the output voltage was raised in 1988 at the recommendation of the vendor, but at which time the trip setpoint was not changed. To correct this condition, the MG overvoltage trip setpoint was raised to restore adequate operating margin to the normal MG output voltage.

"At the time of the event, the plant was in MODE 5 with the reactor cavity flooded to greater than 23 feet above the vessel flange. The shutdown cooling system was promptly restored to service. This event was of minimal safety significance to the health and safety of employees and the public."

The licensee has notified the NRC Resident Inspector.

INADEQUATE WELDS AFFECTING STRUCTURAL CAPACITY OF EMBED PLATES

MOX [Mixed Oxide] Services has determined that the fillet welds connecting the ledger angle to the embed plate did not comply with the minimum size required by AWS D1.1-98 and the design requirements.

The embed plates containing defects were supplied to MOX Services as a basic component by Specialty Maintenance and Construction, Inc. (SMCI) Division of MetalTek International.

The undersize fillet welds connecting the ledger angle to the embed plates were determined to be inadequate. Inadequate welds would adversely affect the load bearing and structural capacity of these components.

CB&I Part 21 interim report, dated January 20, 2015, indicates that Vogtle Units 3 and 4 have been supplied with basic components by SMCI.

These weld defects related to the SMCI embed plates were initially identified by nonconformance report on February 24, 2015.

AGREEMENT STATE REPORT - RADIOGRAPHIC SOURCE FAILS TO RETRACT

The following report was received via e-mail:

"A radiographic source tube was damaged which temporarily restricted retraction of the source.

"The guide tube became crushed by a falling object thereby preventing the source from retracting. The assistant RSO performed a source recovery with help from an assistant radiographer. The damaged guide tube was removed from service. Licensee personnel were trained on proper stabilization techniques. No individual received a dose in excess of limits.

"Manufacturer: QSA
Model: 880D
Serial No.: 9212
Source: lr-192
Activity: 29 Ci"

PA Event #: PA150008.