Event Notification Report for April 15, 2015

AGREEMENT STATE REPORT - SOURCE MOVED DURING MEDICAL TREATMENT

"On 4-15-15 the patient was to receive a fractionated dose of 4 Grays to the 'vaginal cuff' region using a 10.175 Curie Ir-192 source. The dose was to be administered using a Varian Model VariSource 200t remote HDR [High Dose Rate] afterloader, serial number 600349.

"The plan was to administer 6 radiation treatments using a cylinder applicator and holder, the treatment length intended to be 5 cm. Imaging was done after placement of the cylinder prior to treatment to verify location, however, post-treatment imaging showed that the cylinder applicator had come loose from the holder and shifted 3 cm. This was the first of the six fractions.

"Hospital staff physicists are currently working to determine the delivered dose to the target and why the shift occurred. Physician notification has not been verified at this time. The patient has been notified."

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 - FIXED GAUGE SHUTTER FAILED OPEN

The following report was received via e-mail:

"Installed fixed level gauge on a process. The shutters on a fixed level gauge would not close properly due to a breakage of a shutter pin. The situation is the result of extended usage. The gauge was purchased and put into service in 1985. The problem with the shutter function is considered equipment failure of this device. Corrective action will be to de-install this device and [dispose of it]. The gauge will be replaced with a new lower activity source device. The failure is that the shutter blades would not open and close due to a shutter pin breaking. There was no removable radiation released into the environment. The gauge/source holder was 'fixed', and the RSO tagged and posted the broken device. Additionally, all personnel working in the vicinity of the devise were informed of the problem. The RSO advised the employees the radiation exposure levels were in the normal operational range.

"The gauge was an Accuray Mfg. device, SH302, s/r HS302-S6, approximately 200 mCi of Cs-137 when installed and manufactured in 1985. The source serial number is CS11166."

Louisiana Report: LA150007, T163028

MANUAL REACTOR TRIP DUE TO THE LOSS OF A CONDENSATE PUMP

"At 0411 EDT on April 15, 2015, Beaver Valley Power Station (BVPS) Unit 1 manually tripped the reactor from approximately 85% power due to the trip of a condensate pump. The unit was performing an emergent power reduction due to a degraded condensate pump prior to the manual reactor trip. An end of cycle Tave coastdown was in progress at the time of the event. All control rods fully inserted into the core. All three auxiliary feed water pumps started as expected and were subsequently secured in accordance [with] station procedures. The main feedwater system remains available and in service. The unit is currently stable in Mode 3.

"Unit 2 was unaffected and remains at full power."

Decay heat removal is via main feedwater system with steam discharge to the main condenser via the steam bypass valves. Unit 1 is in a normal shutdown electrical lineup. No primary or secondary reliefs or safeties lifted during the transient.

The licensee informed the NRC Resident Inspector.

AGREEMENT STATE REPORT - SOURCE DISCOVERED AT A TRANSFER STATION

The following information was excerpted from a Commonwealth of Massachusetts facsimile:

A radiation source was detected in a trash load at the Roxbury Transfer Station (RTS) by radiation detectors at the transfer station entrance. The RTS consultant performed a survey to separate the radiation source from the remainder of the trash. The consultant transported radioactive trash to Atlantic Nuclear (MA license #56-0477) to perform isotope identification. Atlantic Nuclear' s analysis indicates the radiation source contains about 90 microCuries of Ra-226. A dose rate of 15 millirem/hour was measured at about 1 inch from the object. The consultant separated the single object from the trash bag. The source is stored at Atlantic Nuclear and is waiting for proper disposal.

The Agency [Massachusetts Radiation Control Program] continues to investigate and considers this event to be open.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

INVALID ACTUATIONS OF THE CONTAINMENT VENTILATION ISOLATION SYSTEM

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report two related invalid actuations of the Containment Vent Isolation System at Watts Bar Nuclear Plant Unit 1 (WBN-1).

"On April 14, 2015 at 2101 EDT, a sample pump failed on the WBN-1 Train B containment purge exhaust radiation monitor (1-RM-90-131), prompting control room operators to enter Conditions A and B of Technical Specification (TS) Limiting Condition for Operation (LCO) 3.3.6, Containment Vent Isolation Instrumentation and Condition A of LCO 3.6.3, Containment Isolation Valves.

"On April 15, 2015 at 1207 EDT, 1-RM-90-131 radiation readings increased sharply (spiked), initiating an invalid Containment Vent Isolation (CVI) actuation. The spike occurred following troubleshooting and repairs to 1-RM-90-131 when maintenance technicians agitated the motor starter enclosure in an attempt to free a stuck auxiliary contact that controls local indication. As a result of the CVI actuation, flow to lower containment radiation monitor (1-RM-90-106) was isolated, prompting control room operators to enter Condition B of LCO 3.4.15, RCS Leakage Detection Instrumentation. At 1634 EDT, control room operators exited the TS 3.4.15 condition when 1-RM-90-106 was returned to service.

"On April 17, 2015 at 1327 EDT, control room operators exited LCO 3.3.6 Conditions A and B and LCO 3.6.3 Condition A when sample pump repairs were completed on 1-RM-90-131.

"On April 19, 2015 at 1550 EDT, 1-RM-90-131 radiation readings spiked and initiated a CVI, prompting control room operators to enter TS LCO 3.4.15 Condition B and LCO 3.3.6 Condition A, until flow was restored to 1-RM-90-106 at 1636 EDT and 1-RM-90-131 was returned to service on April 26, 2015 at 1229 EDT.

"Each CVI was documented in accordance with the corrective action program, and TVA completed an equipment apparent cause evaluation (CR 1015781) that revealed the cause of the two CVI actuations was the result of a faulted Start/Stop control unit. TVA replaced the faulted control unit.

"In both instances, the CVI actuations resulted from invalid signals and were limited to a single piece of Train B equipment. There was no loss of safety function and there were no actual safety consequences during the events."

The NRC Resident Inspector has been informed.