Event Notification Report for December 03, 2015

EXCESSIVE CONTROL ROOM IN-LEAKAGE IDENTIFIED

"On December 3, 2015 at 2107 [EST], the Control Room Emergency Ventilation System (CREVS) was declared inoperable due to a higher than allowed identified in-leakage rate for the Control Room Envelope (CRE) when in the Normal Operating Mode. Both Unit 1 & Unit 2 remain at 100 percent power and they share a common CRE.

"At the time of discovery, there is a reasonable expectation this condition could prevent the fulfillment of the safety function of a system that is required to mitigate the consequences of an accident, thus satisfying the reporting criteria for 10CFR50.72(b)(3)(v)(D).

"Actions to implement mitigating actions were immediately initiated in accordance with Technical Specification 3.7.10. CREVS has been placed in Recirculation Ventilation Mode, isolating the control room from outside air.

"The NRC Senior Resident Inspector has been notified of the condition."

* * * RETRACTION ON 1/7/16 AT 1110 EST FROM SHAWN SNOOK TO DONG PARK * * *

"Following the 8-hour 10CFR50.72 notification made on 12/4/2015 (EN 51584) regarding the Control Room Emergency Ventilation System (CREVS) inoperability, an engineering evaluation determined inleakage did not exceed limits described in the Beaver Valley licensing basis. Therefore, the degraded Control Room Emergency Ventilation System remained Operable with the identified air inleakage as determined by the Control Room
Envelope Habitability Program. As such, the safety function was never lost and the event notification is being retracted as it is not reportable pursuant to 10CFR50.72(b)(3)(v)(D). FENOC is planning to repair the degraded components of the system.

"The NRC Resident [Inspector] has been notified." Notified R1DO (Dimitriadis).

ADMINISTERED DOSAGE DIFFERENT FROM PRESCRIBED DOSAGE

The following was received from the Veterans Affairs National Health Physics Program via email:

"As requested via a telephone conversation with the NRC Operation Center, this is a written notification, pursuant to 10 CFR 35.3045(a)(1), regarding a series of medical events that occurred at the VA New Jersey Health Care System in East Orange, New Jersey. A brief description of the events, cause of the events, and other required information are contained in the enclosure. The East Orange VA facility holds VHA Permit Number 29-04481-01 under our master material license, NRC License No. 03-23853-01VA.

"There are six apparent medical events with four resulting from the use of a pre-printed form with the incorrect unit selected; the first occurring on December 3, 2015 involving a dosage of 155 microCuries of radium-223 dichloride; the second on March 7, 2016 involving a dosage of 128 microCuries of radium-223 dichloride; the third on June 3, 2016 involving a dosage of 131 microCuries and the fourth on August 14, 2016 involving a dosage of 155 microCuries of radium-223 dichloride that was administered to patients for treatment of osseous metastases from prostate cancer. The written directives incorrectly stated the intended dosages as 155 milliCuries; 128 milliCuries; 131 milliCuries and 155 milliCuries, respectively. The fifth medical event occurred on February 20, 2016 involving a dosage of radium-223 dichloride 121 microCuries when the written directive stated 211 microCuries. The prescribed dose was 211 microCuries. The dose administered was 121 microCuries, which is a 43% variance. The whole body dose calculation is 85.50 rad/mCi x 0.09 mCi = 7.7 rem, which exceeds the 5 rem dose limit. However, the physician intended to administer 121 microCuries and had transposed the numbers on the written directive. The sixth occurred on March 28, 2017 with 25 milliCuries of sodium iodide iodine-131 where the written directive stated 25 milliCuries of radium-223 dichloride with the intended dose of 25 milliCuries of sodium iodide iodine-131 ordered and administered. No harm to the patients is expected since these treatments were successfully performed by administration of a dosage that was in accordance with the intentions of the authorized user physician. The details of corrective actions are being ascertained at the facility due to the absence of the Radiation Safety Officer at the time of discovery. NHPP [National Health Physics Program] staff was on site and discovered the events on May 2, 2017, during a routine inspection. We notified the NRC Operations Center by telephone on May 3, 2017.

"As part of our routine, we evaluated circumstances of the medical events, reviewed actions to prevent a recurrence, and assessed regulatory compliance."

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.

TWO GAUGES DESTROYED IN A FIRE

The following information was received via email.

"Tower Plastics Mfg., Inc. reported that their two remaining generally licensed NDC Model 103 gauges (SN's 2160 and 2161 containing 150 mCi/Am-241 each) were destroyed in a fire on December 3, 2015. This was reported during the IEMA [Illinois Emergency Management Agency] 2018 annual source reconciliation. The licensee reported that the site was completely destroyed in the fire and debris was hauled to a landfill. Records of the disposal and an IEMA survey of the site are pending."

Item Number: IL180030

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