Event Notification Report for September 06, 2012

AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPHERES ADMINISTERED TO THE WRONG TREATMENT SITE

"On September 6, 2012, the [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (PADEPBRP)] Central Office received notification via a phone call about this medical event.

"The patient received an administration of approximately 1.4 millicuries (mCi) of Y-90 microspheres to the wrong treatment site. The intended treatment was to administer approximately 24 mCi to the left lobe of the liver through three different arteries. During the administration of one of the split doses, the Interventional Radiologist (IR) incorrectly positioned the catheter in the right hepatic artery. A portion of the one split dose was administered to the right lobe of the liver before the IR realized that the catheter was not in the correct artery.

"Cause of the event: Human Error.

"Actions: Both the referring physician and the patient have been notified of the medical event. The [PADEPBRP] plans to do a reactive inspection."

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 - SOURCE RACK STUCK IN UNSHIELDED POSITION

The State of South Carolina submitted the following information via email:

"The SC Department of Health and Environmental Control [SCDHEC] was notified on Thursday, September 6, 2012, at 1500 EDT, that rack #2 failed to return to a shielded position at 0605 EDT due to a cleaning rag that was inadvertently wrapped around the source rack hoist cable. The RSO/Maintenance Manager for the facility stated that authorized personnel were able to clear the obstruction and return the rack to a shielded position at 0700 EDT. There were no personnel exposures and no equipment damage.

"This event is open and pending the licensee's investigation and report to the SCDHEC. Updates will be made through the national NMED system."

LOSS OF SECONDARY CONTAINMENT VENTILATION FOR EIGHT SECONDS

"On September 6, 2012, at 1314 hours, the reactor building ventilation system was being restored to service following planned maintenance and surveillance activities. During the reactor building pressure transition when restoring reactor building ventilation (from the Standby Gas Treatment System), an employee entered a secondary containment interlock and identified a door leading to the environment had opened. The employee immediately secured the door and notified Operations personnel. A review of the door alarm history determined the door was open for approximately eight seconds.

"Given the temporary breech in secondary containment, this event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function."

The licensee notified the NRC Resident Inspector.

BOTH OFFSITE POWER SOURCES INOPERABLE

"At 1416 EDT, after consultation with the Unit 1 control room, the #1 138 KV bus in the Beaver Valley switchyard was deenergized by the grid system operator in response to a degraded switchyard breaker. The bus loss caused the Unit 1 A train offsite power supply to be inoperable. The Unit 1 B train offsite power supply was previously inoperable due to planned maintenance on its transformer cooling fan control circuit. The Unit 1 B train offsite power supply remained energized and available during this event. Both Emergency Diesel Generators remained operable and both emergency buses remained energized from the onsite source and operable during this event.

"At 1425 EDT the #1 138 KV bus was re-energized. The planned maintenance was completed on the B train offsite power supply transformer. Following testing, at 1452 EDT both offsite power supplies were declared operable.

"This notification is provided in accordance with 10CFR50.72(b)(3)(v)(D) since both offsite power supplies were inoperable from 1416 EDT to 1452 EDT on 9/6/12."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM DAN SCHWER TO JOHN KNOKE AT 1242 EDT ON 10/01/12 * * *

"Beaver Valley Unit 1 is retracting EN # 48283 based on completion of an engineering evaluation. The evaluation determined that the Unit 1 'B' train offsite power supply was operable and capable of performing its safety function with its transformer cooling fan control circuit out of service for planned maintenance. Since one train of offsite power was determined to be operable, this condition is not reportable under 10CFR50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified." Notified R1DO (Wayne Schmidt).