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Event Notification Report for January 23, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/22/2013 - 01/23/2013

** EVENT NUMBERS **


48671 48674 48675 48688 48689 48690

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Agreement State Event Number: 48671
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS, INC.
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 01/14/2013
Notification Time: 14:53 [ET]
Event Date: 01/11/2013
Event Time: [EST]
Last Update Date: 01/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING PROSTATE BRACHYTHERAPY IMPLANT

The following information was obtained from the Commonwealth of Pennsylvania Department of Environmental Protection via e-mail:

"On January 11, 2013 the licensee informed the Department's Southeastern Regional Office of the Medical Event. The event is reportable within 24 hours per 10CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified.

"On December 4, 2012 the patient received an iodine-125 prostate seed implant. The patient returned for the 30 day post-treatment follow-up CT scan on January 9, 2013. Upon review of the CT results on January 10, 2013, it was discovered that the prostate received approximately 60% of the intended dose. The D90 was determined to be 56 Gy out of a prescribed dose of 110 Gy.

"The potential cause of the event was noted as possible organ shift or incorrect depth placement of needles.

"The licensee plans to compensate for the undertreated area with follow-up external beam therapy. They will provide the Department a written report in 15 days. The Southeastern Regional Office plans to follow up with 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.

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Agreement State Event Number: 48674
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: METHODIST UNIVERSITY HOSPITAL
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79027-H-15
Agreement: Y
Docket:
NRC Notified By: LAURA TURNER
HQ OPS Officer: VINCE KLCO
Notification Date: 01/15/2013
Notification Time: 12:45 [ET]
Event Date: 01/14/2013
Event Time: 12:15 [EST]
Last Update Date: 01/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
FSME_RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT- SOURCE STUCK IN A TRANSFER TUBE

The following information was received by email:

"On Monday, January 14, 2013, the [State of Tennessee] Division of Radiological Health received a report from Methodist University Hospital regarding a stuck HDR source. A patient was to be treated with the high dose rate remote afterloader (Nucletron model 105.999) on January 14th. The radiation source became stuck in the applicator/transfer tube at the beginning of treatment before reaching the patient. The physicists and physician followed the policy and procedure for removal of the source and tubing. The source was placed in a shielded container. A Nucletron engineer was notified by phone and arrived at 1600 CST, but was unable to dislodge the source from the transfer tube. The source and transfer tube will be sent back to Nucletron and replacements have been ordered. A written report is being prepared and will be sent to the Division of Radiological Health. Inspectors from the Memphis field office will follow-up on this incident and will continue to keep NRC informed of the status of our investigation."

Tennessee Event: TN-13-013

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Non-Agreement State Event Number: 48675
Rep Org: DEFENSE LOGISTICS AGENCY
Licensee: DEFENSE LOGISTICS AGENCY
Region: 1
City: NEW CUMBERLAND State: PA
County:
License #: 37-30062-01
Agreement: Y
Docket:
NRC Notified By: DAVID COLLINS
HQ OPS Officer: VINCE KLCO
Notification Date: 01/15/2013
Notification Time: 17:54 [ET]
Event Date: 01/14/2013
Event Time: [EST]
Last Update Date: 01/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN ROGGE (R1DO)
MICHAEL VASQUEZ (R4DO)
FSME EVENTS (EMAI)
GARY LANGLIE (ILTA)
MEXICO VIA FAX ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

POTENTIAL THEFT OF PRESSURE INDICATOR CONTAINING SR-90 SOURCE

"An item was processed for shipment [from Norfolk, VA] to the manufacturer for repair and was delivered to a contracted carrier on 9 January 2013. The carrier notified the government representative on Monday, 14 January 2013, reporting that the subject material was involved in a police investigation for a potential theft in Riverside, CA. The government contractor reported the loss of freight to the depot who reported the incident to the DLA [Defense Logistics Agency] Distribution Radiation Safety Officer at 1503 hrs on 15 January 2013.

"DLA Distribution [Norfolk, VA] will work with all parties to obtain further information related to this incident and update the NRC as information becomes available."

The shipped item is a pressure indicator [NSN#6620-01-125-8904] containing a Sr-90 source (500 microCuries).

DLA Incident Number: 2013-DLA-001

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

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Power Reactor Event Number: 48688
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: THOMAS MORSE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/22/2013
Notification Time: 06:57 [ET]
Event Date: 01/22/2013
Event Time: 03:32 [EST]
Last Update Date: 01/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
TAMARA BLOOMER (R3DO)
ERIC THOMAS (NRR)
JASON KOZAL (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR PROTECTION SYSTEM ACTUATION

"On January 22, 2013, at approximately 0332 hours [EDT], an automatic Reactor Protection System (RPS) actuation occurred at the Perry Nuclear Power Plant, Unit 1. At the time of the event, the plant was in Mode 1 at 100% power. All control rods are inserted into the reactor core and the plant is currently stable in Mode 3 (Hot Shutdown) with reactor pressure and level being maintained in the normal shutdown range.

"The RPS actuation was initiated by a low reactor water level (Level 3 - 178") signal. In response to the RPS actuation and subsequent reactor Level 2 (130") signal, the High Pressure Core Spray (HPCS) system and Reactor Core Isolation Cooling (RCIC) system both actuated and injected to maintain reactor coolant level. The reactor level is currently being maintained in its normal band by the feedwater system and decay heat is being removed by [turbine bypass valves to] the condenser (both HPCS and RCIC have been returned to standby). The plant is in a normal electrical line-up with all three Emergency Diesel Generators operable and available, if needed. The Containment Isolation Valves (responded to the Level 2 and 3) isolation signals as designed.

"The cause of the RPS actuation is under investigation.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48689
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: KELLEY BLENKY
HQ OPS Officer: PETE SNYDER
Notification Date: 01/22/2013
Notification Time: 08:38 [ET]
Event Date: 01/22/2013
Event Time: 01:13 [EST]
Last Update Date: 01/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
TAMARA BLOOMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

SECONDARY CONTAINMENT PRESSURE POSITIVE FOR 12 SECONDS

"On 01/22/2013 at 00:30 Reactor building HVAC tripped due to low outside air temperature and Standby Gas Treatment system was manually started and maintained Reactor Building differential pressure negative. At 01:13 secondary containment pressure went positive during restart of the Center Reactor Building HVAC Train. This is a loss of secondary containment function. In a 12 second time span secondary containment pressure went above 0 inches WC [Water Column] to +0.17 inches WC and then decreased to < 0 inches WC remaining stable during the Reactor Building HVAC restart. The Center Reactor Building HVAC Exhaust Fan Discharge Damper opened after the Supply Fan discharge damper; this condition would produce the indications noted.

"The System was returned to normal with two Reactor Building HVAC trains running and the Standby Gas Treatment System shutdown and in standby. Reactor building pressure is stable with differential pressure negative < - 0.30 inches WC.

"The loss of Secondary Containment function is reportable under 10 CFR 50.72 (b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48690
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: NEEL SHUKLA
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/22/2013
Notification Time: 12:45 [ET]
Event Date: 11/23/2012
Event Time: 04:35 [CST]
Last Update Date: 01/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

PRIMARY CONTAINMENT ISOLATION ACTUATION SIGNAL DURING SURVEILLANCE

"This 60-day telephone notification is being made in accordance with the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting multiple Main Steam Isolation Valves (MSIVs).

"On November 23, 2012 at 0435 Central Standard Time, during performance of Surveillance Instruction 1-SI-3.3.1.A, ASME Section XI System Leakage Test of the Reactor Pressure Vessel and Associated Piping, as the Residual Heat Removal Loop II Shutdown Cooling was being placed in service, Group 1, Division II Primary Containment Isolation System (PCIS) logic groups A2 and B2 actuated resulting in an unanticipated Division II, Group 1 Complete Isolation and subsequent Inboard MSIV closure. The Outboard MSIVs had been previously tagged closed.

"Plant conditions which initiate Group 1 actuations are Reactor Vessel Low-Low-Low Water Level, Main Steamline Break, and Low Main Steamline Pressure at the Inlet to the Turbine. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The affected equipment responded as designed.

"This condition was the result of the reactor vessel water level being within two inches of the reactor head vent when Shutdown Cooling was placed into service, causing pressure perturbations. When these perturbations occurred, they gave an indication of low water level, causing the isolation and MSIV closure.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the [Browns Ferry Nuclear Plant] Corrective Action Program as Problem Evaluation Report 646607.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, January 23, 2013
Wednesday, January 23, 2013