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Event Notification Report for February 25, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/22/2013 - 02/25/2013

** EVENT NUMBERS **


48752 48753 48757 48759 48772 48777 48778

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Agreement State Event Number: 48752
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENN STATE MILTON S. HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: PA-0127
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2013
Notification Time: 14:28 [ET]
Event Date: 08/28/2012
Event Time: [EST]
Last Update Date: 02/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 SIR-SPHERES

The following information was obtained from the Commonwealth of Pennsylvania via email and facsimile:

"Notifications: On February 13, 2013 the licensee informed the Department's [Pennsylvania Department of Environmental Protection] South-central Regional Office of the medical event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). The referring physician was notified of this event but the patient passed away in November of 2012 as a result of metastatic pancreatic cancer.

"Event Description: During a routine audit of the Y-90 written directive program, an error was noted in a SIR-Sphere procedure that was performed on August 28, 2012. The patient was prescribed 17.6 mCi of Y-90 SIR-Spheres. The patient actually received only 12.8 mCi. This corresponds to a dose that is 27.3% lower than the prescribed dose.

"Cause of the Event: The physician recorded the wrong administered dose on the written directive form. Also a small liquid volume remained in the vial after the 'air-injection' final step.

"Actions: The licensee initiated and completed an audit of all SIR-Sphere procedures and no other issues were identified in any other patients since inception of the program. The South-central Regional Office has been in discussion with the licensee regarding corrective actions that will be implemented."

Pennsylvania Event Report ID No.: PA130006

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: 48753
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: UNKNOWN
Region: 4
City: PORTLAND State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2013
Notification Time: 18:29 [ET]
Event Date: 02/14/2013
Event Time: [PST]
Last Update Date: 02/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME_EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

Event Text

AGREEMENT STATE REPORT - DISCOVERY OF GAS CHROMATOGRAPH IN BUILDING ATTIC

The following is a synopsis of information received from the State of Oregon via email:

When cleaning out an attic storage space acquired from a business partner (Philco International), an employee of the Evonik Corporation discovered a gas chromatograph containing a Ni-63 electron capture device (ECD). The ECD was manufactured in 1993 and contained 15 mCi of Ni-63 at the time of manufacture. The ECD is model number N610-0133 and serial number 1121.

The chromatograph was manufactured by Perkin Elmer and was originally sold to InterMedics of Angleton, TX in October, 1993. In 1998, Guidant bought out InterMedics and eventually closed the facility in 1999. It is unknown what happened to the device after the 1999 closure.

Evonik Corporation will be contracting out proper disposal of the unit and will inform the State of Oregon when it has been removed.

Oregon Incident No.: 13-0009

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Agreement State Event Number: 48757
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: THERMO FISHER SCIENTIFIC, INC.
Region: 1
City: FRANKLIN State: MA
County:
License #: 55-0447
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/15/2013
Notification Time: 14:00 [ET]
Event Date: 02/15/2013
Event Time: 13:00 [EST]
Last Update Date: 02/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED NI-63 SOURCE IN GAS CHROMATOGRAPH

The following information was received from the Commonwealth of Massachusetts via fax:

"The licensee reported to the Agency (MA Radiation Control Board) that a wipe test survey of an SVAC-G module containing a Ni-63 sealed source yielded 0.0068 microcuries. The licensee gave no further details about the sealed source or the device, and stated that a written report was mailed to the Agency. The SS&D registration certificate indicates the sealed source maximum activity is 5 millicuries. The SS&D certificate indicates the source is contained inside the 'Thermo Fisher Scientific' model SVAC-G module which is contained in a 'Thermo Fisher' model EGIS Defender gas chromatograph instrument."

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Non-Agreement State Event Number: 48759
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: CARL VINSON VA MEDICAL CENTER
Region: 1
City: DUBLIN State: GA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/15/2013
Notification Time: 16:56 [ET]
Event Date: 02/15/2013
Event Time: 07:00 [EST]
Last Update Date: 02/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
PATTY PELKE (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

PACKAGE RECEIVED AT VA MEDICAL CENTER WITH OUTSIDE CONTAMINATION EXCEEDING LIMITS

"[The Department of Veterans Affairs, Veterans Health Administration (VHA) National Health Physics Programs] has a master materials license from the Nuclear Regulatory Commission. License number is 03-23853-01VA.

"Per 10 CFR 20.1906(d), [the VA] is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.

"The package was received today (February 15, 2013) at around 7 AM ET by Carl Vinson VA Medical Center, Dublin, Georgia. The package was checked-in and surveyed around 8:30 AM ET. This medical center holds permit number 10-09569-01 under the VHA master materials license.

"Wipe tests performed on the external surface of the package indicated a removable contamination level of 4190 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters.

"The package contained eight unit dosages of radiopharmaceuticals ranging between 6 and 40 millicuries each of Technetium-99m and was shipped from Cardinal Health in Augusta, Georgia. The inner packaging materials were also found to be contaminated.

"The VA facility Nuclear Medicine Technologist who surveyed the packages immediately notified the vendor/shipper, who serves as the final delivery carrier, about the contaminated package at about 9 AM ET. [The VA National Programs] office was not notified until about 4 PM ET.

"As corrective actions: the packaging materials were bagged and set aside in a restricted area at the VA Medical Center and were reclaimed later in the day by the radiopharmacy.

[The VA has also] notified NRC Region III Project Manager (K. Null) ..."

HOO Note: A similar incident at the same facility was reported on 02/11/13 - see EN #48742.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48772
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM ANDERSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/20/2013
Notification Time: 10:21 [ET]
Event Date: 02/20/2013
Event Time: 05:28 [EST]
Last Update Date: 02/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

DEGRADED CONDITION - CONTAINMENT PENETRATION FAILS LOCAL LEAK-RATE TESTING

"On February 20, 2013, at 0538 EST, local leak-rate testing (LLRT) of the 'A' feedwater check valves 2B21-F010A and 2B21-F077A revealed that neither valve would pressurize. Based on this information this line would not remain water filled post-LOCA and would result in the 'as found' minimum pathway leakage exceeding the limiting condition of operation (LCO) for Technical Specification 3.6.1.1. The cause for the LLRT failures will be determined and required corrective maintenance will be performed and valves successfully tested during the current refueling outage."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM KEN HUNTER TO VINCE KLCO ON 2/22/13 AT 1611 EST* * *

"Subsequent investigation into the reported LLRT failure revealed that the initial LLRT performed on feedwater check valve 2B21-F010A was not considered an acceptable test, since that LLRT was not representative of the 'as found' condition of this check valve. The test volume for this valve had been slowly filled such that the check valve did not have the normal expected differential pressure across the valve disc to achieve normal check valve seating. After draining the test volume and refilling it by allowing the test volume to gravity fill from the reactor pressure vessel, the expected differential pressure across the valve disc occurred and seated the disc in such a way that it was more representative of the 'as found' condition for the check valve. An LLRT was then performed with a leakage of 50 accm [actual cubic centimeters per minute] against an acceptance criterion of 194 accm. No maintenance or operation of the check valve had occurred between the initial invalid test and the subsequent test performed with the disc in its 'as found' condition. An engineering evaluation was performed that documented the acceptability of using this means for establishing the test volume for feedwater check valves 2B21-F010A and 2B21-F010B for the 'A' and 'B' loops of feedwater, respectively. This engineering evaluation concluded that establishment of the required test volume in the manner described for primary containment penetration 9A satisfies the Hatch LLRT program requirements and that the leakage acceptance criterion for feedwater check valve 2B21-F010A in its 'as found' state was satisfied. The 2B21-F077A valve will be retested at a later date.

"Based on this information, the LLRT of this check valve in its 'as found' state was successful which actually resulted in successful minimum pathway leak rate test results for primary containment penetration 9A. These conclusive test results clearly indicated that the initial test results were incorrect and the 'as found' condition of this penetration isolation capability did not represent a significant degradation of a principal safety barrier as described in 10CFR50.72(b)(3)(ii)(A). For these reasons Notification # 48772 is being retracted."

The licensee notified the NRC Resident Inspector.

Notified the R2DO (McCoy).

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Power Reactor Event Number: 48777
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DARVIN DUTTRY
HQ OPS Officer: VINCE KLCO
Notification Date: 02/22/2013
Notification Time: 20:13 [ET]
Event Date: 02/22/2013
Event Time: 14:30 [EST]
Last Update Date: 02/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
TODD JACKSON (R1DO)
CYBER TEAM (e-mail) ()

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

COMPUTER PROGRAM ERROR IDENTIFIED IN THE FITNESS FOR DUTY PROGRAM

"On February 22, 2013 at approximately 1430 [EST], Susquehanna identified a computer program error that affected the Susquehanna Fitness for Duty (FFD) program. Specifically, two Behavioral Observation Program (BOP) inquiries were accepted without proper documentation of the required need to continue unescorted access authorization (UAA) and without verification of an actual observation within the required thirty day timeframe. The computer error resulted in answers for two of the three questions on the Behavior Observation Inquiry form not being recorded when the form was submitted by the supervisor. This resulted in the two security accounts being re-zeroed and allowing UAA for an additional 15 days. The BOP supervisor was contacted and verified that these individuals were intended to continue with UAA. At no time were these individuals removed from the FFD or Behavior Observation Program.

"In accordance with 10 CFR 26.719(b)(4), this report is being made based on being a potential programmatic failure, degradation, or discovered vulnerability of the FFD program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program. The [NRC Resident Inspector] and the Branch Chief for the Region I Division of Reactor Safety were notified."

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Power Reactor Event Number: 48778
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW LEENERTS
HQ OPS Officer: VINCE KLCO
Notification Date: 02/24/2013
Notification Time: 15:20 [ET]
Event Date: 02/24/2013
Event Time: 12:05 [EST]
Last Update Date: 02/24/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 25 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSER VACUUM INDICATION

"On February 24, 2013 at 1205 [EST] with reactor power at 25% and the turbine offline, a manual reactor trip for Sequoyah Unit 2 was initiated due to loss of condenser vacuum indication causing closure of condenser steam dumps, opening of the Steam Generator Atmospheric Relief Valves, and lowering hotwell level resulting in imminent loss of hotwell pumps. The cause of the event was determined to be a faulty test connection on B Condenser vacuum pressure switch.

"During the event, steam pressure rose to the setpoint for the first Steam Generator code safety valve (1064 psig). [The safety valve opened, then reseated].

"Following the reactor trip, all safety related equipment operated as designed. Auxiliary feedwater actuated as expected on loss of the operating main feedwater pumps. The reactor trip was uncomplicated.

"Unit 2 is currently being maintained in Mode 3 at NOP/NOT [Normal Pressure and Temperature], with auxiliary feedwater supplying the steam generators and maintaining level at approximately 33% narrow range.

"Method of decay heat removal is via atmospheric reliefs to the atmosphere. Current RCS conditions: temperature [is] 547 degrees F and stable. Pressure [is] 2235 psig and stable. [There is] no indication of any primary/secondary leakage. All rods are inserted. Electrical alignment is normal and supplied from offsite power. [There is] no impact to Unit 1. Unit 1 is operating at 100% power / Mode 1.

"There was no impact on public health and safety. Post-trip investigation is in progress and planned restart is 02/25/2013. [The licensee plans a press release.]"

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, February 25, 2013
Monday, February 25, 2013