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Event Notification Report for October 28, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/25/2013 - 10/28/2013

** EVENT NUMBERS **


49450 49473 49475 49476

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Agreement State Event Number: 49450
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ABINGTON MEMORIAL HOSPITAL
Region: 1
City: ABINGTON State: PA
County:
License #: PA-0055
Agreement: Y
Docket:
NRC Notified By: JOESEPH MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/18/2013
Notification Time: 15:28 [ET]
Event Date: 05/07/2013
Event Time: [EDT]
Last Update Date: 10/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE ADMINISTRATION OF AN UNDER-DOSE TO A PATIENT

The following report was received via email:

"Event type: Medical Event involving the administration of yttrium-90 (Y-90) Sir-Spheres.

"Notifications: On October 17, 2013 the licensee informed the Department's Central Office of the Medical Event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). Appropriate reporting to the referring physician and the patient is currently underway.

"Event Description: The patient was scheduled to receive two split doses on May 7, 2013. The plan was to treat the left hepatic artery segment 2 and 3 with 11.9 mCi (0.44 GBq) and the left hepatic artery segment 4 with 11.9 mCi (0.44 GBq). The unit doses were assayed separately and were found to be within 10% of the prescribed doses. After the doses were assayed, the exposure rate around the jar was measured and documented. After the procedure was completed, the tubing, V-Vial, and the jar were collected and then measured to calculate the residual activity using the same procedure and geometry used during the pre-dose measurements as per procedure. The post treatment measurements and calculations revealed the following delivered doses. The left hepatic artery segment 2 and 3 branches received 9.2 mCi and the left hepatic artery segment 4 branch received 8.92 mCi. This resulted in under-dosing of 22.48% and 30.03% respectively.

"CAUSE OF THE EVENT: Occlusion of SirSpheres in the delivery system. The post treatment measurements were high which indicated that there were some spheres in the tubing or the V-Vial. When the jar was opened, it was found that the three-way stop cock contained some of the activity.

"ACTIONS: A new dose work sheet has been built in as a warning to remind the licensee to notify the regulatory agency should the dose variance exceed 20%.

"Media attention: None at this time."

Pennsylvania Event Report Number - PA130055

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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Power Reactor Event Number: 49473
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MATT REID
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/25/2013
Notification Time: 15:24 [ET]
Event Date: 10/24/2013
Event Time: 10:35 [PDT]
Last Update Date: 10/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
WAYNE WALKER (R4DO)

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

Event Text

FAILURE OF RADWASTE BUILDING EFFLUENT RADIATION MONITOR

"At 1035 [PDT] on October 24, 2013, during a channel functional test (CFT), the intermediate radiation effluent monitor on the radwaste building failed an as found range check and was declared inoperable. A single range check was found out of tolerance low. The as found values on the remaining five ranges that the instrument spans were within the acceptance criteria. This monitor is one of three methods of declaring a general emergency due to offsite radiation releases originating in the radwaste building. Lower emergency classification levels are supported by a separate radiation monitor that was not impacted. The failure to complete the CFT on the intermediate range monitor with all ranges yielding satisfactory as found values represents a potential major loss of emergency assessment capability. This issue is being conservatively reported under 10 CFR 50.73(b)(3)(xiii). Efforts are underway to restore the monitor and an update will be made when the monitor is returned to service."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM EDAN ENGSTROM TO JOHN SHOEMAKER AT 2044 EDT ON 10/26/13 * * *

"The intermediate radiation monitor on the radwaste building has been returned to within tolerance. The radiation monitor has been declared functional at 1558 PDT on 10/26/2013.

"The licensee has notified the NRC Resident Inspector."

Notified the R4DO (Walker).

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Fuel Cycle Facility Event Number: 49475
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/27/2013
Notification Time: 14:16 [ET]
Event Date: 10/27/2013
Event Time: 10:55 [PDT]
Last Update Date: 10/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(5) - ONLY ONE SAFETY ITEM AVAILABLE
Person (Organization):
STEVEN VIAS (R2DO)
MARISSA BAILEY (NMSS)

Event Text

FAILURE OF A STEAM SUPPLY VACUUM BREAKER

"During performance of a preventive maintenance check of [Item Relied On For Safety] IROFS 3526 [Uranium Dioxide steam supply system], it was determined to have failed, that is, blocked preventing it to perform its safety function as a vacuum breaker. This vacuum breaker is in a steam line from an unfavorable geometry steam boiler to process service subsystems. This vacuum breaker is designed to prevent backflow from Tank TK-102 when the heat exchanger E-102 leaks internally and the steam supply is off, Accident Sequence 2.13, in E04-NCSA-070 version 11 for the ADU [Ammonium Diuranate] process. This vacuum breaker is also used in Accident Sequence 5.4, E04-NCSA-120 version 16 for the UNH [Uranal Nitrate Hydroxide] reprocessing Integrated Safety Analysis (ISA). This sequence is the transfer of UNH from uranium powder dissolver to the unfavorable geometry steam boiler when the loss of its heat source causes a vacuum in the steam boiler. Additionally this IROFS is used in Accident Sequence 7.5, E04-NCSA-190 version 10 for the UO2 pellet dissolution process. The IROFS prevents UNH to backflow into the unfavorable geometry steam boiler. The UO2 steam boiler was shut down at the time of the finding and remains shutdown. The other IROFS 3527 in these sequences remained available during the time. This was verified when performing the PM.

"This determination was completed at 1055 PDT on 10/27/2013. The extent of condition to evaluate other potential uses of this type of vacuum breaker is underway. The safety significance is low as the independent IROFS 3527 was verified to be available and reliable via the testing. The system was shut down and remains shutdown for further evaluation, the failed vacuum breaker has been replaced and verified operable."

The licensee will notify Region II.

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Power Reactor Event Number: 49476
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW LEENERTS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/27/2013
Notification Time: 22:29 [ET]
Event Date: 10/27/2013
Event Time: 17:30 [EDT]
Last Update Date: 10/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
STEVEN VIAS (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

AUXILIARY BUILDING GAS TREATMENT SYSTEM INOPERABLE

"At 1730 EDT on 10/27/2013, SQN [Sequoyah Nuclear] discovered that Unit 1 containment penetration X-108 had a maintenance flange installed with a service air connection attached. The service air connection was connected to a temporary air compressor supplying air to maintenance loads inside Unit 1 containment. Contrary to the requirements of the breaching permit, personnel were not stationed at the penetration to isolate the service air connection in the event of the air line rupturing inside Unit 1 containment or upon initiation of an auxiliary building isolation signal. Since the Unit 1 containment is open to the auxiliary building as part of outage activities, if the service air line had ruptured, the additional air into the Unit 1 containment could have exceeded the capacity of the Auxiliary Building Gas Treatment System (ABGTS) and potentially have impacted the ability of the ABGTS to perform its design safety function. This resulted in both trains of the ABGTS being declared inoperable requiring Unit 2 to enter the action of LCO 3.0.3. The service air line was isolated immediately and Unit 2 exited the action of LCO 3.0.3 at 1732 EDT. At the time of the event, Unit 1 was defueled and did not require ABGTS to be operable. Unit 1 subsequently entered Mode 6 at 1904 EDT on 10/27/2013 and is currently conducting refueling operations. Unit 2 remains in Mode 1, 100% power and stable. There were no actual operational impacts to either unit."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, October 28, 2013
Monday, October 28, 2013