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Event Notification Report for March 27, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/26/2014 - 03/27/2014

** EVENT NUMBERS **


49930 49931 49959 49960 49962

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Agreement State Event Number: 49930
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: TRIAD ISOTOPES
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NY STATE
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/19/2014
Notification Time: 15:08 [ET]
Event Date: 03/18/2014
Event Time: [EDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
JULIO LARA (R3DO)
FSME EVENTS RESOURCE ()

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

Event Text

AGREEMENT STATE NOTIFICATION - FOUND DEPLETED URANIUM SHIELD

The following was received from the State of New York via fax:

"On 3/18/2014 NYC sanitation workers clearing a vacant lot in Queens discovered one depleted uranium (DU) shield and the remains of 3 to 4 plastic outer-packs from Mallinckrodt manufactured Mo/Tc radiopharmaceutical generators. Information on the packaging indicates the generators were supplied to NYS Licensee C5413 Triad Isotopes in 2013. Discussions with Triad Isotopes on 3/19/2014 indicate that Mallinckrodt contacted them in October 2013 regarding a shipment of 5 spent generators being returned from Triad to Mallinckrodt via their contractor MDS [that] did not make it to Mallinckrodt in Missouri. The DU shield is being secured by NYC while waiting to be picked up by Triad. NRC Region 3 has been contacted. NYS Incident #1055"

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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Agreement State Event Number: 49931
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: CONFIDENTIAL
Region: 1
City: CONFIDENTIAL State: NY
County:
License #: CONFIDENTIAL
Agreement: Y
Docket:
NRC Notified By: FAX
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/19/2014
Notification Time: 16:03 [ET]
Event Date: 03/04/2014
Event Time: [EDT]
Last Update Date: 03/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF IODINE-125 SOLUTION DURING BRACHYTHERAPY

The following information was received via facsimile:

"A patient was prescribed 50 Gray to be delivered to a brain tumor bed via a GliaSite balloon inflated with 200 mCi of I-125 saline solution implanted for 66 hours. Upon removal of the balloon on March 7, 2014, it was discovered that the balloon had not inflated and no dose to the tumor bed had been delivered.

"A three position stopcock was incorrectly positioned at the time of inflation and the I-125 saline solution was diverted to another syringe rather than to the balloon. All material is accounted for and is being held for DIS. The three position stopcock is not part of the vendor's kit.

"Corrective Actions: In-service by the vendor scheduled, revision of policies and procedures to include verification of balloon via medical imaging post-infusion, and in-service to staff on new policies and procedures."

NYS Incident: #1054

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: 49959
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/26/2014
Notification Time: 10:55 [ET]
Event Date: 02/06/2014
Event Time: 11:43 [EDT]
Last Update Date: 03/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)

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

Event Text

INVALID ACTUATION OF A CONTAINMENT ISOLATION SIGNAL

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to the invalid actuation of a containment isolation signal.

"On February 6, 2014, at 1143 [EST], with the plant in Mode 6 and fuel moves in-progress, an invalid containment isolation actuation signal was generated that affected containment isolation valves in more than one system and caused both trains of the control room heating, ventilation and cooling systems to swap from normal to emergency mode of operation. For both occurrences, all necessary follow-up actions were taken in accordance with the abnormal operating procedure for a spurious containment isolation event. All equipment responded in accordance with the plant design.

"The invalid actuation signal was caused by spurious upscale spikes in fuel handling area radiation monitor, RIA-2316. Actual radiation levels in the vicinity of RIA-2316 were verified to be normal and below the alarm set point. The indication on RIA-2316 spiked momentarily above the high alarm set point and then returned to normal levels. No alarms were received from the redundant fuel handling area radiation monitor, RIA-2317.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49960
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/26/2014
Notification Time: 10:55 [ET]
Event Date: 02/08/2014
Event Time: 00:19 [EDT]
Last Update Date: 03/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)

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

Event Text

INVALID ACTUATION OF A CONTAINMENT ISOLATION SIGNAL

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to the invalid actuation of a containment isolation signal.

"On February 8, 2014, at 0019 [EST], with the plant in Mode 6 and fuel moves in-progress, an invalid containment isolation actuation signal was generated that affected containment isolation valves in more than one system and caused both trains of the control room heating, ventilation and cooling systems to swap from normal to emergency mode of operation. For both occurrences, all necessary follow-up actions were taken in accordance with the abnormal operating procedure for a spurious containment isolation event. All equipment responded in accordance with the plant design.

"The invalid actuation signal was caused by spurious upscale spikes in fuel handling area radiation monitor, RIA-2316. Actual radiation levels in the vicinity of RIA-2316 were verified to be normal and below the alarm set point. The indication on RIA-2316 spiked momentarily above the high alarm set point and then returned to normal levels. No alarms were received from the redundant fuel handling area radiation monitor, RIA-2317.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49962
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JAMES BURKE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/26/2014
Notification Time: 14:32 [ET]
Event Date: 03/26/2014
Event Time: 10:15 [CDT]
Last Update Date: 03/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BILLY DICKSON (R3DO)

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 88 Power Operation 88 Power Operation

Event Text

FITNESS FOR DUTY REPORT INVOLVING A SUPERVISORY LICENSED EMPLOYEE

A supervisory licensed employee had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 27, 2014
Thursday, March 27, 2014