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Event Notification Report for March 4, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/03/2014 - 03/04/2014

** EVENT NUMBERS **


49847 49849 49867 49868

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Agreement State Event Number: 49847
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: TEXAS INSTRUMENTS, INC
Region: 1
City: SOUTH PORTLAND State: ME
County:
License #: 05851G
Agreement: Y
Docket:
NRC Notified By: TOM HILLMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/21/2014
Notification Time: 10:33 [ET]
Event Date: 02/13/2014
Event Time: [EST]
Last Update Date: 02/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

The following was received from the State of Maine via fax:

"An emergency exit sign was lost. A portion of the Texas Instruments facility at 5 Foden Road in South Portland, Maine, where emergency exit signs are in use, was in the process of being renovated by a construction contractor. The contractor removed the sign from the wall unaware that this exit sign was not an electric exit sign. The sign was removed and its location has not been identified."

Event Report ID No. ME-14-0001

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: 49849
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/21/2014
Notification Time: 16:28 [ET]
Event Date: 02/19/2014
Event Time: [EST]
Last Update Date: 02/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 TO A PATIENT

The following information was obtained from the Commonwealth of Massachusetts via email:

"Report of medical event. A dose that differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more.

"The licensee reported to the Agency [Massachusetts Radiation Control Program] on 2/21/2014 that on 2/19/2014 licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver and that treatment was palliative in nature; that 7.2 millicuries of yttrium-90 was prescribed; and that 5.06 millicuries was administered resulting in an underdose of 29.7 percent.

"The licensee reported that the dose administered differs from the dose prescribed by more than 50 rem to the liver and that licensee will determine what the likely dose difference actually was.

"The licensee reported that during the procedure it was apparent that spheres were collecting on the tubing between the stop cock and the source vial and that when procedure was concluded, assays were performed of treatment apparatus and source vial and licensee determined that only 5.06 millicuries of the 7.2 millicuries prescribed was administered.

"The licensee reported that the manufacturer, Sirtex, will be onsite on February 24th to begin a joint investigation.

"The licensee reported that the referring physician has been notified and it is unknown at time of report whether referring physician has elected to notify patient.

"The licensee reported that they do not anticipate any adverse effects on the patient's treatment outcome.

"The licensee will submit a written report within 15 days in accordance with the requirements of 105 CMR 120.594(A)(4).

"Root cause and corrective action are not known at this time and the Massachusetts Radiation Control Program continues to investigate."

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: 49867
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DOUGLAS LaMARCA
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/04/2014
Notification Time: 01:50 [ET]
Event Date: 03/04/2014
Event Time: 00:25 [EST]
Last Update Date: 03/04/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
FRED BOWER (R1DO)

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 N 0 Cold Shutdown 0 Cold Shutdown

Event Text

SECONDARY CONTAINMENT DECLARED INOPERABLE DURING SURVEILLANCE TESTING

"On March 4, 2014 at 0025 EST, Secondary Containment drawdown testing surveillance failed to meet acceptance criteria of SR 3.6.4.1.5 due to maximum flow rate exceeding the allowable value. Secondary Containment drawdown testing was being performed on Reactor Building Zone 1 and Zone 3 with Zone 2 HVAC shutdown.

"Upon failure of the surveillance, Secondary Containment ventilation was realigned to a previous successfully tested and known operable alignment for Zones 1, 2 and 3. This alignment consists of all Reactor Building Zones in service and Zone 3 aligned to the Railroad Bay.

"Upon restoration of Secondary Containment ventilation to a known operable alignment, operability was restored and Secondary Containment LCO 3.6.4.1 was cleared at 0128 EST on March 4, 2014.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG-1022, Rev. 3, Section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 49868
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL M. JONES
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/04/2014
Notification Time: 05:05 [ET]
Event Date: 03/04/2014
Event Time: 01:43 [EST]
Last Update Date: 03/04/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRED BOWER (R1DO)

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

Event Text

UNIT 2 MANUAL REACTOR SCRAM FOLLOWING LOSS OF A UNINTERRUPTIBLE POWER SUPPLY [UPS]

"At 0137 EST Nine Mile Point Unit 2 experienced a loss of an uninterruptible power supply 2VBB-UPS3B which resulted in a half scram and half isolations. This caused a loss of cooling water to the Reactor Recirculation Pumps and other indications for the loss of power.

"At 0143 EST a Manual Reactor Scram was inserted due to the rise of temperatures on the Reactor Recirculation Pump seal cavity temperature and motor winding temperature.

"The reactor building ventilation radiation monitor went non-functional when the reactor building isolated on the loss of UPS power. The standby gas treatment system was started as required and restored the reactor building differential pressure.

"This is a 4-Hour report for 10CFR50.72(b)(2)(iv)(B) RPS Actuation and 8-Hour report for 10CFR50.72(b)(3)(xiii) Loss of Emergency Assessment Capability.

"The NRC Resident inspector has been notified."

All systems functioned as required following the manual scram. All control rods fully inserted.

The cause of the loss of the UPS is under investigation.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014