United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2014 > March 25

Event Notification Report for March 25, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/24/2014 - 03/25/2014

** EVENT NUMBERS **


49917 49948 49949 49950 49951 49952 49953 49954 49956

To top of page
Agreement State Event Number: 49917
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/14/2014
Notification Time: 16:48 [ET]
Event Date: 02/27/2014
Event Time: [EDT]
Last Update Date: 03/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - YTTRIUM 90 MEDICAL EVENT

The following information was received from the State of Georgia via email:

"Event Narrative: A patient was treated with Y-90 microspheres for cholangiocarcinoma. This was a bilateral disease that would require the treatment of both lobes of the liver. Significant tumor burden was in the central (segment IV) and medial sections. The medical team decided to treat the left lobe first as a result.

"For the first treatment, 54.05 mCi was to be delivered to the left lobe. It had an expected dose of 69.0 Gy to the liver. Due to issues with hepatic arterial anatomy not previously anticipated, the medical team could not properly position the catheter. Because it was a bilateral disease that would eventually require the treatment of both lobes, they decided to move forward with the procedure.

"Of the calibrated activity of 52.6 mCi, a post-therapy survey of the vial showed 88% of the dose or 46.3 mCi was delivered. A post-delivery Bremsstrahlung scan showed excellent coverage of Segment IV, with some minor coverage in the right lobe due to the arterial anatomy. 21.8 mCi was localized to Segment IV, and the approximate remainder, 24.5 mCi, ended up in the right lobe. There was no significant extrahepatic activity seen.

"The medical team considered the treatment to be successful due to the patient's bilateral disease. The authorized user intended to treat the right lobe next, and the team reports that the treatment plan will be adjusted to take into account the diseased areas which were treated. There should be no adverse reaction from this initial treatment.

"Cause and Corrective Actions: Occurred due to an arterial aberration causing a the interventional radiologist to be unable to canulate the artery. The hepatic arterial anatomy was different the day of treatment than the initial shunt study suggested on 5 February 2014. The patient's medical team decided to proceed with the catheter orifice just at the origin of the segment IV hepatic artery. The shunt fractions then resulted differently from the intended treatment for that day.

"The medical team and RSO are continuing to discuss if any preventative actions can be achieved. Treatment with Y-90 microspheres is reported to be complicated by the degree that the disease and prior treatments have affected liver vasculature. This makes it hard to plan for these scenarios pre-treatment.

"Generic Implications: Post treatment scans for Y-90 were reported by the licensee not to be a common practice, but they seem vital for determining if a treatment meets reportable limits.

"Procedure Administered: Bilateral radioembolization of liver with Y-90 microspheres.

"Intended Dose: 54.05 mCi (69.0 Gy) to left lobe of liver.

"Actual Dose: 21.8 mCi to Segment IV of left lobe and 24.5 mCi to the right lobe.

"Patient and Referring Physician Notified: Informed following the procedure's post-delivery Bremsstrahlung scan."

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.

To top of page
Power Reactor Event Number: 49948
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CARL JONES
HQ OPS Officer: VINCE KLCO
Notification Date: 03/24/2014
Notification Time: 05:14 [ET]
Event Date: 03/24/2014
Event Time: 00:31 [EDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAKE WELLING (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 18 Power Operation 18 Power Operation

Event Text

SECONDARY CONTAINMENT INOPERABLE AND UNPLANNED ISOLATION OF THE REACTOR BUILDING VENT RADIATION MONITOR

"At 0031 [EDT] on March 24, 2014, Nine Mile Point Unit 2 was lowering power for the planned refueling outage. The loss of reactor building heating resulted in the isolation of the reactor building to maintain building temperature. Isolation of the reactor building resulted in the isolation of the reactor building vent radiation monitor (Vent WRGMS) which is a loss of emergency assessment capability. The isolation of the reactor building also resulted in declaring secondary containment inoperable due to secondary containment differential pressure being positive. Secondary containment was declared operable at 0034 [EDT] when differential pressure was restored to greater than negative 0.25 inches water gauge.

"Secondary containment being inoperable is a 8-hour report for 10 CFR 50.72(b)(3)(v)(c), any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. The unplanned isolation of Vent WRGMS is a 8-hour report for 10 CFR 50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability.

"The NRC Resident Inspector has been notified."

The licensee will notify the New York Public Service Commission.

To top of page
Power Reactor Event Number: 49949
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: BRETT ULRICH
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/24/2014
Notification Time: 13:38 [ET]
Event Date: 03/24/2014
Event Time: 09:05 [EDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED SUPERVISORY EMPLOYEE

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

The licensee notified the NRC Resident Inspector and the New York Public Service Commission.

To top of page
Power Reactor Event Number: 49950
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN MCILNAY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/24/2014
Notification Time: 13:45 [ET]
Event Date: 03/24/2014
Event Time: 12:55 [EDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
SCOTT SHAEFFER (R2DO)
MELANIE GALLOWAY (NRR)
JEFFERY GRANT (IRD)

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

OFFSITE NOTIFICATION DUE TO DEATH OF EMPLOYEE

"On March 24, 2014, at approximately 0200 EDT, with Watts Bar Nuclear Unit 1 at 0% power while commencing a planned refueling outage and Unit 2 under construction, a radiation protection technician was found unresponsive in the protected area.

"An emergency medical team responded and the individual was transported off site to a medical facility where he was pronounced dead at 0530 EDT. The individual was not contaminated and there were no radiological or industrial safety issues associated with Watts Bar Nuclear Plant. Due to notification of OSHA at 1255 EDT, this report is submitted pursuant to 10 CFR 50.72(b)(2)(xi), as a notification to a government agency.

"The NRC Senior Resident Inspector has been notified."

To top of page
Power Reactor Event Number: 49951
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: TODD STRINGFELLOW
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/24/2014
Notification Time: 15:11 [ET]
Event Date: 03/24/2014
Event Time: 10:43 [EDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

RADIATION MONITOR OUT OF SERVICE FOR PRE-PLANNED MAINTENANCE

"System affected: SLCRS [Supplementary Leakage Collection and Release System] radiation monitor.

"Actuations and their initiation signals: N/A.

"Causes: Pre-planned maintenance.

"Effect of event on plant: Ventilation process radiation for SLCRS.

"Actions taken or planned: Return to service within 24 hrs.

"Additional information: None."

The licensee notified the NRC Resident Inspector and applicable State and local agencies.

To top of page
Power Reactor Event Number: 49952
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOHN CLAIRE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/24/2014
Notification Time: 16:34 [ET]
Event Date: 03/24/2014
Event Time: 13:27 [EDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MEL GRAY (R1DO)

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

STACK RADIATION MONITOR REMOVED FROM SERVICE FOR PRE-PLANNED MAINTENANCE

"The Millstone Station Stack Radiation Monitor, RM-8169 was removed from service for pre-planned maintenance. This is reportable as a loss of assessment capability in accordance with 10 CFR 50.72 (b)(3)(xiii).

"RM-8169 was restored at 1539 EDT."

The licensee notified the NRC Resident Inspector and applicable State and local agencies.

To top of page
Fuel Cycle Facility Event Number: 49953
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: RON DOCKERY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/24/2014
Notification Time: 17:00 [ET]
Event Date: 03/23/2014
Event Time: 20:50 [CDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
SCOTT SHAEFFER (R2DO)
JACK GUTTMANN (NMSS)

Event Text

SAFETY EQUIPMENT POTENTIAL FAILURE - HIGH PRESSURE FIRE WATER SPRINKLER SYSTEM

"At 2050 CDT, on 03-23-2014, the Plant Shift Superintendent was notified that the C-333 High Pressure Fire Water (HPFW) Sprinkler System A-16 had been inspected by Fire Services and 11 sprinkler heads had visible corrosion on them, including 4 heads adjacent to each other. The system configuration was evaluated using EN-C-822-99-047, 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads potentially impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to [Technical Safety Review] TSR LCO 2.4.4.5. HPFW system A-16 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage.

"Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the actual affect on operability. This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

"The NRC Region II (Marvin Sykes) has been notified of this event.

"PGDP Assessment and Tracking Report No. ATR-14-0324; PGDP Event Report No. PAD-2014-03; NRC Worksheet No. 49953

"Responsible Division: Operations"

TSR LCO 2.4.4.5 Action B requires an hourly fire patrol in the affected area.

To top of page
Power Reactor Event Number: 49954
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM TAYLOR
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/24/2014
Notification Time: 18:47 [ET]
Event Date: 03/24/2014
Event Time: 14:12 [CDT]
Last Update Date: 03/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 97 Power Operation 97 Power Operation

Event Text

UNANALYZED CONDITION DUE TO POSTULATED FIRE-INDUCED SHORT

"On March 24, 2014, during an extent of condition review for a separate problem evaluation report (PER) for the Browns Ferry Nuclear Plant (BFN), it was discovered that a postulated fire-induced wire-to-wire short of 250V DC control cables associated with 480V AC Shutdown Boards 2B, 3A, and 3B could cause the 480V AC Shutdown Board control power to spuriously transfer and could result in loss of control power to the 480V AC Shutdown Board. In the event of a 10 CFR 50 Appendix R fire, these conditions could result in loss of power to credited safe shutdown equipment that would challenge the ability to provide adequate core cooling during performance of BFN Safe Shutdown Instructions.

"Roving fire watches have been established as compensatory measures in accordance with the BFN Fire Protection Report.

"These conditions are being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). These conditions are also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(ii)(B). These conditions have been entered into the Corrective Action Program.

"The NRC Resident Inspector has been notified of this event."

To top of page
Power Reactor Event Number: 49956
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS GARRISON
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/24/2014
Notification Time: 21:30 [ET]
Event Date: 03/24/2014
Event Time: 23:00 [EDT]
Last Update Date: 03/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
SCOTT SHAEFFER (R2DO)

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

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the work activity affects the functionality of an emergency response facility. Planned maintenance activities are being performed on 03/24/14 starting at approximately 2300 [EDT] to the Technical Support Center (TSC) ventilation system.

"The work includes performance of planned carbon bed filter sample. The planned work activity duration is approximately 5 hours.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures.

"The NRC Resident Inspector has been notified.

"This event poses no threat to the public or station employees."

* * * UPDATE FROM THOMAS GARRISON TO HOWIE CROUCH AT 0325 EDT ON 3/25/14 * * *

The TSC was returned to service at 0325 EDT on 3/25/14. The licensee will be notifying the NRC Resident Inspector.

Notified R2DO (Shaeffer).

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