Event Notification Report for April 01, 2014

AGREEMENT STATE REPORT - BROKEN I-125 SEED DURING IMPLANTATION

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

"This is a synopsis of an I-125 seed breaking during an implant procedure at GBMC [Greater Baltimore Medical Center]. We [GMBC] will be meeting as a team to discuss corrective action and how to avoid something like this happening again.

"An I-125 implant was performed at GBMC Hospital on Tuesday, April 1, 2014. 78 Bard I-125 seeds, activity 0.319 mCi/seed, were ordered for the procedure, 71 seeds were used, and 70 seeds were confirmed after the procedure on CT evaluation in Radiation Oncology. The unused seeds (7.5 seeds) were returned to Radiation Oncology and recorded as per policy and procedure.

"The chief physicist and dosimetrist were called to Cysto at approximately 0900 EDT when the case was completed to [the attending physician's] satisfaction. Upon entry of the Cysto room [the attending physician] informed the physics staff that a seed had jammed in the Mick applicator and he had to use force to continue and complete the case.

"On arrival, the physics staff surveyed the patient 1 meter above the umbilicus and found 1.7 mR/hr reading using Model 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). The patient was removed from the OR and sent to recovery room.

"Upon additional survey of the room, it was discovered that a seed was fractured, when a portion of the seed was found on the sterile table. At that time, a thorough and complete area survey was performed. The reading was found to be 1.2 mR/hour on the table, trash, and blood drain. [A staff member] was called to bring an additional survey meter (Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13). All contaminated items were collected for proper storage in the hot lab in Radiation Oncology. All staff and personnel involved in the case were thoroughly monitored and cleared using 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). After the removal of the contaminated items the Cysto room was thoroughly monitored and clear of radiation contamination.

"The patient was then brought down to the Radiation Oncology department where a CT scan was performed to ensure seed count. VeriSeed program was used to confirm that the patient was implanted with 70 seeds.

"[The Chief Medical Physicist] contacted Bard to discuss the shattered seed. It was suggested that radiation oncology staff be monitored for thyroid uptake. Bioassay studies were thereby performed and the results were found to match background readings.

"On Wednesday, April 2, 2014, the patient's recovery area was scanned using Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13. A reading of 300 CPM was recorded. The background was also recorded to be 300 CPM. "

UNIT 2 SECONDARY CONTAINMENT INTERLOCKED DOORS OPENED SIMULTANEOUSLY

"On April 1, 2014, at 1357 hours, the Control Room was notified that two Secondary Containment interlock doors (between the Unit 2 Reactor Building and Unit 2 Turbine Building) were open simultaneously. The doors were immediately closed and Secondary Containment pressure remained negative.

"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2 given two doors in a single access opening were open simultaneously. As a result entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to Secondary Containment being inoperable.

"This event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC Senior Resident Inspector has been notified."

AUTOMATIC REACTOR TRIP DUE TO ELECTRICAL ISSUE

"At 0026 on 04/01/2014, following the turbine shutdown and removal of the main generator from service in preparation for refueling outage 16, Seabrook had a reactor trip and all control rods were fully inserted. The trip was caused by an electrical issue that caused 345 KV bus 6 to deenergize and power was lost to the Unit Auxiliary Transformers (UATs). The in-house busses transferred to the Reserve Auxiliary Transformer (RAT) supplies and the momentary loss of power to in-house Bus 1 caused 2 reactor coolant pumps to trip, generating a 2 loop loss of flow reactor trip signal. The exact cause of the initiating electrical issue is being investigated.

"The NRC Resident Inspector has been notified.

"Emergency feedwater actuated at 0035 due to a low low water level in steam generator 'C'. Plant equipment response is being evaluated and the plant is stabilized in Mode 3 with decay heat removal through the steam dump system to the condensers. There was no release and the emergency feedwater system is being restored to standby.

"The event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73."

OFFSITE NOTIFICATION DUE TO FATALITY ON SITE

"At approximately 0616 CDT on April 1, 2014, a supplemental employee at Wolf Creek developed a personal medical condition. Wolf Creek Emergency Medical Technicians on site responded and an ambulance transported the individual to an offsite hospital. The individual was located in one of the office areas inside the protected area. The offsite hospital declared the individual deceased upon arrival on April 1, 2014.

"The individual was outside the Radiological Controlled Area. No radioactive material or contamination was involved. This notification is being performed in accordance with 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

The licensee will notify the State and Coffey County.

THEFT OF SEAMAN MODEL C-200 NUCLEAR DENSITY GAUGE

A technician for Patriot Engineering and Environmental, Inc. took possession of a Seaman Model C-200 (Serial # L-102) nuclear density gauge on the evening of 3/31/2014 for use at a jobsite the next day. He secured the gauge in the back of his pickup truck with a chain and 3 padlocks. Two of the padlocks secured the gauge to the bed of the pickup truck and the third padlock secured the wrapped chain to the device. Between 0100 EDT and 0730 EDT on the morning of 4/1/2014, the gauge was stolen from the back of the pickup truck. Indianapolis Metro Police Department was contacted and they are investigating. The gauge contains 4.5 mCi of Radium 226 (Source Serial # B8633)

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

VENTILATION FAN FAILURE AFFECTING RHRSW/ESW PUMP OPERABILITY AND EDG OPERABILITY

"At 0645 EDT on the morning of April 1, 2014, with James A. FitzPatrick Nuclear Power Plant (JAF) operating at 100 percent power, the Control Room received an alarm associated with the ventilation system for the 'B' division of the Residual Heat Removal Service Water (RHRSW) and Emergency Service Water (ESW) pump room. Investigation identified that the ventilation exhaust fan (73FN-3B) associated with this pump room had tripped due to thermal overload. The overload relay was reset at 0704 EDT and the fan automatically started; the fan is currently operable. During this period, the fan would not have automatically started.

"The ventilation systems for the RHRSW and ESW pump rooms are not included in the JAF Technical Specifications (TS), nor are they in the JAF Technical Requirements Manual (TRM). The ambient temperature limit in the RHRSW and ESW pump room was never challenged. However, with 73FN-3B non-functional, it is procedurally required to declare 10P-1B (RHRSW Pump B), 10P-1D (RHRSW Pump D) and 46P-2B (ESW Pump B) inoperable. The 'B' ESW pump cools the 'B' EDG subsystem, which would therefore also be inoperable. During this period, the 'A' EDG subsystem was inoperable for an emergent issue. Because the 'A' and 'B' EDG subsystems were concurrently inoperable for a period of approximately 45 minutes, this condition resulted in a loss of safety function for the Emergency Diesel Generators, which is reportable pursuant to 10 CFR 50.72(b)(3)(v)(A)."

Both affected emergency diesel generators were in the same division with another redundant division operable.

The licensee notified the NRC Resident Inspector and will be notifying the State of New York.


* * * UPDATE AT 1200 EDT ON 4/2/14 FROM CHRIS ADNER TO S. SANDIN * * *

The statement "Both affected emergency diesel generators were in the same division with another redundant division operable" is incorrect. Both divisions of emergency diesel generators were inoperable, since one of two available emergency diesel generators per division were inoperable at the time of this event.

The Licensee notified the NRC Resident Inspector.

Notified R1DO (Cahill).

ADMINISTRATIVE ERROR MEDICAL EVENT

"A patient at the Lee's Summit location in Missouri was administered the radiopharmaceutical Xofigo. The normal therapy regimen is six doses. On two of those instances (April 29 and April 1, 2014), the prescription sheet/written directive form that was used shows the units in millicurie instead of microcurie. The dosing amount of Xofigo is in microcuries. This was discovered during a routine NRC inspection on May 19, 2014. The NRC contacted us on May 29, 2014 to inform us that this was being declared a medical event. The patient received the correct dose in both instances; the error was a transcription error on the paperwork. A new form just for Xofigo administrations has been created which defaults to showing the units in microcurie."

The licensee notified R3 (Bramnik).

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.

LOST HEWLETT-PACKARD GAS CHROMATOGRAPH

"The NOAA Atlantic Oceanographic and Meteorological Laboratory (AOML) reported a lost Ni-63 source. The licensed device is an [generally licensed, Hewlett Packard/Agilent Technologies Gas Chromatograph, [Model 5890A, Serial Number M1827, containing a 15 mCi Ni-63 source]. [It was discovered that the chromatograph was missing after an April 2014 inventory.] According to several end users of the device, the item was disposed of prior to the annual 2014 inventory. To the best of NOAA's knowledge, the device was disposed of through UNICOR and the Federal Bureau of Prisons (FBP) by a previous property custodian, who has since retired from the agency. Documentation does not exist for this transfer. Another previous property custodian, requested that this item be removed from AOML inventory on 8/4/2014, based on the verbal report from the previous property custodian. Between July 28 and August 19th, 2014, the current property custodian unsuccessfully attempted to contact UNICOR, to confirm that this device did get transferred to UNICOR."

It cannot be confirmed the device was been disposed of via UNICOR and is therefore considered lost.

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