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Event Notification Report for May 14, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/13/2014 - 05/14/2014

** EVENT NUMBERS **


50087 50088 50091 50112

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Agreement State Event Number: 50087
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: HONEYWELL RESINS AND CHEMICALS LLC
Region: 1
City: CHESTER State: VA
County: CHESTERFIELD
License #: 041-344-2
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 05/06/2014
Notification Time: 09:26 [ET]
Event Date: 05/05/2014
Event Time: [EDT]
Last Update Date: 05/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER

The following information was received from the Commonwealth of Virginia:

"The licensee discovered a shutter stuck in the open position during a routine test of a fixed gauge on May 5, 2014. The gauge is a Ronan Engineering Model SA1, serial number M-7299. It is used as a low-level indicator in a pre-dryer vessel and contains a 26.9 milliCurie (decay corrected) cesium-137 source. The licensee indicated that using unusual force to try to close the shutter would likely damage the actuator rod mechanism. The shutter is kept in the open position during operations and does not pose an additional radiation exposure to personnel. The licensee performs radiation surveys at one foot from the gauge surface during routine tests. The maximum reported result for this gauge was 300 microR per hour. The licensee has contacted the manufacturer to repair the gauge. The Agency [Virginia Radioactive Materials Program] will continue to monitor the situation until the shutter is repaired."

Virginia Event: VA-2014-004

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Non-Agreement State Event Number: 50088
Rep Org: MANSON CONSTRUCTION
Licensee: MANSON CONSTRUCTION
Region: 4
City: ANCHORAGE State: AK
County:
License #: WN-I0448-1
Agreement: N
Docket:
NRC Notified By: ISAAC BRADLEY
HQ OPS Officer: PETE SNYDER
Notification Date: 05/06/2014
Notification Time: 11:47 [ET]
Event Date: 05/03/2014
Event Time: 12:00 [YDT]
Last Update Date: 05/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

PROCESS GAUGE SHUTTER FAILED TO FUNCTION PROPERLY

The licensee Radiation Safety Officer (RSO) determined that the shutter to a Berthold Model LB7440-D-CR process gauge with a 500 mCi Cs-137 source (source s/n: 031-08) did not open despite repeated attempts to cycle and lubricate the shutter opening mechanism. The RSO made this determination using instrumentation after rotating the shutter opening handle 180 degrees to the normally open position. The shutter had apparently become disconnected from the opening mechanism. The instrument is installed on a hopper dredge and is pointed down in an area not normally accessible by personnel.

A licensed Berthold technician has been contacted and will come to the site to repair the gauge.

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Agreement State Event Number: 50091
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CEDARS SINAI MEDICAL CENTER
Region: 4
City: LOS ANGELES State: CA
County:
License #: CA 0404
Agreement: Y
Docket:
NRC Notified By: JOSEPHINE ORTEGO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/06/2014
Notification Time: 15:15 [ET]
Event Date: 04/30/2014
Event Time: [PDT]
Last Update Date: 05/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSAGE ADMINISTERED TO PATIENT

"I am reporting a Medical Event and Abnormal Occurrence. The event resulted from incorrect dosage administered to the patient for the second phase of the yttrium-90 SirSperes for treatment of the liver. The patient was administered 43 millicuries of Y-90 for the second phase instead of 12 to 12.5 mCi as intended. The event occurred at Cedars Sinai Medical Center (California Radioactive Materials License number 0404-19) in Los Angeles, CA, on April 30, 2014. Los Angeles County Public Health, Radiation Management was notified on May 1, 2014. During the original report date, the licensee did not have any information regarding the radiation dose to the patient and was working with their Medical Physicists. On May 6, 2014, Cedars Sinai Medical Center reported that the patient received 363 Gray instead of the intended dose within the range of 53-102 Gray. Per the licensee, both the patient and referring physicians have been notified. The patient has not reported any side effects that were unanticipated and the patient will continue to be medically monitored."

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: 50112
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/13/2014
Notification Time: 14:40 [ET]
Event Date: 03/18/2014
Event Time: 19:30 [EST]
Last Update Date: 05/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
HIRONORI PETERSON (R3DO)

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

Event Text

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

"This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made pursuant to 10 CFR 50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of containment isolation valves which occurred during the most recent refueling outage at Fermi 2. On 3/18/2014, at approximately 1930 EST, shortly after transferring Division 2 Reactor Protection System (RPS B) from the alternate to the normal power supply, Operations personnel noted that an unexpected half-scram occurred. Initial investigation found a fuse in an RPS Power Distribution Panel had blown. Further investigation found that a power contactor had failed causing the fuse to blow. The contactor failure resulted in an invalid half scram and actuations (closure) of Torus Water Management System (TWMS) Outboard containment isolation valves, Division 2 Drywell Pneumatics Inboard and Outboard containment isolation valves and the Drywell Floor and Equipment Drain Sumps Inboard containment isolation valves. All valves operated as expected. Since containment isolation valves in more than one system were actuated by this failure, this event constitutes an event or condition that resulted in manual or automatic actuation of the system listed in paragraph 10 CFR 50.73 (a)(2)(iv)(B)(2) and is reportable under 10 CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector has been informed of this notification."

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