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Event Notification Report for August 27, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/26/2014 - 08/27/2014

** EVENT NUMBERS **


50377 50379 50400 50404

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Non-Agreement State Event Number: 50377
Rep Org: PATRIOT ENGINEERING AND ENVIRONMENT
Licensee: PATRIOT ENGINEERING AND ENVIRONMENT
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 092-1073-1
Agreement: N
Docket:
NRC Notified By: BRIAN KING
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/18/2014
Notification Time: 15:28 [ET]
Event Date: 08/15/2014
Event Time: 16:30 [EDT]
Last Update Date: 08/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DAVE PASSEHL (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

DAMAGED MOISTURE/DENSITY GAUGE

A moisture/density gauge was run over by a bulldozer at a construction site in Indianapolis, Indiana. The RSO performed surveys of the gauge and no abnormal dose rates were observed. The gauge was leak tested and the data has been sent to Seaman Nuclear Products for analysis. The gauge has been removed from service and is secured at the licensee's facility.

The gauge is a Seaman Model C-75 moisture/density gauge and typically contains 8 mCi of Cs-137 and 40 mCi of Am-241/Be.

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Agreement State Event Number: 50379
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAYLOR ALL SAINTS MEDICAL CENTER
Region: 4
City: FORT WORTH State: TX
County:
License #: L-02212
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/19/2014
Notification Time: 10:08 [ET]
Event Date: 08/15/2014
Event Time: [CDT]
Last Update Date: 08/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - IODINE-125 SEEDS POSITIONED INCORRECTLY DURING IMPLANTATION

The following information was received via E-mail:

"On August 18, 2014, the licensee notified the Agency [Texas Department of State Health Services] that on August 15, 2014, it discovered that a medical event had occurred. One of the licensee's patients had iodine-125 seed implantation in July 2014 and on August 7, 2014, a post-plan computed tomography scan was performed. During the post-plan evaluation, the licensee discovered that the seeds had not been positioned in the target tissue as prescribed during implantation. The licensee believes that approximately 30 percent of the prescribed dose was delivered to the target tissue. The licensee is evaluating the data to determine actual dosimetrics and will report its calculated dose to the intended and other tissue to the Agency upon completion. The Agency will provide further information in accordance with SA-300."

This event occurred at the Baylor All Saints Medical Center in Fort Worth, Texas.

Texas Incident #: I-9221

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.

* * * UPDATE FROM KAREN BLANCHARD TO CHARLES TEAL AT 1706 EDT ON 8/25/14 * * *

The following was received from the State of Texas via email:

"The licensee for this event was initially reported as Texas Oncology, license L-05545. It has been determined that Baylor All Saints Medical Center Radiology Department, license L-02212, is the actual licensee the implantation procedure in this event was licensed under. The licensees are continuing their investigation and will submit a written report within the required 15 days."

Notified R4DO (Pick) and FSME Events Resource via email.

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Power Reactor Event Number: 50400
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: GERALD BAKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/26/2014
Notification Time: 11:54 [ET]
Event Date: 08/26/2014
Event Time: 07:59 [EDT]
Last Update Date: 08/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY MCKINLEY (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

UNIT 2 HIGH RANGE STACK RADIATION MONITOR TAKEN OUT OF SERVICE FOR PRE-PLANNED MAINTENANCE

Millstone removed their unit 2 high range site radiation monitor, RM-8168, from service for pre-planned maintenance. RM-8168 was restored to service at 1012 EDT on 8/26/14.

The licensee notified the NRC Resident Inspector, the State of Connecticut, and the town of Waterford.

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Power Reactor Event Number: 50404
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: NEEL SHUKLA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/26/2014
Notification Time: 21:24 [ET]
Event Date: 08/26/2014
Event Time: 17:30 [CDT]
Last Update Date: 08/26/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVE ROSE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 95 Power Operation 0 Hot Shutdown

Event Text

TURBINE GENERATOR NEUTRAL OVERVOLTAGE CAUSES A REACTOR SCRAM

"At 1730 CDT on August 26, 2014, Browns Ferry Unit 1 experienced a turbine trip resulting in an automatic reactor scram. The cause of the turbine trip was a control valve fast closure signal that was generated by a turbine trip on generator neutral over voltage signal. The Main Steam Isolation Valves (MSIVs) remained open with the main turbine bypass valves controlling reactor pressure. The Reactor Feedwater Pumps are in service to control reactor water level.

"Primary Containment Isolation Systems (PCIS) Groups 2, 3, 6, and 8 isolation signals were received. Upon receipt of these signals, all required components actuated as required with the exception of Standby Gas Treatment (SBGT) train A, which is under a clearance for planned maintenance. Neither High Pressure Coolant Injection (HPCI) nor Reactor Core Isolation Cooling (RCIC) initiation signals were received. Initially, three Main Steam Relief Valves (MSRVs) opened to control the pressure surge and subsequently reclosed.

"This event requires a 4 hour report per 10 CFR 50.72(b)(2)(iv)(B), 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"This event also requires an 8 hour report per 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), (1) Reactor protection system (RPS) including reactor scram or reactor trip, and (2) General containment Isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs).'

"The NRC Resident Inspector has been notified.

"Service Request 926468 was initiated in the Corrective Action Program."

The plant is in its normal shutdown electrical lineup. The licensee is investigating the cause of the generator neutral overvoltage signal. There was no impact on units 2 and 3.

Page Last Reviewed/Updated Wednesday, August 27, 2014
Wednesday, August 27, 2014