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Event Notification Report for January 26, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/23/2015 - 01/26/2015

** EVENT NUMBERS **


50736 50738 50741 50742 50753 50754 50759

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Non-Agreement State Event Number: 50736
Rep Org: SAINT VINCENTS MEDICAL CENTER
Licensee: SAINT VINCENTS MEDICAL CENTER
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-00843-03
Agreement: N
Docket:
NRC Notified By: SHAWN MATTHEWS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/15/2015
Notification Time: 12:00 [ET]
Event Date: 01/14/2015
Event Time: 13:30 [EST]
Last Update Date: 01/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ART BURRITT (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

MEDICAL EVENT INVOLVING A Y-90 SIR-SPHERE UNDER DOSE

Notification of a medical event that occurred on January 14, 2015 at 1330 EST, in which the Y-90 SIR-Sphere dose delivered to the patient's liver was less than the prescribed dose. The intended dose to the patient was 22 mCi, however the catheter disconnected during administration, resulting in a spill on the table which caused the underdose to the patient. It is estimated the patient received only 11.5 mCi or approximately 52% of intended dose and there was no harm to the patient.

The patient and prescribing physician have been informed and a follow-up treatment is planned. There was no contamination or exposure to other personal.

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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Agreement State Event Number: 50738
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KAISER PERMANENTE MEDICAL CENTER - ANTIOCH
Region: 4
City: Antioch State: CA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: KENT PENDERGAST
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/15/2015
Notification Time: 15:36 [ET]
Event Date: 01/07/2015
Event Time: [PST]
Last Update Date: 01/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (NMSS)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED EXCEEDED 50 REM

The following information was provided by the State of California Department of Public Health - Radiological Health Branch (RHB) via email:

"On 01/14/15, RHB received an email from the RSO reporting a Medical Event. On 1/7/15 a patient was scheduled for a thyroid uptake scan. Instead of the prescribed dose of 300 microcuries of Sodium Iodide 123, 3.69 mCi [3690 microcuries] of the isotope was administered to the patient. Due to quality of the scan, the error was noted. An initial calculation performed on 1/8/15 indicated target organ [dose] exceeding 50 rem. On 1/9/14, another calculation performed by the consulting physicist using patient's actual measured uptake values, the target organ [dose] was deemed less than 50 rem and it was decided to be non-reportable. On 1/13/15, the chief of Nuclear Medicine reviewed the reference source and contacted the same physicist to review his calculations, and the physicist realized that he made an error in calculations, and informed the facility that the organ dose exceeded 50 rem. On 1/14/15, the Kaiser Medical Physicist confirmed the [dose] to be 53.6 rem to the thyroid, and the RSO notified RHB of the Medical Event. RHB will be following up on this matter."

CA Event Report Number: 011415

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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Agreement State Event Number: 50741
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: NON-LICENSEE
Region: 4
City: FAYETTEVILLE State: AR
County: WASHINGTON
License #: ARK-0064-0112
Agreement: Y
Docket:
NRC Notified By: ANGIE D. HILL
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/16/2015
Notification Time: 15:48 [ET]
Event Date: 01/15/2015
Event Time: 14:00 [CST]
Last Update Date: 01/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - SMALL QUANTITIES OF UO2 AND U-235 FOUND IN THE PUBLIC DOMAIN

The following information was received from the Arkansas Department of Health via email:

"The University of Arkansas (U of A), Arkansas Radioactive Materials Licensee Number ARK-0064-01120, notified the Arkansas Department of Health, Radioactive Materials Program, via e-mail on Thursday, January 15, 2015 at 1400 hours, of the following labeled items found in the public domain (private home): (1) UO2 (3% U-235) in a small glass vial with lid and (2) U-235 in a medium size glass jar with lid. The isotopes and weights of these items will be identified and/or confirmed once in State possession.

"The U of A's Radiation Safety Officer reported exposure readings of item (1), listed above, at '2 mR/hr' and stated item (2), listed above, 'did not produce any readable dose.' The Radiation Safety Officer also performed swipe tests and surveys for contamination.

"The State requested the U of A to take immediate possession, properly store and secure the items. The State will retrieve these items promptly, which will be properly secured and stored at the State's authorized storage location.

"It is unknown at this time if there has been any exposure(s) to the public. The State is awaiting a written report from the licensee and will continue to investigate this event. The State will update this event as more information becomes available."

Arkansas Department of Health event number: ARK-2015-001

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Agreement State Event Number: 50742
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BRADKEN-AMITE, INC.
Region: 4
City: AMITE State: LA
County:
License #: LA-7631-L01,
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/16/2015
Notification Time: 18:17 [ET]
Event Date: 01/15/2015
Event Time: 11:00 [CST]
Last Update Date: 01/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE IN RADIOGRAPHY CAMERA

The following information was received via E-mail:

"This event occurred at a permanent shooting cell at the licensee's facility in Amite LA.

"The RSO was performing the semi-annual leak test on his radiography cameras. One is loaded for use in radiography and the other is essentially considered in storage. He removed the guide tube to swab the port entry and finished the paperwork for the leak test. Later he went to make an exposure and the source extended the length of the drive cable and would not retract into the shielded position. The source was stuck out into the vault shooting bay area.

"The equipment was an Amersham Model 680-BE, s/n BE 178 loaded with approximately 50 Ci of Co-60, a QSA Global source s/n 45274B. The associated equipment was an Amertest Automatic Exposure Control, Model 957, s/n 67.

"This was operator error. The RSO did not reattach the guide tube after performing a leak test at the camera's port. The source was being utilized in a fixed shooting cell/vault when it would not retract.

"[In order to retrieve the source] the side panel was removed from the camera and a manual source retraction was performed. The source was shielded from unnecessary exposure, ALARA [as low as reasonably achievable], during the source retrieval. Again, this was operator error, not equipment failure.

"The source is secure from removal and unnecessary exposure. This event is not closed and additional investigation and evaluation will continue. The source is in a safe shielded position and no threat to workers or the general public."

Louisiana Event Report ID No.: LA150001

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Power Reactor Event Number: 50753
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/23/2015
Notification Time: 09:34 [ET]
Event Date: 01/23/2015
Event Time: 06:13 [EST]
Last Update Date: 01/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GERALD MCCOY (R2DO)
HAROLD CHERNOFF (NRR)
BERNARD STAPLETON (IRD)

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

OFFSITE NOTIFICATION DUE TO NON-WORK RELATED ON-SITE CONTRACTOR FATALITY

"At approximately 0531 EST on January 23, 2015, the Brunswick Nuclear Plant main control room received an emergency call for a contract employee experiencing a non-work related medical issue. Site first responders were dispatched in conjunction with a request for off-site medical assistance. At approximately 0613 EST, the responding off-site paramedics determined that the efforts to revive the patient were unsuccessful. The individual was outside of the protected area (within the owner controlled area), and no radioactive material or contamination was involved. The cause of death has not been determined.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) for situation related to the health of on-site personnel for which a notification to other government agencies is planned. The Occupational Safety and Health Administration (OSHA) will be notified. A press release is not planned at this time.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 50754
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TODD BOHANAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/23/2015
Notification Time: 11:00 [ET]
Event Date: 11/26/2014
Event Time: 14:27 [CST]
Last Update Date: 01/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
GERALD MCCOY (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

Event Text

INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.

"On November 26, 2014, at approximately 1427 hours Central Standard Time (CST), the Browns Ferry Nuclear Plant (BFN), 1A Reactor Protection System (RPS) Motor-Generator (MG) Set Power Supply unexpectedly de-energized resulting in a BFN Unit 1 half scram and Primary Containment Isolation System (PCIS) Groups 1, 2, 3, 6, and 8 isolation signals. The PCIS Groups 1, 2, 3, 6, and 8 isolations caused the initiation of all three trains of the Standby Gas Treatment (SBGT) system and Control Room Emergency Ventilation (CREV) subsystem 'A', and isolations of the BFN, Unit 1, Reactor Zone ventilation and BFN, Units 1 and 2, Refuel Zone ventilation (Unit 3 Refuel Zone ventilation was tagged out under 3-TO-2014-0001 at the time of this event). Operations personnel responded to the PCIS initiation, ensured all equipment operated as designed, placed the BFN 1A RPS on alternate power, and reset the RPS logic and PCIS isolations.

"Plant conditions which initiate PCIS Group 1 actuations are Reactor Pressure Vessel (RPV) Low Low Low Water Level (Level 1), Main Steam Line (MSL) High Flow, MSL Area High Temperature, or MSL Low Pressure. Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The apparent cause for this condition was an intermittent problem with the BFN 1A RPS MG Set voltage adjust potentiometer.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Problem Evaluation Report 961518.

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

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Power Reactor Event Number: 50759
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DANIEL MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/26/2015
Notification Time: 05:04 [ET]
Event Date: 01/26/2015
Event Time: 03:55 [CST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (R3DO)

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

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED PREVENTATIVE MAINTENANCE

"At 0355 [CST] on Monday, January 26, 2015, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system was removed from service for planned preventative maintenance activities on the TSC air handling unit, air compressor units, and TSC air filtration unit. During the maintenance, the TSC Ventilation will be shut down. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 38 hours. Contingency plans are in place so that if an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning (EP) procedures and checklists. If radiological or environmental conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with station procedures.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, January 26, 2015
Monday, January 26, 2015