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Event Notification Report for February 12, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/11/2015 - 02/12/2015

** EVENT NUMBERS **


50783 50785 50807 50808 50809 50811 50812 50813

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Agreement State Event Number: 50783
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: AVID RADIOPHARMACEUTICALS, PHILADELPHIA, PA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0988
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/03/2015
Notification Time: 14:18 [ET]
Event Date: 01/30/2015
Event Time: [EST]
Last Update Date: 02/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION FOUND ON FLOURINE-18 PACKAGE

The following information was received from the Pennsylvania Department of Environmental Protection via email:

"Event type: Removable contamination greater than the limits specified in 10 CFR 20.1906(d)(1).

"Notifications: The Department became aware of this event on Tuesday, February 3, 2015. The event is immediately reportable as per 10 CFR 20.1906(d)(1).

"Event Description: A package containing Fluorine-18 was found to have removable radioactive surface contamination upon receipt at the Philadelphia facility. An average of five wipe tests performed on the container resulted in 39,000 dpm of removable contamination; however the wipe area dimensions have not been provided. This will be clarified during the reactive inspection. The distributing radiopharmacy (PETNET Solutions) has been contacted but it is unknown at this time if the courier was contacted.

"Cause of the Event: Unknown at this time.

"The [Pennsylvania DEP Bureau of Radiation Protection] plans a reactive inspection. More information will be given when known."

PA Event Report ID No: PA150002.

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Non-Agreement State Event Number: 50785
Rep Org: IU HEALTH BALL MEMORIAL HOSPITAL
Licensee: IU HEALTH BALL MEMORIAL HOSPITAL
Region: 3
City: MUNCIE State: IN
County: DELAWARE
License #: 13-00951-03
Agreement: N
Docket:
NRC Notified By: ALVIS FOSTER
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/04/2015
Notification Time: 17:23 [ET]
Event Date: 01/15/2014
Event Time: [EST]
Last Update Date: 02/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

INERT CAPSULE ADMINISTERED TO PATIENT DURING TREATMENT

The following was received from the licensee via email:

"A 40 year old adult male patient was scheduled to receive 150 mCi of radioactive Iodine 131 as a thyroid cancer therapy. The dose, in pill form, was assayed as prescribed on Wednesday 1/15/14 and was believed to have been [administered to the patient].

"On 1/23/14, the patient returned for a whole body scan, [which is] a routine part of the procedure. After scanning the patient, it was noted that there was no activity remaining, which could not be possible under normal circumstances, because Iodine 131 has an 8 day physical half-life. Even with biological excretion occurring, one would expect significant detectable activity 8 days after administration.

"Two technologists were involved, one assayed the dose and put it back in temporary storage, the other subsequently retrieved the capsule and administered it. Upon investigation it was found that an inert capsule was inadvertently retrieved rather than the patient's capsule. The capsule the patient should have received was discovered and assayed, and found to be the actual capsule that should have been delivered.

"The tablet given to the patient had an activity of 30 mCi of Iodine 131 on 8/2/13, this was some 20 half-lives prior to the January 2014 date of this incident and [the capsule] was therefore completely inert, therefore no dose was administered.

"[The licensee] talked with [the licensee's] Nuclear Medicine consultant, to review the regulations. Upon review of USNRC regulations and based upon advice from [the consultant], this was not deemed a medical event but rather a self-identified violation of our procedures.

"Based upon an NRC review during an inspection on 2/3/15 we were advised that this occurrence, in [the NRC inspector's] opinion, constitutes a Medical Event based on Title 10 of the Code of Federal Regulations Part 35.3045.

"We were advised to contact the USNRC offices in Region III by the end of business on 2/4/15 and report the occurrence as a Medical Event.

"With respect to patient impact, papillary/follicular cancers are slowing growing and indolent, and a delay in treatment would not be expected to adversely affect the outcome. The patient was subsequently rescheduled and administered the [prescribed] dose of Iodine 131.

"In order to determine cause and institute corrective measures, a root cause analysis investigation was conducted and as a result, procedure revisions were implemented to prevent the likelihood of additional errors of this type."

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: 50807
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JAY VAN HULZEN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2015
Notification Time: 01:03 [ET]
Event Date: 02/10/2015
Event Time: 17:50 [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
REBECCA NEASE (R2DO)

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

Event Text

HIGH HEAD SAFETY INJECTION INOPERABLE DUE TO MISSING PIPING SUPPORT

"This is a non-emergency 8 hour report in accordance with 10 CFR 50.72(b)(3)(ii)(B).

"At 1750 [EST] hours on 2/10/15, Unit 4 entered Technical Specification 3.0.3 due to missing tubing supports identified for two separate high point vent lines. This condition is unanalyzed and potentially rendered the cold leg High Head Safety Injection flow path inoperable. Upon discovery, the vent line root isolation valves were closed and Technical Specification 3.0.3 was exited at 1805. Investigation has been initiated to determine cause."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 50808
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: NATHAN BIBUS
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2015
Notification Time: 05:12 [ET]
Event Date: 02/10/2015
Event Time: 22:05 [CST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

CONTAINMENT DECLARED INOPERABLE DUE TO CONTAINMENT FAN COIL LEAK

"At 2205 CST on February 10, 2015, a cooling water leak of approximately 60 to 90 drops per minute was identified on the 14 Containment Fan Coil Unit Cooling Water face gasket. As a result, Unit 1 Containment was declared inoperable. This required entry into Technical Specifications (TS) LCO 3.6.1 Condition A, Containment inoperable, applicable in MODES 1, 2, 3, and 4. Immediate action was taken to isolate the fan coil unit within 1 hour from the initial identification of the leak.

"After isolating the cooling water leak to 14 Containment Fan Coil Unit, containment was declared operable and TS 3.6.1 Condition A was exited at 2232 CST. A Work Request (WR) has been initiated to restore 14 Containment Fan Coil Unit to an operable condition.

"This condition is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.

"The plant remains in a safe condition and there was no effect to the health and safety of the public.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 50809
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BRET RICKERT
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2015
Notification Time: 09:41 [ET]
Event Date: 02/10/2015
Event Time: 13:00 [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (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

CONFIRMED POSITIVE TEST FOR CONTROLLED SUBSTANCE

On February 10, 2015, at approximately 1300 EST, the Dominion Medical Review Officer determined that a licensed operator had a confirmed positive follow up test for a controlled substance. The individual's unescorted access has been denied at all of the Dominion sites.

The licensee has notified the NRC Resident Inspector.

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Part 21 Event Number: 50811
Rep Org: WEIR VALVES & CONTROLS USA, INC.
Licensee: WEIR VALVES & CONTROLS USA, INC.
Region: 1
City: IPSWICH State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ARTHUR C. BUTTERS
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/11/2015
Notification Time: 14:52 [ET]
Event Date: 02/10/2015
Event Time: [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RAY POWELL (R1DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT - WEIR VALVES AND CONTROLS SPLINE ADAPTER VIBRATED LOOSE

This report was received from Weir Valves & Controls via email:

During a walk down it was discovered that one of the spline adapters had slipped down the shaft of a TRICENTRIC valve supplied by Weir Valves & Controls, USA. This condition could have allowed the valve disc/stem to move from its normally open position to a partially closed or fully closed position. Weir Valve and Controls determined that the valve is designed with a single set screw tightened against the stem key and is susceptible to Human Performance Factors if it is not properly tightened against the shaft.

Name of Manufacturer:
Weir Valves and Controls, USA

Affected Component:
TRICENTRIC Triple Offset Valve

Affected Plant(s):
Peach Bottom Atomic Power Station

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Power Reactor Event Number: 50812
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: GREGORY L. SMITH
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/11/2015
Notification Time: 16:16 [ET]
Event Date: 02/11/2015
Event Time: 08:20 [CST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
REBECCA NEASE (R2DO)

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

HIGH PRESSURE COOLANT INJECTION SYSTEM SUCTION PATH ISOLATION

"While performing 3-SR-3.5.1.2(HPCI) High Pressure Coolant Injection System Monthly Valve Position Verification, Operators closed the supply breaker for 3-FCV-2-166, CST #3 EMERGENCY HEADER ISOLATION VALVE, in order to verify the valve is in its required OPEN position. When the breaker was closed, the position indication 3-ZI-2-166 indicated OPEN and it was observed that the valve was traveling closed. The operator at the breaker reported that the breaker contactor energized when the breaker was closed. Control Room Operators re-opened 3-FCV-2-166 using the hand switch in the control room and when the valve indicated full open, directed the operator in the field to open the breaker for 3-FCV-2-166. Valve 3-FCV-2-166 isolates both the HPCI and [Reactor Core Isolation Cooling] RCIC suction path from the Condensate storage tank, both HPCI and RCIC were declared inoperable.

"The duration of the loss of suction path the HPCI and RCIC was 4 minutes.

"Applicable Technical Specification required actions were entered for the concurrent HPCI and RCIC inoperability and exited when the suction path was restored.

"This incident is reportable as an 8-hour ENS notification under 10 CFR 50.72 (b)(3)(v) as '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.'

"It also requires a 60 day written report in accordance with 10 CFR 50.73(a)(2)(vii)

"The NRC Resident Inspector has been notified"

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Power Reactor Event Number: 50813
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOSH FERGUSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/11/2015
Notification Time: 23:15 [ET]
Event Date: 02/11/2015
Event Time: 19:41 [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
RAY POWELL (R1DO)

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

NINE MILE POINT MOMENTARY LOSS OF SECONDARY CONTAINMENT

"Nine Mile Point Unit 1 (NMP1) had a momentary loss of Secondary Containment due to both Reactor Building Airlock doors being opened at the same time.

"At 1941 EST on 02/11/2015, both Reactor Building Airlock doors at NMP1 were opened simultaneously for approximately 1 second. This results in a momentary loss of Secondary Containment operability (TS 3.4.3). The doors were closed and operability was restored.

"Secondary Containment being inoperable is an 8 hour notification per 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 control the release of radioactive material.'

"The condition has been entered into the station's corrective action program and the Senior Resident NRC Inspector was notified."

Page Last Reviewed/Updated Thursday, February 12, 2015
Thursday, February 12, 2015