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Event Notification Report for February 13, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/12/2015 - 02/13/2015

** EVENT NUMBERS **


50785 50788 50815 50816

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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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Non-Agreement State Event Number: 50788
Rep Org: HELLER AND JOHNSEN
Licensee: HELLER AND JOHNSEN
Region: 1
City: STRATFORD State: CT
County:
License #: 06-30033-01
Agreement: N
Docket:
NRC Notified By: JUAN BEDOYA
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/05/2015
Notification Time: 14:00 [ET]
Event Date: 01/16/2015
Event Time: 12:00 [EST]
Last Update Date: 02/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ANNE DeFRANCISCO (R1DO)
DENNIS ALLSTON (ILTA)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

MOISTURE DENSITY GAUGE IN TRUNK OF STOLEN CAR

The licensee reported that a technician had a Troxler moisture/density gauge, Model #3430 (Serial #19531), locked in the trunk of his car. The technician's brother took the car for a "joy ride" and the car was reported to the Fairfield police as stolen. The brother was pulled over by the police roughly 1/2 hour later. The gauge was recovered undamaged and still locked in the trunk of the car. The licensee reported that they lost possession of the gauge for no more than 1/2 hour and that the brother probably did not intend to steal the gauge. The gauge contains 27mCi of Cesium 137 and 132 mCi of Americium 241. The Fairfield police, bomb squad, and the local FBI responded to the event.

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

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Power Reactor Event Number: 50815
Facility: SUMMER
Region: 2 State: SC
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: MATTHEW PRESSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/12/2015
Notification Time: 17:19 [ET]
Event Date: 08/25/2014
Event Time: 08:00 [EDT]
Last Update Date: 02/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.55(e) - CONSTRUCT DEFICIENCY
Person (Organization):
REBECCA NEASE (R2DO)
PART 21/50.55 REACT (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Under Construction 0 Under Construction
3 N N 0 Under Construction 0 Under Construction

Event Text

BREAKDOWN IN THE QUALITY ASSURANCE PROGRAM FOR V. C. SUMMER 2 & 3 CONSTRUCTION PROJECT

"This is a 10 CFR 50.55 initial notification for a significant breakdown in the Quality Assurance (QA) Program of Chicago Bridge & Iron (CB&I), an agent for the Licensee of the V. C. Summer 2 & 3 Construction Project.

"In August 2014, deviations were found in sub-modules CA03-06, -08, and -09 for the Vogtle 3 Construction Project, which initiated the discovery and evaluation processes for both Part 21 and 10 CFR 50.55. The conditions were determined to be not reportable by CB&I under 10 CFR 21, but an evaluation of the root cause analysis results concluded that a significant QA program breakdown had occurred that could have produced a defect. No defect has been identified.

"This initial notification is being made in accordance with 10 CFR 50.55(e)(4)(iii) and 10 CFR 50.55(e)(5)(i).

"The NRC Resident Inspector has been notified.".

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Power Reactor Event Number: 50816
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOEL GORDON
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/12/2015
Notification Time: 20:45 [ET]
Event Date: 02/12/2015
Event Time: 13:36 [EST]
Last Update Date: 02/12/2015
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
1 N Y 100 Power Operation 100 Power Operation

Event Text

HPCI DECLARED INOPERABLE DURING WEEKLY INSPECTION

"EVENT DESCRIPTION: On February 12, 2015, at 1336 Eastern Standard Time (EST) the Unit 1 High Pressure Coolant Injection (HPCI) system was declared inoperable due to a failure of the HPCI Auxiliary Oil Pump. During performance of a routine HPCI weekly inspection, the auxiliary oil pump was started and subsequently experienced a loss of discharge oil pressure. The HPCI Auxiliary Oil Pump provides hydraulic pressure required to open the HPCI Turbine Stop Valve and the HPCI Turbine Control Valve during initial HPCI startup. Failure of the HPCI Auxiliary Oil Pump prevents the HPCI system from performing its design safety function. As such, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of the safety function of a system that is needed to mitigate the consequences of an accident.

"This event did not result in any adverse impact to the health and safety of the public.

"INITIAL SAFETY SIGNIFICANCE EVALUATION: The safety significance of this condition is minimal. All other Emergency Core Cooling Systems and the Reactor Core Isolation Cooling (RCIC) system remain operable [per the requirements of 14-day LCO (Limiting Condition of Operation) 3.5.1].

"CORRECTIVE ACTIONS: Troubleshooting activities are in progress. The HPCI system will remain inoperable until the cause of the failure has been corrected.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, February 13, 2015
Friday, February 13, 2015