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Event Notification Report for February 20, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/19/2015 - 02/20/2015

** EVENT NUMBERS **


50810 50814 50831 50835 50836

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Agreement State Event Number: 50810
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/11/2015
Notification Time: 12:27 [ET]
Event Date: 01/12/2015
Event Time: [EST]
Last Update Date: 02/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DURING CANCER TREATMENT

The following information was received from the New York State Department of Health Bureau of Environmental Radiation Protection via fax:

"[The New York State Department of Health] NYSDOH received telephone notification from a licensee reporting a therapy misadministration involving a patient undergoing treatment of vaginal cancer. The treatment involved the use of a GammaMedplus iX brachytherapy HDR remote afterloader utilizing an Iridium-192 radiation source. The patient was administered the treatment using a vaginal applicator for proper placement of the therapy source. However, the vaginal applicator was improperly placed within the organ, which resulted in the irradiation of healthy tissue and significantly less radiation to the cancer site. Three treatments were given to the patient by the same oncologist over a three week period. Each treatment was prescribed to provide approximately 600 to 700 centigray of absorbed radiation. Preliminary investigations show that the therapy equipment was functioning properly and the treatment plan was appropriate. The licensee is investigating the oncologist's procedures. A written report will be sent to [the New York State Department of Health] DOH within seven days with more detailed information."

NY Report #: NY-15-02

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: 50814
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALLEGHENY GENERAL HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/12/2015
Notification Time: 10:38 [ET]
Event Date: 02/10/2015
Event Time: [EST]
Last Update Date: 02/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE ADMINISTRATION OF Y-90 MICROSPHERES

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"Notifications: The Department [Pennsylvania Department of Environmental Protection] was notified of this event on Wednesday, February 11, 2015. It is immediately reportable as per 10 CFR 35.3045(a)(1)(i).

"Event Description: A patient was receiving Y-90 Sirtex Sirspheres when the administering device failed and a portion of the dose was lost in the apparatus. The patient received 10.4 mCi, or 58% of the prescribed 17.82 mCi dose.

"Cause of the event: The device came apart during the procedure and the remainder of the dose was contained in the packaging.

"Actions: The Department plans a reactive inspection."

Pennsylvania Event Report ID No: PA150004

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: 50831
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/19/2015
Notification Time: 09:55 [ET]
Event Date: 02/19/2015
Event Time: 03:04 [EST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
DAVID HILLS (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

Event Text

SECONDARY CONTAINMENT BUILDING DECLARED INOPERABLE DUE TO VENTILATION SYSTEM TRIP

"At 0304 EST on February 19, 2015, Fermi 2 experienced a trip of the Reactor Building Ventilation (RB) (HVAC) during plant operations associated with very cold temperatures outside. At the time of the trip, outside air temperature was -1 degrees Fahrenheit and RB HVAC tripped due to a Freeze-Stat actuation [a freeze protection feature].

"The plant Technical Specifications require that Secondary Containment pressure be maintained greater than or equal to -0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1). This specification was not maintained and the highest pressure observed was -0.11 inches of vacuum water gauge. Subsequently, at 0450, during restoration activities, RB pressure degraded again to higher than -0.125 inches of vacuum water gauge for 38 seconds. The lowest observed pressure was -0.11 inches of vacuum water gauge. RB HVAC has been restored by resetting the Freeze-Stat and the Standby Gas Treatment System (SGTS) has been placed back in a standby condition.

"The technical specification requirement is to maintain secondary containment at -0.125 inches of vacuum water gauge for secondary containment operability. Declaring secondary containment inoperable is reportable under 10CFR50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 50835
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY PATE
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/19/2015
Notification Time: 20:18 [ET]
Event Date: 02/19/2015
Event Time: 16:00 [CST]
Last Update Date: 02/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NICK TAYLOR (R4DO)

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

UNANALYZED CONDITION INVOLVING NORMALLY CLOSED WATERTIGHT DOORS

"During Main Steam Safety Valve testing conducted prior to refueling outages, normally closed watertight doors are opened in support of the testing. If a postulated one square foot non-mechanistic crack were to occur within the Break Exclusion Area during the test, safety related equipment located just outside of these doors could be adversely affected. With these watertight doors open, compliance with the Comanche Peak licensing basis may not be assured.

"This condition has been conservatively determined to be reportable as an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B). Currently, the watertight doors on both Units 1 and 2 are closed, therefore, all safety related equipment is currently operable. Comanche Peak Engineering is performing a review of the original Comanche Peak licensing basis regarding the non-mechanistic crack event to determine what equipment impacts are required to be assessed."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 50836
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHEL CICCONE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/20/2015
Notification Time: 00:49 [ET]
Event Date: 01/19/2015
Event Time: 20:18 [EST]
Last Update Date: 02/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY POWELL (R1DO)

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

HELB BOUNDARY DOOR NOT LATCHING

"A High Energy Line Break (HELB) boundary door was discovered not latching. HELB boundary affects both trains of safety related [480V] switchgear and was not operable for approximately seven minutes. [The licensee] entered the technical specification action statement, restored the door to functional, and exited the technical specification action statement."

The licensee notified the NRC Resident Inspector, the State of Connecticut and local officials.

Page Last Reviewed/Updated Friday, February 20, 2015
Friday, February 20, 2015