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Event Notification Report for April 22, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/21/2015 - 04/22/2015

** EVENT NUMBERS **


50982 50983 50998 50999 51001 51002

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Non-Agreement State Event Number: 50982
Rep Org: ST VINCENT HOSPITAL AND HEALTH CENT
Licensee: ST VINCENT HOSPITAL AND HEALTH CENT
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: WILL BREEDEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/13/2015
Notification Time: 14:51 [ET]
Event Date: 04/13/2015
Event Time: 08:42 [EDT]
Last Update Date: 04/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
AARON MCCRAW (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

DUMMY WIRE JAMMED DURING BRACHYTHERAPY TREATMENT

A patient was receiving brachytherapy treatment using a SAVI device that used 11 channels. The patient was treated with 2 channels when the dummy wire jammed in the out position. The patient was prescribed a fractional dose 340 cGy, but received only received 60 cGy.

There are no adverse effects expected to the patient. The prescribing physician has been informed.

The licensee has contacted a company to repair the device and has ceased all operations until repairs can be made.

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 50983
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARDS
HQ OPS Officer: VINCE KLCO
Notification Date: 04/14/2015
Notification Time: 11:44 [ET]
Event Date: 04/14/2015
Event Time: 10:00 [EDT]
Last Update Date: 04/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
AARON MCCRAW (R3DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

Y-90 MICROSPHERE DOSE LESS THAN PRESCRIBED

A medical event involving Y-90 microspheres (TheraSpheres) occurred at approximately 1000 EDT on 4/14/15. The prescribed dosage was 34.6 mCi and the delivered dosage was 25.5 mCi. This equates to a 26.3 percent underdose. The patient was notified by the authorized user following treatment and before discharge on 4/13/15. The referring physician was notified by the authorized user via electronic mail at 1149 EDT on 4/13/15. The initial hypothesis on cause may have been related to difficult access to an anatomical region in the liver, resulting in the need to use lower than normal pressure on the syringe used for microsphere delivery. All established administration procedures were followed. A written report to the appropriate NRC offices will follow within 15 days.

* * * RETRACTION FROM MACK RICHARD TO VINCE KLCO ON 4/14/15 AT 1515 EDT * * *

The following information was excerpted from the licensee email:

"The reason for this retraction is based upon discussions with the Authorized User [AU] who performed the Y-90 treatment and additional questions raised and clarifications made by the NRC Region III Office. During that discussion, the AU indicated that he utilized a lower syringe pressure than normal to prevent reflux of the Y-90 microspheres which would have resulted in a less than optimal treatment. The AU acknowledged that the amount administered was acceptable, given the need to use the lower syringe pressure and that he will modify the written directive to appropriately reflect a change in the written directive based upon those circumstances."

Notified the R3DO (McCraw) and NMSS Events Notification via email.

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: 50998
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVE BRUNSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/20/2015
Notification Time: 21:26 [ET]
Event Date: 08/07/2014
Event Time: 17:07 [EDT]
Last Update Date: 04/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ALAN BLAMEY (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 90 Power Operation 90 Power Operation

Event Text

THIS IS A CONTINUATION OF EN #50351

* * * UPDATE FROM STEVE BRUNSON TO CHARLES TEAL ON 4/20/15 AT 2126 EDT * * *

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was found at penetration 1Z43H594D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- Near penetration 1Z43J837D, and approximately 12" south and above 1Z43H837D, gaps were observed in the mortar joint between CMU on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A triangular gap 1" wide, 1" tall and 6" deep was found at penetration 1Z43H592D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- A gap 4" tall and 3" wide was found behind Turn Box TB1-1272 which covers penetrations 1Z43H590D, 1Z43H589D, 1Z43H588, and 1Z43H587D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 1020)

- At the architectural joint between the vertical wall to the horizontal floor/ceiling assembly above door 1C-22, above and to the south of 1Z43H1105D, a gap was observed approximately " tall, 3" wide, and 6" deep on the west wall of the U1 East Cableway Foyer (separating Fire Area 1105 and Fire Area 0014K)

- Gap between the grout and the conduit of penetration 1Z43H778D approximately " tall x 1.5" wide x 6" deep on the east wall of the Unit 1 130' Elevation Control Building Working Floor Hallway (separating Fire Area 0014K and Fire Area 1105)

"The nonconforming conditions observed for the affected fire penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensure the safe shutdown paths are preserved until the degraded conditions are repaired.

"CR 10058276; CR 10058278

"The following deficiencies were also observed causing the affected penetrations to be considered nonfunctional:

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H532D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire Area 0014M)

- A gap 1/8" wide, 1" tall and 6" deep was located at penetration 1Z43H780D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M)

- A gap " wide, 1" tall, and 6" deep was located at penetration 1Z43H781D on the west wall of the U1 East Cableway (separating Fire Area 1104 and Fire 0014M). A " x " defect was also identified at penetration 1Z43H781D on the east wall of the Men's Restroom in the Control Building (separating Fire Area 0014M and Fire Area 1104)

"The nonconforming conditions observed for the affected penetrations were identified as affecting both safe shutdown paths for Unit 1 and Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until degraded conditions are repaired.

"CR 10058277

"The expanded scope inspection activity is continuing and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."

The licensee has notified the NRC Resident Inspector. Notified R2DO (Blamey).

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Power Reactor Event Number: 50999
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DYLAN SCHELBERT
HQ OPS Officer: DAN LIVERMORE
Notification Date: 04/21/2015
Notification Time: 12:06 [ET]
Event Date: 04/21/2015
Event Time: [CDT]
Last Update Date: 04/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 93 Power Operation 93 Power Operation

Event Text

LOSS OF ASSESSMENT CAPABILITY DUE TO NON-FUNCTIONAL SEISMIC MONITOR LAPTOP

"Clinton Power Station (CPS) has completed a review of the station seismic monitor performance. The CPS seismic monitor laptop is currently operable; however, this review identified 3 times in the last 3 years that the seismic monitoring laptop was declared non-functional such that the capability to perform an EAL assessment in accordance with the Radiological Emergency Plan Annex would be adversely impacted. A loss of the seismic laptop computer prevents active seismic data from processing through the central recording unit and will not alarm in the main control room.
The seismic monitor laptop became non-functional and unresponsive on the following dates:

1) January 4, 2013
2) July 19, 2013
3) November 2, 2014

"The loss of assessment capability is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72 (b)(3)(xiii) This report is required per 10 CFR 50.72(1)(1)(ii) as an event that occurred within 3 years of the date of discovery."

The NRC Resident Inspector has been notified.

Notified the R3DO (Valos).

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Power Reactor Event Number: 51001
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALEX MCLELLAN
HQ OPS Officer: VINCE KLCO
Notification Date: 04/22/2015
Notification Time: 01:58 [ET]
Event Date: 04/21/2015
Event Time: 22:58 [EDT]
Last Update Date: 04/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMES NOGGLE (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
2 N N 0 Refueling 0 Refueling

Event Text

INOPERABLE SECONDARY CONTAINMENT

On April 21, 2015 at 2258 [EDT], Secondary Containment became inoperable requiring a Technical Specification 3.6.4.1 entry for failure to meet SR 3.6.4.1.1 on Unit 1 and Unit 2.

The inoperability was caused by Zone 3 differential pressure lowering to less than 0.25 [inches Water Column] when Zone III fans tripped during 30mph wind gusts.

Fans were restarted and differential pressure restored to greater than 0.25 [inches Water Column] at 2314 hrs. April 21, 2015.

This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 51002
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN PANAGOTOPULOS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/22/2015
Notification Time: 03:17 [ET]
Event Date: 04/21/2015
Event Time: 23:30 [EDT]
Last Update Date: 04/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES NOGGLE (R1DO)
WILLIAM GOTT (IRD)

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

Event Text

OFFSITE NOTIFICATION DUE TO WORKER FATALITY NOT RELATED TO PLANT OPERATION

"At approximately 2330 [EDT] on April 21, 2015, a worker collapsed in the turbine building inside the protected area. Initial response by on-site responders found the person unresponsive. Subsequent response by off-site medical responders determined the person had died and the station was notified at approximately 0130 on April 22, 2015. The fatality was due to an apparent personal medical issue and not work related . The individual was not contaminated. The individual was transported off-site via onsite Site Protection personnel. Plant operation was not impacted by the event."

The licensee informed Lower Alloways Creek Township and will inform the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, April 22, 2015
Wednesday, April 22, 2015