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Event Notification Report for April 23, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/22/2015 - 04/23/2015

** EVENT NUMBERS **


50983 50986 50987 51001 51002 51003

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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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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Agreement State Event Number: 50986
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UNKNOWN
Region: 1
City: ROXBURY State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: VINCE KLCO
Notification Date: 04/15/2015
Notification Time: 16:02 [ET]
Event Date: 04/15/2015
Event Time: 15:15 [EDT]
Last Update Date: 04/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - SOURCE DISCOVERED AT A TRANSFER STATION

The following information was excerpted from a Commonwealth of Massachusetts facsimile:

A radiation source was detected in a trash load at the Roxbury Transfer Station (RTS) by radiation detectors at the transfer station entrance. The RTS consultant performed a survey to separate the radiation source from the remainder of the trash. The consultant transported radioactive trash to Atlantic Nuclear (MA license #56-0477) to perform isotope identification. Atlantic Nuclear' s analysis indicates the radiation source contains about 90 microCuries of Ra-226. A dose rate of 15 millirem/hour was measured at about 1 inch from the object. The consultant separated the single object from the trash bag. The source is stored at Atlantic Nuclear and is waiting for proper disposal.

The Agency [Massachusetts Radiation Control Program] continues to investigate and considers this event to be open.

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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Agreement State Event Number: 50987
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THERMO PROCESS INSTRUMENTS LP
Region: 4
City: SUGAR LAND State: TX
County:
License #: L03524
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/15/2015
Notification Time: 18:41 [ET]
Event Date: 04/14/2015
Event Time: 16:00 [CDT]
Last Update Date: 04/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE CAPSULE BREACHED RESULTING IN CONTAMINATED AREA AND INDIVIDUAL

"On April 15, 2015, the licensee notified the Agency that on April 14, 2015, one of its technicians was removing a cesium-137 source, with a current activity of 694 millicuries (original activity was 1200 millicuries in 06/1991), from an Ohmart SHLG-1 nuclear gauge. When he opened up the gauge, the source was ruptured. The cause of the rupture has not yet been determined. Areas of the workroom and the technician were contaminated. The technician was immediately [externally] decontaminated. The licensee swabbed the technician's nasal passages and found contamination. The licensee has sent the technician's dosimetry for immediate processing and is in the process of determining the internal dose estimate. Surveys confirmed that no contamination was carried outside the work room. Cleanup and surveys of the workroom are being performed. Access has been restricted since the incident. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.

Texas Incident I-9302

* * * UPDATE FROM ART TUCKER TO DAN LIVERMORE AT 1326 ON 04/21/15 * * *

"Currently 3 homes of employees have been found to have contamination, characterization has not been performed. Various articles of clothing have been confiscated by the company and residents have been moved to hotels, with all objects brought along cleared.

"The room in which the incident occurred has been sealed off. Additional licensee personnel have arrived to assist with surveys and cleanup. Assay of the source to determine what activity remains within the capsule has not yet been performed. Interviews of involved individuals are ongoing.

"Full body counts have been performed with initial readings of 4.86 mrem CEDE for one employee and 290 mrem CEDE for another."

Notified R4DO (Drake) and NMSS Events Notification via email.

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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.

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Power Reactor Event Number: 51003
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RUSSELL ZAHORCHAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/22/2015
Notification Time: 14:18 [ET]
Event Date: 02/24/2015
Event Time: 17:02 [CDT]
Last Update Date: 04/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES DRAKE (R4DO)

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

Event Text

60-DAY OPTIONAL TELEPHONE NOTIFICATION OF INVALID SYSTEM ACTUATION DUE TO MOTOR GENERATOR OUTPUT BREAKER TRIP

"On February 24, 2015, at approximately 1702 CDT, while the plant was in cold shutdown, power was lost on the Division 1 reactor protection system (RPS) bus. This event resulted in the automatic closure of the Division 1 primary containment isolation valves in the residual heat removal (RHR) and reactor water cleanup systems. Additionally, the primary containment atmospheric monitoring system automatically actuated, and ventilation systems in the fuel building, auxiliary building, and control building shifted to emergency mode. The closure of the isolation valves in the residual heat removal system caused an automatic trip of the 'A' RHR pump, which had been in the shutdown cooling alignment. The equipment response to the isolation signal was as expected. This event is being reported in accordance with 10 CFR 50.73(a)(1) as an invalid actuation of the Division 1 primary containment isolation system.

"The isolation was promptly diagnosed as having resulted from a trip of the output breaker of the RPS motor generator (MG) set 'A,' and not from a valid signal. Operators implemented the appropriate response procedures to align power to the bus via the alternate source, and began restoring the affected systems. The 'A' RHR pump was re-started within twelve minutes, during which time coolant temperature increased approximately seven degrees to a maximum of approximately 100F. Other affected systems were restored over the next few hours.

"The causal analysis concluded that the MG set output breaker tripped due to an overly conservative setpoint on the overvoltage trip relay. The low trip setpoint was a latent condition that had existed since the output voltage was raised in 1988 at the recommendation of the vendor, but at which time the trip setpoint was not changed. To correct this condition, the MG overvoltage trip setpoint was raised to restore adequate operating margin to the normal MG output voltage.

"At the time of the event, the plant was in MODE 5 with the reactor cavity flooded to greater than 23 feet above the vessel flange. The shutdown cooling system was promptly restored to service. This event was of minimal safety significance to the health and safety of employees and the public."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, April 23, 2015
Thursday, April 23, 2015