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Event Notification Report for May 5, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/04/2015 - 05/05/2015

** EVENT NUMBERS **


51009 51016 51038 51040 51041

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Agreement State Event Number: 51009
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BAYSTATE HEALTH
Region: 1
City: SPRINGFIELD State: MA
County:
License #: 60-0095
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: VINCE KLCO
Notification Date: 04/24/2015
Notification Time: 09:22 [ET]
Event Date: 04/22/2015
Event Time: [EDT]
Last Update Date: 04/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - BULK DOSE ADMINISTERED TO PATIENT

The following information was received from the Commonwealth of Massachusetts via email:

"The licensee's Radiation Safety Officer (RSO) reported on April 23, 2015 that, on the morning of April 22, 2015, the licensee mistakenly administered to a patient the wrong radioactive drug, a 118 mCi Tc-99m bulk dose instead of the prescribed 12.9 mCi Tc-99m Sestamibi dose, at the licensee's Baystate Franklin Medical Center facility.

"The wrong radioactive drug administered was reported by the licensee's RSO to have resulted in 5.6 rem effective dose equivalent to the patient, a reportable medical event in accordance with 105 CMR 120.594(A)(1)(b)1.

"The licensee's RSO reported that the patient and the referring physician have been notified and that the RSO did not expect any harm to the patient.

"The RSO reported the cause included that proper procedures were not followed.

"The Agency (Massachusetts Radiation Control Program) plans to perform a special inspection and considers this event to be open."

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: 51016
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: EASTMAN CHEMICAL COMPANY
Region: 1
City: KINGSPORT State: TN
County:
License #: R-82007-H18
Agreement: Y
Docket:
NRC Notified By: SEBLE AYNACHEW
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/27/2015
Notification Time: 13:11 [ET]
Event Date: 04/23/2015
Event Time: 11:00 [EDT]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER STUCK OPEN

The following report was received via fax:

"TDEC [Tennessee Department of Environment and Conservation] was notified on 4/24/2015 by [the licensee's] Radiation Safety Officer that during the performance of a 6-month shutter check on a Vega Model SHGL-1 gauge, the shutter was found to be inoperable and couldn't be moved to the closed position. The isotope involved was 30 mCi of Cs-137 (sealed source) contained in a Vega Model SHLG-1 level gauge, S/N OV0604. No radiation exposure occurred as a result of the incident. Current levels at the gauge are the same as dose rates under normal operating conditions."

Tennessee Event: TN-15-071

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Power Reactor Event Number: 51038
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JIM PETERSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 13:05 [ET]
Event Date: 05/04/2015
Event Time: 06:15 [CDT]
Last Update Date: 05/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

Event Text

LOSS OF POWER TO THE AREA RADIATION AND PROCESS RADIATION LOCAL AREA NETWORK

"At approximately 0615 [CDT] on 5/4/2015, the Area Radiation (AR)/Process Radiation (PR) Local Area Network (LAN) lost power following preparation for a planned Unit Sub 1M outage during the current refueling outage. Preparations for this planned outage included de-energizing the plant process computer data diode uninterruptible power supply that in turn caused a loss of power to the AR/PR LAN. As a result of this power loss, indication was lost in the Main Control Room for the main HVAC and Standby Gas Treatment System effluent radiation monitors without any viable compensatory measure to determine Total Noble Gas Release Rates. The station has determined that this constitutes a major loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Local radiation monitors continue to function properly. Power to the AR/PR LAN has been restored. Time of restoration was 1159 CDT.

"There is no impact to current plant operation. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51040
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2015
Notification Time: 21:44 [ET]
Event Date: 05/04/2015
Event Time: 14:39 [EDT]
Last Update Date: 05/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
DAN SCHROEDER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation
2 N N 0 Refueling 0 Refueling

Event Text

LOW DIFFERENTIAL PRESSURE RESULTING IN LOSS OF SECONDARY CONTAINMENT

"On May 4, 2015 at 1439 [EDT], during maintenance activities on Unit 2 Zone 3 fan discharge exhaust dampers, the control room received a low DP [Differential Pressure] alarm and other confirmatory indications of a loss of building DP.

"Secondary Containment DP was restored after approximately 2 minutes. The fan exhaust dampers are outside the isolation dampers, therefore, there was no impact on the SGTS [Standby Gas Treatment System] ability to drawdown secondary containment.

"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 has notified the NRC Resident Inspector.

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Power Reactor Event Number: 51041
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ANTON PESTKA
HQ OPS Officer: VINCE KLCO
Notification Date: 05/05/2015
Notification Time: 00:48 [ET]
Event Date: 05/04/2015
Event Time: 03:20 [MST]
Last Update Date: 05/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG PICK (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

SEISMIC MONITORING SYSTEM OUT OF SERVICE

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) for a loss of emergency assessment capability at the Palo Verde Nuclear Generating Station (PVNGS). On May 4, 2015 at 0320, seismic monitoring (SM) system force balance accelerometer R0006 was determined to be non-functional due to an emergent equipment failure. On May 4,2015, at approximately 1600, further review of this equipment failure and the related impact to the capability of the SM system determined that this was a reportable loss of emergency assessment capability.

"This specific accelerometer functions to provide indication that the Operational Basis Earthquake threshold has been exceeded following a seismic event and is used in the PVNGS Emergency Plan to perform classification for emergency action level HA1.1, Natural or Destructive Phenomena affecting Vital Areas. As a compensatory measure, PVNGS procedures for seismic event evaluation provide alternative methods for HA1.1 event classification with accelerometer R0006 out of service. Maintenance to correct the condition is in-progress.

"The NRC Resident Inspector has been informed of this condition."

Page Last Reviewed/Updated Tuesday, May 05, 2015
Tuesday, May 05, 2015