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Event Notification Report for June 15, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/12/2015 - 06/15/2015

** EVENT NUMBERS **


51103 51118 51121 51122 51125 51127 51130 51148 51151 51152 51153

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Power Reactor Event Number: 51103
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS GARRISON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/29/2015
Notification Time: 20:17 [ET]
Event Date: 05/29/2015
Event Time: 12:30 [EDT]
Last Update Date: 06/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (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 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION SYSTEM OUT OF SERVICE DUE TO DISCOVERED CONDITION

"This is non-emergency eight hour notification for a loss of Emergency Assessment Capability.

"This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affects the functionality of an emergency response facility.

"A condition impacting functionality of the TSC [Technical Support Center] Ventilation system was discovered on 05/29/2015 at 1230 [EDT]. The issue involves a loss of cooling capability of the TSC ventilation system due to a failed relay. Maintenance will begin repairs at 0700 [EDT] on 05/30/2015. Estimated time to repair is unknown at this time.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Coordinator will relocate the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team will be notified of the condition and the possible need to relocate during an emergency. This condition does not affect the health and safety of the public or station employees. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector will be notified."

* * * UPDATE FROM AARON MICHALSKI TO DANIEL MILLS AT 1557 EDT ON 6/12/15 * * *

The TSC ventilation system has been returned to service. The licensee will notify the NRC Resident Inspector.

Notified R2DO (Guthrie).

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Agreement State Event Number: 51118
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RIVERSIDE MEDICAL CENTER
Region: 3
City: KANKAKEE State: IL
County:
License #: IL-01242-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 12:28 [ET]
Event Date: 06/02/2015
Event Time: [CDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO MIS-ADMINISTRATION OF Y-90 SIR-SPHERES

The following information was received via E-mail:

"The Director of Radiology at Riverside Medical Center, Kankakee, IL called the Agency [Illinois Emergency Management Agency] to advise that a medical event had occurred during the administration of a Y-90 SIR-Sphere treatment on the morning of June 2, 2015. 35.2 mCi of Y-90 was intended to be delivered to the patient's liver to treat metastatic cancer lesions via the hepatic artery. However, when the patient was imaged immediately following the treatment, the kidney was observed as the organ which had received the dose with no material evident in the liver. It was determined that the infusion catheter was improperly placed. Instead of placement in the patient's hepatic artery, the renal artery was the infusion site. This was the facility's first patient to undergo this treatment modality. As a result, the manufacturer's proctor was present in addition to the treatment team members which included the radiologist, the radiation safety officer, the nuclear medicine technologist as well as others.

"The radiologist immediately informed the patient of the error while he was in post-op. As the facility had a second dose of Y-90 on hand of the same amount, and the patient consented, a second attempt was made that same afternoon where the infusion went as expected and the intended dose was delivered as originally planned to the liver with no complications.

"Although normally, an outpatient procedure, the patient was held overnight. Universal precautions were implemented throughout the time period and although the patient's sweat and saliva were not sources of contamination, the hospital managed the patient as they would an I-131 therapy patient and routine collection and measurement of the patient's urine was performed before discharge to the sewer system.. Radioactivity was confirmed as present in the urine when measured with a Geiger counter near the surface of the container. No other contamination was noted in the room. The patient was discharged the next day and follow up appointments are pending with the radiologist as well as a urologist.

"Dose estimates to the patient's kidney as a result of the event are being performed by the manufacturer as well as the medical center's consultant. The Agency is investigating this event and the licensee has been advised that a written report must be submitted per regulation."

Illinois Item Number: IL15013

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: 51121
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LEIGHTON & ASSOCIATES
Region: 4
City: IRVINE State: CA
County:
License #: 3109-30
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 14:32 [ET]
Event Date: 06/03/2015
Event Time: [PDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAVEY TOTTERER (ILTA)
CNSNS (MEXICO) (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE/DENSITY GAUGE

The following information was received via E-mail.

"On June 3, 2015, Leighton & Associates notified RHB [California Department of Public Health, Radiologic Health Branch] that a moisture/density gauge was stolen from a pick-up truck's bed at a temporary job site in Riverside that morning. The gauge is a 2014 InstroTek model MC-3 Elite, s/n 30481, containing a 10 mCi Cs-137 source, s/n CZ4587 and a 50 mCi Am-241/Be source, s/n 038/14.

"The authorized gauge technician reported the security cables were cut and the density gauge was missing while he was parked at the job site but away from his vehicle. He immediately notified his RSO and the Riverside Police, who took report number P15-082748. RHB's inspector spoke with the RSO and recommended that a lost and found ad be placed in the local newspaper offering a cash reward for the return of the stolen gauge and requested additional information from the responsible technician. The Inspection/Compliance/Enforcement section will review the security measures that were in place to determine if a violation of their license condition took place."

California 5010 Report Number: 060315

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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Non-Agreement State Event Number: 51122
Rep Org: ARCELORMITTAL BURNS HARBOR
Licensee: ARCELORMITTAL BURNS HARBOR
Region: 3
City: BURNS HARBOR State: IN
County:
License #: 13-32670-01
Agreement: N
Docket:
NRC Notified By: CHRIS SARVANIDIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/04/2015
Notification Time: 15:12 [ET]
Event Date: 06/04/2015
Event Time: 08:30 [EDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

STUCK GAUGE SHUTTER

The following was received via email:

"On June 4, 2015 at approximately 0830 [EDT], [the Radiation Safety Officer] was contacted by radiation trained employees at the licensee's Hot Rolling Facility. The employees indicated that the shutter on one of the slab detection radiation gauges would not close. The employee also indicated he noticed a shiny metallic material adjacent to the gauge housing on one side. As a result, they contacted the Radiation Safety Officer (RSO) and [he] proceeded to the site to investigate.

"[The RSO] informed them to barricade the area until [he] arrived. Upon arrival, [the RSO] conducted a survey of the area and compared the levels to prior surveys (including the installation survey). [The RSO] found no significant difference in radiation levels. [He] also performed a wipe test on the gauge and checked it with a survey meter and pancake probe, finding no detectable radiation. The melted metallic material appeared to possibly be lead from the device shielding. As a result, [he] believes some shielding may have overheated and blocked the shutter open.

"Because radiation levels were normal and the device was functioning normally, the device was left in its operating position on the furnace. This was the safest possible scenario until resources can be obtained to safely remove and store the device with the shutter open. The RSO will obtain a container that will house the device safely and will transport the device to a secure location in the plant (controlled by the RSO) until it can be retrieved and repaired by Ronan Engineering (manufacturer). The furnace will be in operation until the device is removed so there is no physical possibility of anyone being inside the furnace and being exposed."

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Agreement State Event Number: 51125
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BASF CORPORATION
Region: 4
City: FREEPORT State: TX
County:
License #: 01021
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/04/2015
Notification Time: 18:10 [ET]
Event Date: 06/03/2015
Event Time: [CDT]
Last Update Date: 06/04/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SHUTTERS ON FOUR FIXED NUCLEAR GAUGES TO CLOSE

The following information was received via E-mail:

"On June 4, 2015, the licensee notified the Agency [Texas Department of State Health Services] that on June 3, 2015, it was performing routine shutter checks on fixed nuclear gauges at its facility and found the shutters on four of the gauges would not close. All four gauges were Ronan Model SA-1 containing cesium-137 sources (20, 40, 50, and 200 millicuries). The licensee lubricated the shutter mechanisms on all four gauges and let them sit overnight. Two of the gauges closed the next morning (June 4th) with no problem. The other two shutters still would not close. The licensee contacted an outside service group and it recommended using a different lubricant. The licensee followed the suggestion and both became operable that afternoon. These gauges normally operate with the shutter in the open position. There were no radiation exposures or increased risk of exposure as a result of this event. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9318

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Non-Agreement State Event Number: 51127
Rep Org: INDIANA UNIVERSITY HEALTH
Licensee: INDIANA UNIVERSITY HEALTH
Region: 3
City: MUNCIE State: IN
County:
License #: 13-00951-03
Agreement: N
Docket:
NRC Notified By: ALVIS FOSTER
HQ OPS Officer: VINCE KLCO
Notification Date: 06/05/2015
Notification Time: 09:27 [ET]
Event Date: 06/05/2015
Event Time: 02:00 [EDT]
Last Update Date: 06/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
DAVE PASSEHL (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

RADIOACTIVE SURFACE CONTAMINATION EXCEEDS LIMITS

The licensee nuclear medicine technologist ordered a package containing radioisotopesTc-99m and Xenon for a patient. The package was delivered by an offsite nuclear pharmacy to the Indiana University Health- Ball Memorial Hospital. When the technician surveyed the package, the surface contamination exceeded specified limits and nominally measured about 14,000 dpm. The package was quarantined and the vendor/shipper was notified concerning the surface contamination. The package was placed in a gamma camera and the indicated camera spectrum indicates Xenon package contamination. The Radiation Safety Officer has ordered the package to remain quarantined. No personnel contamination resulted from this event.

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Agreement State Event Number: 51130
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK State: AR
County: PULASKI
License #: ARK-0001-0211
Agreement: Y
Docket:
NRC Notified By: JARED THOMPSON
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/05/2015
Notification Time: 15:22 [ET]
Event Date: 06/04/2015
Event Time: 00:00 [CDT]
Last Update Date: 06/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL TREATMENT INCORRECT DOSE

The following was received via email:

"On June 5, 2015, the Arkansas Department of Health (ADH) received notification from the licensee's Radiation Safety Officer (RSO) of a possible medical event that occurred during an Yttrium-90 Theraspheres procedure on June 4, 2015. The licensee has not completed the investigation and has provided limited information to determine if the procedure constituted a medical event.

"The patient was treated with Y-90 TheraSpheres. The written directive prescribed a dose of 114 Gy, but received a dose of 18.3 Gy. Preliminary findings seem to indicate that an incorrect dose may have been administered to the patient.

"The patient and referring physician have been notified.

"The licensee and ADH are continuing to investigate this event. ADH considers this event to be opened and will provide more information as it becomes available.

"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."

ARKANSAS EVENT #2015-005

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Power Reactor Event Number: 51148
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROBERT NORRIS
HQ OPS Officer: STEVEN VITTO
Notification Date: 06/11/2015
Notification Time: 13:15 [ET]
Event Date: 06/10/2015
Event Time: 15:20 [CDT]
Last Update Date: 06/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
EUGENE GUTHRIE (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 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY

A licensed employee supervisor had a confirmed positive test for a controlled substance during a random fitness-for-duty test. The employee's plant access has been placed on administrative hold.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 51151
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ROBERT WISE
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/12/2015
Notification Time: 14:05 [ET]
Event Date: 06/12/2015
Event Time: 09:24 [EDT]
Last Update Date: 06/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DWYER (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

Event Text

LOSS OF TONE ALERT RADIO SYSTEM

"At 1027 [EDT] on June 12, 2015, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management Center notified JAF that the Tone Alert Radio System had been out of service since 0924 [EDT].

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the JAF Nuclear Power Plant. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The county alert sirens which also function as part of the Public Prompt Notification System remain operable.

"The loss of the Tone Alert Radio System constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local law enforcement personnel are also available for 'route alerting' of the affected areas of the EPZ.

"The event has been entered into the corrective action program and the [NRC] Resident Inspector has been briefed."

National Weather Service is investigating the failures.

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Power Reactor Event Number: 51152
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/12/2015
Notification Time: 14:52 [ET]
Event Date: 04/15/2015
Event Time: 12:07 [EDT]
Last Update Date: 06/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
EUGENE GUTHRIE (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

INVALID ACTUATIONS OF THE CONTAINMENT VENTILATION ISOLATION SYSTEM

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report two related invalid actuations of the Containment Vent Isolation System at Watts Bar Nuclear Plant Unit 1 (WBN-1).

"On April 14, 2015 at 2101 EDT, a sample pump failed on the WBN-1 Train B containment purge exhaust radiation monitor (1-RM-90-131), prompting control room operators to enter Conditions A and B of Technical Specification (TS) Limiting Condition for Operation (LCO) 3.3.6, Containment Vent Isolation Instrumentation and Condition A of LCO 3.6.3, Containment Isolation Valves.

"On April 15, 2015 at 1207 EDT, 1-RM-90-131 radiation readings increased sharply (spiked), initiating an invalid Containment Vent Isolation (CVI) actuation. The spike occurred following troubleshooting and repairs to 1-RM-90-131 when maintenance technicians agitated the motor starter enclosure in an attempt to free a stuck auxiliary contact that controls local indication. As a result of the CVI actuation, flow to lower containment radiation monitor (1-RM-90-106) was isolated, prompting control room operators to enter Condition B of LCO 3.4.15, RCS Leakage Detection Instrumentation. At 1634 EDT, control room operators exited the TS 3.4.15 condition when 1-RM-90-106 was returned to service.

"On April 17, 2015 at 1327 EDT, control room operators exited LCO 3.3.6 Conditions A and B and LCO 3.6.3 Condition A when sample pump repairs were completed on 1-RM-90-131.

"On April 19, 2015 at 1550 EDT, 1-RM-90-131 radiation readings spiked and initiated a CVI, prompting control room operators to enter TS LCO 3.4.15 Condition B and LCO 3.3.6 Condition A, until flow was restored to 1-RM-90-106 at 1636 EDT and 1-RM-90-131 was returned to service on April 26, 2015 at 1229 EDT.

"Each CVI was documented in accordance with the corrective action program, and TVA completed an equipment apparent cause evaluation (CR 1015781) that revealed the cause of the two CVI actuations was the result of a faulted Start/Stop control unit. TVA replaced the faulted control unit.

"In both instances, the CVI actuations resulted from invalid signals and were limited to a single piece of Train B equipment. There was no loss of safety function and there were no actual safety consequences during the events."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 51153
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MARK MOEBES
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/12/2015
Notification Time: 17:18 [ET]
Event Date: 06/12/2015
Event Time: 10:30 [CDT]
Last Update Date: 06/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

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

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"On June 12, 2015 at 1030 CDT, the Browns Ferry Nuclear Plant Unit 3 High Pressure Coolant Injection (HPCI) system was declared inoperable due to the time to drain the Turbine Exhaust Drain Pot after running the system for periodic testing. The concern is that the turbine may be partially flooded after shutting down and a subsequent restart could cause a water hammer event, possibly damaging the system. This issue was previously analyzed by Engineering as acceptable, but the time to drain the pot after the latest test indicates more water in the exhaust than the maximum amount used in the analysis.

"Technical Specification 3.5.1, ECCS Operating, Condition C, was entered as a result of the inoperable HPCI system. This constitutes an unplanned HPCI system inoperability and requires an 8-hour NRC notification in accordance with 10 CFR 50.72(b)(3)(v)(D) due to the failure of a single train system affecting accident mitigation, and a 60 day written report in accordance with 10 CFR 50.73(a)(2)(v)

"The NRC Resident Inspector has been notified."

The Technical Specification Action statement allows 14 days to restore the HPCI system to operable status.

Page Last Reviewed/Updated Monday, June 15, 2015
Monday, June 15, 2015