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Event Notification Report for December 3, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/02/2015 - 12/03/2015

** EVENT NUMBERS **


51038 51387 51565 51567 51579

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 12/02/2015
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."

* * * RETRACTION PROVIDED BY MARK CONSTABLE TO JEFF ROTTON AT 1420 EST ON 12/02/2015 * * *

"This event has been reviewed and it was determined that the radioactive release rates displayed on the Safety Parameter Display System screens are obtained directly from the associated radiation monitors (0RIX-PR008 and 0RIX-PR012) and HVAC stack and Standby Gas Treatment System stack flow monitors (0UIX-PR050 and 0UIX-PR051) and are not processed through the AR/PR LAN. As a result, there was no loss of radiation release Emergency Action Level assessment capability with a loss of the AR/PR LAN. Therefore, there was no major loss of emergency assessment capability and this event is not reportable.

"The NRC Resident Inspector has been notified."

Notified R3DO (Lipa)

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Agreement State Event Number: 51387
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HI TECH TESTING
Region: 4
City: LONGVIEW State: TX
County:
License #: L05021
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2015
Notification Time: 15:41 [ET]
Event Date: 09/11/2015
Event Time: [CDT]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

The following report was received from the State of Texas via E-mail:

"The licensee reported [to Texas Department of State Health Services] that a disconnect had occurred and that an investigation is in progress. The radiography crew was working at a temporary job site [in Gainesville, TX] and the person reporting the event did not have complete information. Source activity and details of the disconnect are not available at this time."

The State of Texas does not believe that any over exposures have occurred.

Texas Incident #: I-9337


* * * UPDATE FROM IRENE CASARES TO DONALD NORWOOD AT 1618 ON 12/2/2015 * * *

The following information was received via E-mail:

"On September 11, 2015, the Agency [Texas Department of State Health Services] received a call from a licensee's radiation safety officer explaining that one of its crew had a source which was not retracting. The camera was a QSA Delta 880, serial number D4855, with a 92 Ci Ir-192 source, serial number 20487G. The camera and crank mechanism failed to operate as normal. It was described that the crank would connect to the camera without connecting to the pigtail. It also was described that the go/no go procedures were completed and had produced good results. The RSO was puzzled as to the connector working without the pigtail connection. He sent both the camera and the crank mechanism to the manufacture for a service check.

"The manufacture repaired the device. The manufacture performed a misconnect test stating that the rear plate assembly ring rotated from the Connect to Operate position without attaching the drive cable connector to the source assembly. This indicated a failure of the misconnect test. The manufacture disassembled the drive cables. A measurement of the connecting plug assembly revealed excessive component failure. This condition caused the misconnect. The device also showed signs of wear through to the DU shield. Both the control cable and the exposure device have been removed from service and will be disposed of accordingly. The source will be reloaded into a conforming Delta 880 device. The RSO provided corrective actions to prevent a recurrence of the misconnect. A company wide inspection of all drive cable control units was to be carried out immediately. All controls are routinely checked during quarterly maintenance field audits. Instructions for the misconnect test are provided in all source notebooks as part of the daily inspection. Nothing further for this investigation. No violations were cited.

"File closed."

Notified R4DO (Gepford). Notified via E-mail the NMSS Events Notification group.

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Agreement State Event Number: 51565
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MERCY-HEALTH - EASTGATE MEDICAL CENTER
Region: 3
City: CINCINNATI State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/24/2015
Notification Time: 15:00 [ET]
Event Date: 07/24/2014
Event Time: [EST]
Last Update Date: 11/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"The licensee performed a prostate Iodine-125 (I-125) seed implant on July 24, 2014. The prescribed dose of 144 Gray (Gy) to 90 percent of the prostate gland (D90) was not within 20 percent of prescribed dose [144 Gy prescribed, 86.1 Gy administered]. The post plan performed on August 12, 2014, demonstrated that the prostate D90 was 59.79 percent, not within 20 percent limit of the prescribed dose. The licensee did not notify the Ohio Department of Health of this occurrence as a medical event. The medical event was discovered as a result of an inspection conducted on 10/28/15.

"A Notice of Violation for the medical event and failure to report the medical event has been issued to the licensee. The investigation is ongoing."

Ohio Report: OH150012

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: 51567
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PITTSBURGH
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/25/2015
Notification Time: 11:34 [ET]
Event Date: 11/20/2015
Event Time: [EST]
Last Update Date: 11/25/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST RADIOACTIVE SEED

The following was received from the Commonwealth of Pennsylvania via email:

"The licensee discovered the event on November 23, 2015 and notified the Department [Commonwealth of Pennsylvania] on November 25, 2015. It is reportable as per 10 CFR 20.2201(a)(1)(ii).

"An iodine-125 (I-125) seed was used for radioactive seed localization of a breast lesion. After surgical excision of the breast tissue at an outpatient surgical center, the specimen was placed in a plastic bag and imaged radiographically to confirm the presence of the seed. The seed was noted to be at the edge of the specimen. The specimen was then transferred to a plastic container for transport to the main hospital pathology department. When the specimen was received at pathology, a survey indicated that there was no seed present.

"Radionuclide: I-125 Seed
"Manufacturer: Best Medical
"Model No.: 2301
"Activity: 113 microCi

"The licensee assumes the seed became separated from the specimen and remained in the plastic bag which was disposed as biohazardous waste. A survey of the surgical center was performed, but the seed was not able to be located.

"A reactive inspection is planned by the Department. More information will be provided upon receipt."

Event Report ID No: PA150030


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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Power Reactor Event Number: 51579
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUSTIN SCURLOCK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2015
Notification Time: 14:14 [ET]
Event Date: 12/01/2015
Event Time: 20:36 [EST]
Last Update Date: 12/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
WILLIAM COOK (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

SECONDARY CONTAINMENT INOPERABLE DUE TO SECONDARY CONTAINMENT VACUUM BEING LESS THAN REQUIRED TS VALUE

"On December 1, 2015 at 2036 EST, with James A. FitzPatrick Nuclear Power Plant (JAF) operating at 100 percent power, Secondary Containment differential pressure exceeded the Technical Specification (TS) Surveillance Requirement (SR) of greater than or equal to 0.25 inches of vacuum water gauge for approximately one (1) minute and twenty (20) seconds. Secondary Containment (SC) had been declared inoperable prior to this event, to facilitate a planned evolution related to a previous failure that occurred on September 18, 2015 [reference EN #51409].

"Operators attempted to restore the Reactor Building Ventilation System (RBVS) to the normal system lineup upon completion of the planned evolution. The Secondary Containment differential pressure trended positive, and exceeded the TS SR differential pressure requirement during this transition.

"Preliminary investigations indicate that the cause of this event is associated with the Above Refuel Floor Exhaust Fan (66FN-13B). The design of the Above Refuel Floor Exhaust portion of the RBVS includes an interlock between the exhaust fan and a downstream damper position switch, which starts the fan when the damper is in the full open position. During the approximate one (1) minute and twenty (20) second duration that the TS SR was not met, 66FN-13B was not running with the associated discharge damper in the open position.

"Secondary Containment was operable after the SC differential pressure was restored upon start of 66FN-13B, and remains operable.

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(c), as an event or condition that could have prevented fulfillment of a safety function."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, December 03, 2015
Thursday, December 03, 2015