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Event Notification Report for December 28, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/27/2016 - 12/28/2016

** EVENT NUMBERS **


52329 52446 52447 52448

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52329
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID ARCELUS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/28/2016
Notification Time: 17:36 [ET]
Event Date: 10/28/2016
Event Time: 09:40 [EDT]
Last Update Date: 12/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BLAKE WELLING (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 72 Power Operation 72 Power Operation

Event Text

UNANALYZED CONDITION DUE TO FIRE BARRIER/HELB DOOR INOPERABLE

The licensee reported an unanalyzed condition under 10 CFR 50.72(b)(3)(ii)(B) due to a fire barrier/HELB (high energy line break) door being inoperable during maintenance. This resulted in two of five safe shutdown panels to be declared inoperable.

The door, located between the Turbine and Administrative Buildings, was opened for approximately two minutes for 'tool pouch work'. When Operations discovered the door was opened for maintenance, they declared the door inoperable until Operations performed the surveillance required to declare the door operable. The total time the door was inoperable was approximately 1 hour and 11 minutes.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION AT 1642 EST ON 12/27/2016 FROM DUSTIN SCURLOCK TO MARK ABRAMOVITZ * * *

The condition reported in ENS 52329 pursuant to 10 CFR 50.72(b)(3)(ii)(B) has been evaluated, and determined not to be an unanalyzed condition that significantly degraded plant safety.

"NRC Regulatory Issue Summary (RIS) 2001-09, 'Control of Hazard Barriers,' allows breaching of HELB barriers, provided the risk associated with the applicable maintenance activity is assessed and managed in accordance with 10 CFR 50.65(a)(4) of the Maintenance Rule. The hazard barrier controls procedure at JAF [James A. Fitzpatrick] is consistent with this guidance, and includes compensatory measures for opening of the subject HELB door (76FDR-A-272-26). Per the JAF hazard barrier controls procedure the secondary HELB doors are to be verified operable, and the Alternate Shutdown Panels 25ASP-4 and 25ASP-5 declared inoperable.

"Based on a review of previous performances of ST-76Y, Fire Door Inspection and Operability Test, and the JAF Paperless Condition Reporting System, all applicable secondary HELB doors were operable prior to and during the 'tool pouch work' on 76FDR-A-272-26. JAF TS LCO 3.3.3.2, Remote Shutdown System (RSS), stipulates a completion time of thirty days to restore one or more required remote shutdown functions to operable. The duration of the 'tool pouch work' and inoperability of 76FDR-A-272-26 is well within this thirty day allowed outage time. In addition, the Alternate Shutdown Panels that were rendered inoperable by this condition are not required for mitigation of a HELB, and steam line break accidents are not discussed in the Technical Specification (TS) Bases for the Remote Shutdown System."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Lilliendahl).

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Agreement State Event Number: 52446
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EAGLE NDT, LLC
Region: 4
City: POTH State: TX
County:
License #: 06176
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 12:49 [ET]
Event Date: 12/20/2016
Event Time: [CST]
Last Update Date: 12/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERAS DAMAGED IN BUILDING FIRE

The following information was obtained from the State of Texas via email:

"On December 20, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee's corporate radiation safety officer (CRSO) that a fire had occurred at their Poth, Texas location causing extensive damage to the building. The licensee reported that inside the building was its storage location for its radiography exposure devices. The storage location had ten QSA 880D cameras containing between 32.2 and 90.2 curies Ir-192. Dose rates five feet from the storage location after the fire was out were near normal.

"Once the licensee gained access to the storage location they discovered that at least two of the handles on the devices had been melted to some degree. The licensee removed all the cameras from the storage location and a radiation survey on each was completed. The licensee stated the measured dose rates were normal. It appears the integrity of the shielding was maintained, but could have been affected. The CRSO stated all cameras were being returned to the manufacturer for leak test and inspection.

"No licensee personnel or member of the general public were exposed to any significant levels of radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-9452

* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1049 EST ON 12/23/16 * * *

The following report update was received from the State of Texas via email:

"On December 23, 2016, the Agency contacted the licensee to get an update on the status of the radiography exposure devices. The licensee stated ten exposure devices were involved in the event and all have been delivered to the manufacturers Houston, Texas location for leak test and inspection. The licensee stated the exposure device storage area has been surveyed and no contamination was found. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO(Hay) and NMSS_Events_Notification via email.

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Agreement State Event Number: 52447
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: MARY HITCHCOCK MEMORIAL HOSPITAL
Region: 1
City: LEBANON State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: AUGUSTINUS ONG
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 16:01 [ET]
Event Date: 11/23/2016
Event Time: [EST]
Last Update Date: 12/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING HIGH DOSE RATE THERAPY DOSE TO AN UNINTENDED LOCATION

The following information was obtained from the state of New Hampshire via facsimile:

"NH Radiological Health Section 'Agency' was notified on November 23 by Chief Physicist followed by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital on November 24, 2016, of the HDR [high dose rate therapy] dose to an unintended location. The patient and the Authorized User were notified of the error and the correct fraction was administered.

"The licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. Cause of incident was identified as equipment malfunction (a deformed transfer tube)."

New Hampshire Event Report ID No.: NH-16-001

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: 52448
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINEGENERAL MEDICAL CENTER
Region: 1
City: AUGUSTA State: ME
County:
License #: 11623 #30
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 16:36 [ET]
Event Date: 12/20/2016
Event Time: 13:00 [EST]
Last Update Date: 12/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING WRONG TREATMENT SITE

The following information was obtained from the state of Maine via facsimile:

"On 12/19/2016, patient was scheduled for initial verification and treatment with electrons of a right sided metastatic rib lesion of 5 fractions at 400cGy per fraction. Patient was also to be treated with photons to a spinal lesion. Patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment location tattoos were present for each of these sites. Failure to identify the correct treatment tattoo and confusion over the treatment note led to the patient being setup to the previous rib tattoo location and treated. A single fraction of 400 cGy was delivered to the previous treatment site. Following treatment, the physician suspected a setup error. Further review of treatment plan confirmed the error. The licensee has notified the patient.

"A review of causes of the event and corrective actions was initiated."

Maine Event Report ID No.: ME 16-002

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.

Page Last Reviewed/Updated Wednesday, December 28, 2016
Wednesday, December 28, 2016