United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 1, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/30/2013 - 10/01/2013

** EVENT NUMBERS **


49366 49367 49368 49392 49394 49395 49397 49398

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Agreement State Event Number: 49366
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/20/2013
Notification Time: 11:58 [ET]
Event Date: 05/09/2013
Event Time: [EDT]
Last Update Date: 09/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING DOSE TO THE WRONG ORGAN

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

"At 1000 [EDT] on Sept 20, 2013 the Cleveland Clinic Foundation (CCF) RSO called the Ohio Department of Health (ODH) Bureau of Radiation Protection to report the determination of a medical event based on the back calculations from a symptomatic patient that had received a Y-90 microsphere treatment on May 9, 2013. The patient received a treatment of Y-90 SIR-Spheres to both the left and right lobes of the liver.

"The vessel to the stomach area was coiled to prevent shunting. At the time of the treatment, the patient complained of some abdominal pain. The post-treatment scan was inconclusive regarding the shunting to the stomach area. The AU [authorized user] and interventional radiologist concluded that a shunt was unlikely.

"The patient continued to complain of stomach pain and returned to the CCF on Sept 5, 2013 for an endoscopy. The endoscopy revealed ulcers in the potentially affected areas.

"After additional review of the post-treatment scan by the licensee, it was not abundantly apparent, but possible, that shunting did occur. Based on the assumption that shunting did occur, the licensee determined that the gastric antrum, an unintended treatment area, received a dose of 62 Gy.

"The ODH Bureau of Radiation will be conducting an onsite investigation.

"This incident was assigned ODH incident report number 2013-011."

NMED Item Number: OH130014

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: 49367
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: EQUISTAR CHEMICALS LP
Region: 3
City: MORRIS State: IL
County:
License #: IL-01737-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/20/2013
Notification Time: 12:17 [ET]
Event Date: 09/18/2013
Event Time: [CDT]
Last Update Date: 09/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON PROCESS GAUGE

The following was received by the State of Illinois via email:

"On September 18, 2013, Equistar Chemical's Radiation Safety Officer contacted the Agency [Illinois Emergency Management Agency] to report that a shutter on a fixed gauge could not be closed at their Morris, Illinois facility. The shutter on the fixed level gauge, manufactured by Vega America, could not be closed during a routine shutter check. The gauge is located on a vessel that is not routinely accessible to personnel due to temperatures on their hot particle line. The gauge normally operates in the constant 'open' position. It remains in its normal operational configuration at this time. This situation does not pose an immediate threat to health or safety unless an emergency shutdown condition were necessary requiring access to the vessel. At the time of discovery, a consultant was on-site performing the shutter checks and he immediately performed a dose rate survey of the device with no unusual measurements noted. This device was last checked and found to be operational in June 2013. The manufacturer was contacted to arrange service of the device on-site.

"The next day, the Radiation Safety Officer reported that following several additional attempts, they had been able to close the shutter. Per the manufacturer, the gauge shutter and handle shaft were sprayed with a light penetrating oil and after some time spent partially rotating the shutter, it will now rotate 90 degrees and allow the licensee to close the gauge if necessary. Arrangements were made with the manufacturer's field engineering group to have a shutter repair kit sent to the site within the next week when a field technician can perform the necessary repairs. The licensee believes that since all of the symptoms were very similar to previous device issues at the facility in the same area of the plant, water and resulting corrosion are inside of the gauge housing which is binding the shutter."

Illinois NMED Number: IL13029

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Fuel Cycle Facility Event Number: 49368
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/20/2013
Notification Time: 12:18 [ET]
Event Date: 09/20/2013
Event Time: 08:00 [EDT]
Last Update Date: 09/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DEBORAH SEYMOUR (R2DO)
KING STABLEIN (NMSS)

Event Text

SUPERVISOR TESTED POSITIVE FOR ALCOHOL ON A FOR CAUSE TEST

A facility supervisor tested positive for alcohol on a for-cause fitness for duty test. The supervisor's access to the facility has been restricted.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49392
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JAMES SCHWER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/30/2013
Notification Time: 09:26 [ET]
Event Date: 09/30/2013
Event Time: 02:38 [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JUDY JOUSTRA (R1DO)

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

Event Text

MANUAL START OF MOTOR DRIVEN AUXILIARY FEEDWATER PUMP

"At 0238 [EDT] hours on September 30, 2013, during a planned shutdown of Beaver Valley Unit 1 for a refueling outage, the 'B' Motor Driven Auxiliary Feedwater (AFW) pump was manually started in Mode 3 due to lowering levels in the steam generators. The steam generator levels were restored to normal following the start of the AFW pump. The lowering [steam generator] levels were a result of a component failure in a normal non-safety related make up system. The manual start for the AFW pump is being reported as a system actuation per 10 CFR 50 72(b)(3)(iv). The plant is currently in Mode 5.

"The NRC Resident Inspector has been notified."

A condensate pump recirculation valve failing open was the component failure in the normal non-safety related make up system.

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Power Reactor Event Number: 49394
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: RICHARD HONEYCUTT
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/30/2013
Notification Time: 12:52 [ET]
Event Date: 09/27/2013
Event Time: 21:15 [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARVIN SYKES (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

TRITIATED WATER LEAK FROM TEMPORARY PIPING ON PLANT SITE

"Harris Nuclear Plant is following the guidance in NEI 07-07 and has initiated this Event Notification as a result of our voluntary communication to state agencies in accordance with the Groundwater Protection Initiative.

"On Sept. 27, 2013, at 9:15 pm EDT, plant personnel identified a leak from a temporary transfer pipe on plant property, well within the site boundary. The pipe carries secondary plant and water treatment building waste water for chemical processing. The leak is conservatively estimated to be 240 gallons of water containing a low level of tritium (3,954 picocuries per liter) leaked into the surrounding soil. The EPA drinking water standard is 20,000 picocuries per liter. The leak was stopped and the piping replaced.

"The health and safety of the public and employees on site are not affected by this event based on the leak location and low tritium level."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 49395
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JAMES SCHWER
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/30/2013
Notification Time: 15:35 [ET]
Event Date: 09/30/2013
Event Time: 14:22 [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
JUDY JOUSTRA (R1DO)

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

Event Text

TRANSPORT OF POTENTIALLY CONTAMINATED INJURED WORKER

"At approximately 1422 EDT on 9/30/2013, a craft contractor worker was transported to an off-site medical facility due a work-related injury. The injured individual was in a radiologically controlled area when the injury occurred. The injured was partially surveyed by a Health Physics technician in their anti-contamination clothing prior to leaving the site and no radioactive contamination was detected. The injured individual was then transported by ambulance accompanied by a Health Physics technician to the local hospital for medical treatment.

"Follow up surveys determined that no contamination was detected on the individual or materials transported. All materials are being recovered and returned to the site.

"This notification is being made under the 10CFR50.72(b)(3)(xii) reporting requirements, since a complete survey of the injured individual was unable to be made and he was considered to be potentially contaminated prior to being transported off-site."

The NRC Resident Inspector has been notified.

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Part 21 Event Number: 49397
Rep Org: SHAW AREVA MOX SERVICES, LLC
Licensee: FLANDERS
Region: 1
City: AIKEN State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MARTIN WASHINGTON
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/30/2013
Notification Time: 16:21 [ET]
Event Date: 08/07/2013
Event Time: [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARVIN SYKES (R2DO)
PART 21 GROUP (EMAI)

Event Text

NONCONFORMING WELDS RESULTING IN CRACKS IN HVAC FILTER HOUSING REPAIR WELDS

Summary of information received via fax:

The Shaw AREVA Mixed Oxide Fuel Fabrication Facility found nonconforming welds that resulted in cracks in HVAC filter housings supplied to MOX Services by Flanders. The filter housings are credited for the confinement of radioactive material. There is a possibility for additional material stresses to be placed on the subject filter housings which could cause the propagation and increase in size of the cracks. Because the cracks identified in the non-conformance report could propagate to an indeterminate size, the ability of the portions of the HDE system upstream of these filter housings to maintain the confinement boundary and perform its safety function cannot be determined. MOX Services will ensure repairs are performed by either the vendor, MOX Services, or a third party. These repairs will be performed in support of the construction schedule.

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Power Reactor Event Number: 49398
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID LANTZ
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/01/2013
Notification Time: 01:05 [ET]
Event Date: 09/30/2013
Event Time: 22:57 [CDT]
Last Update Date: 10/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HEATHER GEPFORD (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

Event Text

OFF-SITE EMERGENCY OPERATIONS FACILITY DECLARED INOPERABLE DUE TO AIR IN-LEAKAGE

"At 2257 CDT on September 30, 2013 the Callaway Plant Emergency Off-Site Facility (EOF) was declared nonfunctional due to air in-leakage outside acceptance criteria while ventilation is in filtration mode.

"Efforts are underway to restore the air in-leakage within acceptance criteria at the EOF.

"If EOF activation is necessary during the period of EOF non-functionality, the Recovery Manager will evaluate the suitability of the facility for the specific conditions of the event.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the unavailability of an emergency response facility.

"The NRC Senior Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, October 01, 2013
Tuesday, October 01, 2013