United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 22, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2013 - 11/22/2013

** EVENT NUMBERS **


49532 49537 49540 49565 49566 49569 49570 49571

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Agreement State Event Number: 49532
Rep Org: COLORADO DEPT OF HEALTH
Licensee: MIDWEST INSPECTION DBA DESERT NDT
Region: 4
City: BARNSVILLE State: CO
County: WELD
License #: CO-RML#902-01
Agreement: Y
Docket:
NRC Notified By: CHERI HALL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/13/2013
Notification Time: 10:23 [ET]
Event Date: 11/13/2013
Event Time: [MST]
Last Update Date: 11/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT

The following Agreement State Report was received via email:

"On Thursday, November 7, 2013, Midwest Inspection dba [doing business as] Desert NDT experienced a source disconnect [on a INC Radiography Camera]. The RSO was able to retrieve the source into a shielded source exchange container as authorized to do on the license. No over-exposures are reported at this time, and an investigation is underway by [Colorado] Department employees. A full report will follow in the next 30 days."

The camera is an INC radiography camera, Model 32, Serial # 7292. The licensee RSO received 54 mrem while performing a source exchange on the camera.

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Agreement State Event Number: 49537
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH HOSPITAL AND MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: CURT DEMARIS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/14/2013
Notification Time: 14:40 [ET]
Event Date: 11/08/2013
Event Time: [PST]
Last Update Date: 11/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - Y-90 THERASHPERE DOSE LESS THAN PRESCRIBED

The following report was received from the Washington Department of Health [WA DOH] via e-mail:

"The licensee was performing an administration of Nordion TheraSpheres, a procedure performed without incident for over sixty administrations so far, when measurements indicated that an inordinate amount of the material remained in the waste/tubing. The licensee has confirmed the catheter used had an internal diameter [ID] of 0.68mm, which equals and exceeds the manufacturer's specifications of equal or greater than 0.5 mm ID.

"1. On Friday, November 8, 2013 at approximately 1040 [PST], the RSO received notification of a possible medical event involving the administration of Y-90 microspheres (TheraSpheres). The Radiation Safety Specialist contacted WA DOH at approximately 1100 on Friday, November 8, 2013 to report a medical event in accordance with requirements in WAC 246-240-651.

"2. The routine procedure for Y-90 microsphere administration requires the measurement of the materials used for the administration at a fixed geometry both before and after administration. The ratio of the exposure rate measured (minus background) indicates the percentage of the microspheres remaining in the tubing. This value subtracted from the originally prescribed activity determines the percentage of activity actually administered to the patient. The prescribed dose was 129 Gy to the left lobe, equivalent to an administered activity of 5.0 GBq. The measured activity (via Capintec CRC-15R) was 5.04 GBq which resulted in a pre-administration exposure rate of 5.3 mR/hr. Post-administration, the residual waste exposure rate measurement was 3.8 mR/hr (using the same geometry). The post-administration measurement was taken about 2 hours after the pre-administration measurement. Based on the post administration measurement, it is estimated that at least 73% of the prescribed dose was still present in the waste materials implying that only 27% of the prescribed dose was administered or 1.36 Gbq which would result in a target dose of 35 Gy.

"3. Investigation into the root cause indicated that the use of a Surefire Catheter may have been the underlying factor of this medical event. The interventional radiologist (RA) reported that this was the first time he had used the Surefire Catheter in conjunction with a TheraSphere case. This catheter was chosen due to medical need. The interventional radiologist wanted to minimize the amount of auxiliary embolization required for this case and this catheter satisfied that requirement. Prior to administration, contrast was administered to verify the integrity of the infusion system. No issues were noted during the contrast administration. During the administration of the microspheres, the interventional radiologist noted that the feel of the syringe was different from past administrations and that it was more difficult to push the plunger, however it did appear that the infusion was occurring. After completion of the infusion, the interventional radiologist noted that the syringe plunger pushed back. Final measurement of both the patient and the waste materials by medical physics and nuclear medicine indicated that the dose was not properly infused and consequently an underdose had occurred.

"4. During the investigation it was noted that this case was the first time the Surefire Catheter was utilized. There were no other changes in the set up. The vendor representative mentioned that he had previously observed issues with the use of this catheter, however there are no documents or other notices issued with regards to catheter usage combinations. Review of the infusion materials did not reveal any physical issues with the setup, though based on the physician's report regarding the feel of the plunger during the infusion, it is possible that there was a kink or other similar issue in either the catheter or infusion system that resulted in incomplete administration of the TheraSphere dose.

"5. The interventional radiologist communicated directly with the patient regarding this medical event. Both the interventional radiologist and the radiation oncologist (who is also the physician authorized user for this material) do not anticipate any additional medical issues that would be a result of this incomplete administration. This is based on the history of the patient who had previously received a TheraSphere administration to his right primary lobe vs. the current administration to the left secondary lobe.

"6. In order to minimize the possibility of future medical events, the Surefire Catheter will not be used for future procedures. Since there have been no cases during our experience with this procedure prior to this event that have resulted in an underdosing due to equipment malfunction and since the only significant change in equipment set up was the use of the Surefire catheter, it is expected that a return to our previous catheter will insure that underdosing will not occur.

"7. In accordance with WAC 246-240-651 a full report regarding this event has been transmitted to WA DOH. "

Washington Incident : WA-13-055

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: 49540
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City: SEATTLE State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 11/14/2013
Notification Time: 17:49 [ET]
Event Date: 11/12/2013
Event Time: [PST]
Last Update Date: 11/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL UNACCOUNTED FOR

The following was received via email from the Washington Dept. of Health, Office of Radiation Protection:

"Tuesday, November 12, 2013, I [State of WA] received a call from the Radiation Safety Officer of the University of Washington. He informed me that his staff was unable to account for 3.3 mCi of C-14 and 7 mCi of H-3, the sum of several vials [unsealed sources used for research], when reconciling the inventory of an AUI [Authorized Investigator] after he died. The AUI had a radioactive materials authorization at the university for well over 20 years. A staff member investigated the problem and interviewed current and previous laboratory staff in an effort to find the documentation of disposition of the missing material. This is believed to be a paperwork/failure to document issue with no actual loss or release. It will be discussed at their next Radiation Safety Committee meeting which the state will attend on 26 November 2013. The licensee will provide us with a full report by then. It is the C-14 which exceeds the reporting activities."

State incident number WA-13-056

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: 49565
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALEXANDER MCLELLAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/21/2013
Notification Time: 04:23 [ET]
Event Date: 11/20/2103
Event Time: 22:40 [EST]
Last Update Date: 11/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
FRED BOWER (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

SECONDARY CONTAINMENT FAILS DRAWDOWN SURVEILLANCE TESTING

"On November 20, 2013 at 2240 [EST], secondary containment drawndown testing surveillance failed to meet acceptance criteria SR 3.6.4.1.5 due to maximum flow rate exceeding the allowable value.

"SSES [Susquehanna Steam Electric Station] previously entered SR 3.0.3 at 0900 on 11/15/2013 due to not meeting SR 3.6.4.1.4 and SR 3.6.4.1.5 because of an untested alignment of the 101 bay with ventilation aligned as a no zone during past performances of the drawdown testing surveillance. The surveillance being performed on 11/20/2013 was testing this previously unsurveilled alignment.

"Upon failure of the surveillance, secondary containment ventilation was realigned to the previously tested 818 hatch alignment.

"Upon restoration of secondary containment ventilation to a known operable alignment, secondary containment LCO 3.6.4.1 was cleared and operability restored.

"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 placed administrative controls on the 101 bay doors to prevent loss of secondary containment during the investigation to determine the reason for the surveillance test failure.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49566
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE SPEIRS
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/21/2013
Notification Time: 10:38 [ET]
Event Date: 11/21/2013
Event Time: 02:29 [CST]
Last Update Date: 11/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (R3DO)

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

DIESEL GENERATOR INOPERABILITY

"Following preplanned maintenance on the inoperable 'A' Standby Diesel Generator (SBDG), the operability surveillance (STP-3.8.1-04A Slow Start from Normal Air) was in progress. While securing the 'A' SBDG, the 'B' SBDG control power failure annunciator was received.

"The 'B' Standby Diesel Generator was declared inoperable and Technical Specification 3.8.1.B was entered for the 'B' SBDG. Additionally, Technical Specification 3.8.1.D was entered for two Standby Diesel Generators inoperable. Technical Specification 3.8.1.D allows 2 hours to restore 1 SBDG to operable.

"At 0343 [CST], the 'A' SBDG was restored to operable and Technical Specification 3.8.1.D was exited.

"This condition is reported under 50.72(b)(3)(v)(D), any event or condition at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"The NRC Resident Inspector was informed."

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Part 21 Event Number: 49569
Rep Org: COLUMBIANA HI TECH, LLC
Licensee: COLUMBIANA HI TECH, LLC
Region: 1
City: GREENSBORO State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LARRY WALKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/21/2013
Notification Time: 16:23 [ET]
Event Date: 11/14/2013
Event Time: [EST]
Last Update Date: 11/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
FRANK EHRHARDT (R2DO)
PART 21 GROUP (EMAI)
MERAJ RAHIMI (NMSS)

Event Text

PART 21 REPORT REGARDING IDENTIFIED DISCREPANCY WITH INDIVIDUAL NDT LEVEL II CERTIFICATION

Received the following information was obtained via fax:

"Columbiana HI Tech, LLC is performing an evaluation to determine a potentially reportable condition per 10 CFR Part 21 requirements. Description of Noncompliance: A review of NDE certifications revealed discrepant training and work experience records from previous employment provided by a Columbiana HI Tech, LLC employee at the time of certification. This condition was first discovered on 11/14/13. The employee was certified under the Columbiana HI Tech, LLC Qualification & Certification of Nondestructive Examination Personnel Procedure passing all written and practical examinations required for Visual (VT) and Liquid Penetrant (PT) Inspection methods. The discrepant experience and training records from a previous employer were used to help fulfill the training and experience requirements for certification.

"Items affected: Columbiana Hi Tech, LLC Licensed components: Package USA/9196/B(U)F-96; certification number 9196 Rev. 26 UX-30 Overpack. A list of units affected will be compiled.

"Columbiana HI Tech, LLC CUSTOMER components: A list of components manufactured and inspected during the effected time is being reviewed to allow CUSTOMER Notification. Full disclosure will be made to all effected customers as soon as identified and within the reporting requirements of 10 CFR Part 21."

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Power Reactor Event Number: 49570
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVEN P. JOHNSTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/21/2013
Notification Time: 20:30 [ET]
Event Date: 11/21/2013
Event Time: 17:37 [EST]
Last Update Date: 11/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
FRED BOWER (R1DO)

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

Event Text

OFFSITE NOTIFICATION TO NJDEP CONCERNING A SMALL SODIUM HYPOCHLORITE SPILL

"Today, November 21, 2013, at approximately 1737 EST, the New Jersey Department of Environmental Protection [NJDEP] was notified that an indeterminate amount (less than 1 gallon) of sodium hypochlorite was spilled onto the lands of the State of New Jersey. The spill has been contained and cleaned-up. There was no actual or potential impact on the environment and no impact on the health and safety of the public or onsite personnel.

"The spill did not reach the federal reportable quantities limit.

"Due to notification of a government agency, this event is being reported under 10CFR50.72 (b)(2)(xi)."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 49571
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: BOB PAGE
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/21/2013
Notification Time: 21:41 [ET]
Event Date: 11/21/2013
Event Time: 16:41 [EST]
Last Update Date: 11/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
FRANK EHRHARDT (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

LOW CASING COOLING SYSTEM TANK LEVEL POTENTIALLY CAUSES LOSS OF NPSH TO OUTSIDE RECIRCULATION SPRAY PUMPS

"The Casing Cooling system at North Anna Power Station (NAPS) Units 1 and 2 provides cold, borated water to the suction of the Outside Recirculation Spray (ORS) pumps to increase net positive suction head (NPSH) following the initiation of a Containment Depressurization Actuation (CDA). As Casing Cooling tank level decreases to the isolation setpoint, it has been determined that vortexing/air entrainment may occur. This air would then enter the suction of the ORS pumps and potentially cause degradation in design flow and/or loss of NPSH. As a result, this constitutes an event or condition that could have prevented fulfillment of a safety function and is reportable per 50.72(b)(3)(v). A prompt operability determination is in progress that should restore the function of the recirculation spray system.

"The licensee has notified the NRC Resident Inspector."

The licensee will be notifying the Louisa County Administration in the morning.

Page Last Reviewed/Updated Friday, November 22, 2013
Friday, November 22, 2013