Event Notification Report for October 29, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/28/2010 - 10/29/2010
General Information or Other
Event Number: 46376
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: CHARLES TEAL
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/29/2010
Notification Time: 10:14 [ET]
Event Date: 10/29/2010
Event Time: 00:00 [EDT]
Last Update Date: 10/29/2010
Notification Time: 10:14 [ET]
Event Date: 10/29/2010
Event Time: 00:00 [EDT]
Last Update Date: 10/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
CHRISTIAN EINBERG (FSME)
RICHARD SKOKOWSKI (R3DO)
CHRISTIAN EINBERG (FSME)
AGREEMENT STATE - DOSE DELIVERED TO WRONG ORGAN
The following was received from the state of Ohio via email:
"Approximately three (3) weeks prior to therapy, the patient was scanned for extra hepatic shunting through injection of Tc-99m MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.
"On Tuesday, October 26, 2010, at approximately 1455 hours, the patient was treated with 3.959 GBq Y-90 TheraSphere microspheres per protocol. A Interventional Radiologist properly placed catheter, and confirmed by second Interventionist Radiologist.
"On Tuesday, October 26, 2010, at approximately 1930 hours, a post-procedure scan identified significant activity in the duodenum. Initial estimate indicates dose to duodenum approximately 90 Gy (90 Sv).
"Patient has been hospitalized at Cleveland Clinic for observation and possible intervention as a result of dose to the duodenum.
"[The] patient has been notified. [The] referring physician has been notified. [A] literature search indicates patient may have developed vascularization post-scan, pre-treatment."
Ohio Report #: OH 2010-060
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.
The following was received from the state of Ohio via email:
"Approximately three (3) weeks prior to therapy, the patient was scanned for extra hepatic shunting through injection of Tc-99m MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.
"On Tuesday, October 26, 2010, at approximately 1455 hours, the patient was treated with 3.959 GBq Y-90 TheraSphere microspheres per protocol. A Interventional Radiologist properly placed catheter, and confirmed by second Interventionist Radiologist.
"On Tuesday, October 26, 2010, at approximately 1930 hours, a post-procedure scan identified significant activity in the duodenum. Initial estimate indicates dose to duodenum approximately 90 Gy (90 Sv).
"Patient has been hospitalized at Cleveland Clinic for observation and possible intervention as a result of dose to the duodenum.
"[The] patient has been notified. [The] referring physician has been notified. [A] literature search indicates patient may have developed vascularization post-scan, pre-treatment."
Ohio Report #: OH 2010-060
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.
Power Reactor
Event Number: 46377
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: DONG HWA PARK
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/29/2010
Notification Time: 14:11 [ET]
Event Date: 10/29/2010
Event Time: 14:00 [EDT]
Last Update Date: 10/29/2010
Notification Time: 14:11 [ET]
Event Date: 10/29/2010
Event Time: 14:00 [EDT]
Last Update Date: 10/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
REBECCA NEASE (R2DO)
REBECCA NEASE (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 7 | Power Operation | 7 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO INCREASE IN TRITIUM LEVELS IN A GROUND WATER SAMPLE
"This report is being made pursuant to 10 CFR 50.72(b)(2)(xi) for notification to other government agencies.
"Dominion North Anna Power Station intends to voluntarily notify state and local agencies regarding an increase in tritium levels in one (1) onsite ground water monitoring sample point. This increase in tritium levels has not exceeded any NRC regulatory dose limits nor has it exceeded the voluntary reporting limits (i.e., 20,000 picoCuries per liter) specified in NEI 07-07 Industry Ground Water Protection - Final Guidance Document. Two (2) adjacent onsite ground water monitoring sample points have not shown a similar increase. None of the eight (8) ground water monitoring sample points surrounding the station have shown any detectable levels of tritium. All indications show that the tritium in the one (1) onsite ground water monitoring sample point has not migrated to the lake or any drinking water sources.
"The station continues to monitor, sample and investigate the source of the tritium anomaly. This condition does not present a health hazard to station employees or the general public."
Normal tritium levels at the particular sample point are 3-4000 picoCuries per liter. One sample read 16,500 picoCuries per liter. Samples afterwards have return to normal readings.
The NRC Resident Inspector has been notified.
"This report is being made pursuant to 10 CFR 50.72(b)(2)(xi) for notification to other government agencies.
"Dominion North Anna Power Station intends to voluntarily notify state and local agencies regarding an increase in tritium levels in one (1) onsite ground water monitoring sample point. This increase in tritium levels has not exceeded any NRC regulatory dose limits nor has it exceeded the voluntary reporting limits (i.e., 20,000 picoCuries per liter) specified in NEI 07-07 Industry Ground Water Protection - Final Guidance Document. Two (2) adjacent onsite ground water monitoring sample points have not shown a similar increase. None of the eight (8) ground water monitoring sample points surrounding the station have shown any detectable levels of tritium. All indications show that the tritium in the one (1) onsite ground water monitoring sample point has not migrated to the lake or any drinking water sources.
"The station continues to monitor, sample and investigate the source of the tritium anomaly. This condition does not present a health hazard to station employees or the general public."
Normal tritium levels at the particular sample point are 3-4000 picoCuries per liter. One sample read 16,500 picoCuries per liter. Samples afterwards have return to normal readings.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 46379
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DICK FOWLER
HQ OPS Officer: DONG HWA PARK
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DICK FOWLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/29/2010
Notification Time: 20:59 [ET]
Event Date: 10/29/2010
Event Time: 16:21 [CDT]
Last Update Date: 10/29/2010
Notification Time: 20:59 [ET]
Event Date: 10/29/2010
Event Time: 16:21 [CDT]
Last Update Date: 10/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
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 |
DEGRADED CONDITION - 71% THROUGH WALL INDICATION ON REACTOR RECIRC NOZZLE
"Information from a Phased Array UT [Ultrasonic Testing] examination of RRA-F002A indicates that a linear indication 6.5" long and a maximum depth of 71 % through wall extent (ID [Inner Diameter] connected) exists. The Phased Array UT examination of RRA-F002A was performed as part of scheduled outage activities.
"TRM [Technical Requirements Manual] LCO [Limiting Condition for Operation] 3.7.3 for Structural Integrity, Condition B has been entered for the Recirc nozzle/piping.
"This event is being reported as a degraded condition pursuant to 10CFR50.72(b)(3)(ii)(A) based on the fact that the indications result in a material defect in the primary coolant system which cannot be found acceptable under ASME Section XI, IWB-3600, 'Analytical Evaluation of Flaws' or ASME Section XI, Table IWB-3410-1, 'Acceptance Standards.'
"The licensee informed the NRC Resident Inspector."
"Information from a Phased Array UT [Ultrasonic Testing] examination of RRA-F002A indicates that a linear indication 6.5" long and a maximum depth of 71 % through wall extent (ID [Inner Diameter] connected) exists. The Phased Array UT examination of RRA-F002A was performed as part of scheduled outage activities.
"TRM [Technical Requirements Manual] LCO [Limiting Condition for Operation] 3.7.3 for Structural Integrity, Condition B has been entered for the Recirc nozzle/piping.
"This event is being reported as a degraded condition pursuant to 10CFR50.72(b)(3)(ii)(A) based on the fact that the indications result in a material defect in the primary coolant system which cannot be found acceptable under ASME Section XI, IWB-3600, 'Analytical Evaluation of Flaws' or ASME Section XI, Table IWB-3410-1, 'Acceptance Standards.'
"The licensee informed the NRC Resident Inspector."