Event Notification Report for May 09, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/08/2013 - 05/09/2013
EVENT NUMBERS
4936649018490194901449016
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
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: 00:00 [EDT]
Last Update Date: 09/20/2013
Notification Time: 11:58 [ET]
Event Date: 05/09/2013
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KENNETH RIEMER (R3DO)
FSME EVENTS RESOURCE (EMAI)
KENNETH RIEMER (R3DO)
FSME EVENTS RESOURCE (EMAI)
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.
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.
Agreement State
Event Number: 49018
Rep Org: COLORADO DEPT OF HEALTH
Licensee: VARIOUS
Region: 4
City: DENVER State: CO
County:
License #: VARIOUS
Agreement: Y
Docket:
NRC Notified By: JENNIFER OPILA
HQ OPS Officer: JOHN SHOEMAKER
Licensee: VARIOUS
Region: 4
City: DENVER State: CO
County:
License #: VARIOUS
Agreement: Y
Docket:
NRC Notified By: JENNIFER OPILA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/09/2013
Notification Time: 17:29 [ET]
Event Date: 05/09/2013
Event Time: 00:00 [MDT]
Last Update Date: 05/13/2013
Notification Time: 17:29 [ET]
Event Date: 05/09/2013
Event Time: 00:00 [MDT]
Last Update Date: 05/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCES (EMAI)
ILTAB (EMAI)
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCES (EMAI)
ILTAB (EMAI)
AGREEMENT STATE REPORT - REPORT OF MISSING GENERAL DEVICES
The following is a list of missing general devices reported by the State of Colorado, missing between 1998-2011, via email.
The following table details the type and number of devices that the State previously neglected to report:
Type of Device Number Reported as Missing 1998-2011
- Exit Signs 1096
- Calibration 7
- Dust Monitor 1
- Electron Capture Detector 13
- Gas Chromatograph 6
- Standard Reference Materials 1
- Gauge 2
- Static Eliminator 44
- Unknown 1
- X-Ray Florescence 14
The State does not believe these devices represent a risk to human health or the environment and has taken steps to improve the general licensing registration program to ensure accurate reporting in the future.
See EN #48609 for a list of missing general devices in 2012.
* * * UPDATE FROM J. OPILA TO V. KLCO ON 5/13/2013 AT 1634 EDT * * *
The following information was excerpted from a received facsimile:
The State of Colorado checked with the general licensee and there was a report error. A Pepsi Bottling Group LLC source (Am-241; 100 mCi) was never missing and still is in the possession of the licensee.
Notified the R4DO (Hay), ILTAB and FSME Resources via email.
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
The following is a list of missing general devices reported by the State of Colorado, missing between 1998-2011, via email.
The following table details the type and number of devices that the State previously neglected to report:
Type of Device Number Reported as Missing 1998-2011
- Exit Signs 1096
- Calibration 7
- Dust Monitor 1
- Electron Capture Detector 13
- Gas Chromatograph 6
- Standard Reference Materials 1
- Gauge 2
- Static Eliminator 44
- Unknown 1
- X-Ray Florescence 14
The State does not believe these devices represent a risk to human health or the environment and has taken steps to improve the general licensing registration program to ensure accurate reporting in the future.
See EN #48609 for a list of missing general devices in 2012.
* * * UPDATE FROM J. OPILA TO V. KLCO ON 5/13/2013 AT 1634 EDT * * *
The following information was excerpted from a received facsimile:
The State of Colorado checked with the general licensee and there was a report error. A Pepsi Bottling Group LLC source (Am-241; 100 mCi) was never missing and still is in the possession of the licensee.
Notified the R4DO (Hay), ILTAB and FSME Resources via email.
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
Power Reactor
Event Number: 49019
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: CHRIS LAWS
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: CHRIS LAWS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/10/2013
Notification Time: 00:19 [ET]
Event Date: 05/09/2013
Event Time: 18:00 [PDT]
Last Update Date: 05/10/2013
Notification Time: 00:19 [ET]
Event Date: 05/09/2013
Event Time: 18:00 [PDT]
Last Update Date: 05/10/2013
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):
MICHAEL VASQUEZ (R4DO)
MICHAEL VASQUEZ (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
INLET/OUTLET TURBIDITY FLOCCULATOR NOT RECORDING DATA
"The following is a non-emergency notification in accordance with 10CFR50.72(b)(2)(xi) due to the notification requirement to other government agencies that will be made within 48 hours.
"At 1800, May 9, 2013, the Columbia Generating Station main control room received notification that PWC-XR-1 had been found to be not recording data. A review of the stored data indicated that the data collection had been stopped since 5/2/2013 at 0934. The screen does show real time data, although that data is not being stored. Some of the data is recorded manually by chemistry technicians and operators during rounds that may be used for reporting purposes.
"Automatic functions for high turbidity shutdown and low chlorine setpoints remain active when the data is not being stored. The data collected by PWC-XR-1 includes inlet and outlet flocculator turbidity, water temperature, flow rate and free residual chlorine. Washington Administrative Code, WAC, 246-290-664 outlines the requirements for monitoring filtered systems. WAC 246-290-480 section 2.a requires this failure to be reported as a failure to comply with monitoring requirements to the Washington Department of Health within 48 hours.
"PWC-XR-1 data storage has been re-initiated and is working as expected."
The licensee notified the NRC Resident Inspector.
"The following is a non-emergency notification in accordance with 10CFR50.72(b)(2)(xi) due to the notification requirement to other government agencies that will be made within 48 hours.
"At 1800, May 9, 2013, the Columbia Generating Station main control room received notification that PWC-XR-1 had been found to be not recording data. A review of the stored data indicated that the data collection had been stopped since 5/2/2013 at 0934. The screen does show real time data, although that data is not being stored. Some of the data is recorded manually by chemistry technicians and operators during rounds that may be used for reporting purposes.
"Automatic functions for high turbidity shutdown and low chlorine setpoints remain active when the data is not being stored. The data collected by PWC-XR-1 includes inlet and outlet flocculator turbidity, water temperature, flow rate and free residual chlorine. Washington Administrative Code, WAC, 246-290-664 outlines the requirements for monitoring filtered systems. WAC 246-290-480 section 2.a requires this failure to be reported as a failure to comply with monitoring requirements to the Washington Department of Health within 48 hours.
"PWC-XR-1 data storage has been re-initiated and is working as expected."
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 49014
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: GERRY RAUCH
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: GERRY RAUCH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/09/2013
Notification Time: 07:18 [ET]
Event Date: 05/09/2013
Event Time: 05:09 [CDT]
Last Update Date: 05/09/2013
Notification Time: 07:18 [ET]
Event Date: 05/09/2013
Event Time: 05:09 [CDT]
Last Update Date: 05/09/2013
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):
MICHAEL VASQUEZ (R4DO)
MICHAEL VASQUEZ (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
REACTOR COOLANT PRESSURE BOUNDARY LEAKAGE
"During Callaway refueling outage 19 on 5/8/13 at approximately 1900 hour CDT, water was observed dripping from piping insulation in the overhead by RCS loop 4. Further investigation determined it was near Safety Injection (EP) vent valve EPV0109. A scaffold was built and insulation was removed to perform an inspection. At approximately 0509 hours CDT on 5/9/13, engineering inspected the piping and determined there was a crack in the socket weld where 3/4 inch vent valve EPV0109 is connected to the 'B' train injection piping to RCS loop 4 Cold Leg. The estimated leakage rate through the crack is 6 (six) drops per minute. The configuration of this vent valve is a 3/8 inch flow restrictor socket welded to the six inch piping and a 3/4 inch vent valve socket welded to the flow restrictor. The crack is in the socket weld between the ASME code class 1 flow restrictor socket and the ASME code class 2 vent piping.
"Callaway plant was in mode 6 with refueling pool level greater than 23 feet above the reactor vessel flange at the time of the discovery. The 'A' RHR train which discharges to RCS loops 1 and 3 Cold Legs is the currently operable RHR train. 'B' RHR train was declared inoperable when the weld crack was identified. Only one RHR train is required to be operable at the present plant Mode of applicability. Repair plans are being developed.
"Basis for Reportability: This condition constitutes abnormal degradation of a principle safety barrier due to unacceptable welding defects within the primary coolant system."
There is a check valve between this leak and the reactor coolant system. Therefore, this is considered unisolable and pressure boundary leakage.
The licensee notified the NRC Resident Inspector.
"During Callaway refueling outage 19 on 5/8/13 at approximately 1900 hour CDT, water was observed dripping from piping insulation in the overhead by RCS loop 4. Further investigation determined it was near Safety Injection (EP) vent valve EPV0109. A scaffold was built and insulation was removed to perform an inspection. At approximately 0509 hours CDT on 5/9/13, engineering inspected the piping and determined there was a crack in the socket weld where 3/4 inch vent valve EPV0109 is connected to the 'B' train injection piping to RCS loop 4 Cold Leg. The estimated leakage rate through the crack is 6 (six) drops per minute. The configuration of this vent valve is a 3/8 inch flow restrictor socket welded to the six inch piping and a 3/4 inch vent valve socket welded to the flow restrictor. The crack is in the socket weld between the ASME code class 1 flow restrictor socket and the ASME code class 2 vent piping.
"Callaway plant was in mode 6 with refueling pool level greater than 23 feet above the reactor vessel flange at the time of the discovery. The 'A' RHR train which discharges to RCS loops 1 and 3 Cold Legs is the currently operable RHR train. 'B' RHR train was declared inoperable when the weld crack was identified. Only one RHR train is required to be operable at the present plant Mode of applicability. Repair plans are being developed.
"Basis for Reportability: This condition constitutes abnormal degradation of a principle safety barrier due to unacceptable welding defects within the primary coolant system."
There is a check valve between this leak and the reactor coolant system. Therefore, this is considered unisolable and pressure boundary leakage.
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 49016
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MATERON PRECISION OPTICS
Region: 1
City: TYNGSBOROUGH State: MA
County:
License #: G0272
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOHN SHOEMAKER
Licensee: MATERON PRECISION OPTICS
Region: 1
City: TYNGSBOROUGH State: MA
County:
License #: G0272
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/09/2013
Notification Time: 14:18 [ET]
Event Date: 05/09/2013
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2013
Notification Time: 14:18 [ET]
Event Date: 05/09/2013
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DWYER (R1DO)
FSME EVENTS RESOURCE (EMAI)
JAMES DWYER (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - LOST IONIZING STATIC DISSIPATER
The licensee reported to the state that a ionizing static dissipater, licensed under a General License [GL] and used on lines for clearing small parts of dust, was lost. The device is Model: NRD P-2021-8101 with Serial Number: A2HN439 and contained a Po-210 with an up to a 10 mCi source, on 1/18/12, which has decayed to approximately 0.9 mCi as of 5/9/13.
The licensee has properly returned all other devices for destruction from the facility.
The State has initiated an investigation and will assign an event number as new information is obtained.
* * * UPDATE ON 5/30/2013 AT 1430 EDT FROM TONY CARPENITO TO MARK ABRAMOVITZ * * *
The following update was received via e-mail:
"The agency [Massachusetts Radiation Control Program] conducted a site visit on 5/29/13. The general licensee implemented a search through facilities and determined the missing device may have been inadvertently dispositioned during recent building renovations and subsequent departmental reorganizations and relocations. The missing device was last used in 2012. The general licensee is seeking to terminate GL registration due to GL devices having been phased out and replaced with non-RAM [radioactive material] equipment. All other GL devices were accounted for and have already been dispositioned. The missing device component is a small metallic cylindrical object 0.5 inches in diameter and 2.7 inches in length.
"The agency considers this event to be CLOSED."
Massachusetts Event Docket #17-0766
NMED Item #130233
Notified the R1DO (Holody) and FSME Event Resources (via e-mail).
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
The licensee reported to the state that a ionizing static dissipater, licensed under a General License [GL] and used on lines for clearing small parts of dust, was lost. The device is Model: NRD P-2021-8101 with Serial Number: A2HN439 and contained a Po-210 with an up to a 10 mCi source, on 1/18/12, which has decayed to approximately 0.9 mCi as of 5/9/13.
The licensee has properly returned all other devices for destruction from the facility.
The State has initiated an investigation and will assign an event number as new information is obtained.
* * * UPDATE ON 5/30/2013 AT 1430 EDT FROM TONY CARPENITO TO MARK ABRAMOVITZ * * *
The following update was received via e-mail:
"The agency [Massachusetts Radiation Control Program] conducted a site visit on 5/29/13. The general licensee implemented a search through facilities and determined the missing device may have been inadvertently dispositioned during recent building renovations and subsequent departmental reorganizations and relocations. The missing device was last used in 2012. The general licensee is seeking to terminate GL registration due to GL devices having been phased out and replaced with non-RAM [radioactive material] equipment. All other GL devices were accounted for and have already been dispositioned. The missing device component is a small metallic cylindrical object 0.5 inches in diameter and 2.7 inches in length.
"The agency considers this event to be CLOSED."
Massachusetts Event Docket #17-0766
NMED Item #130233
Notified the R1DO (Holody) and FSME Event Resources (via e-mail).
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