Event Notification Report for October 29, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/28/2013 - 10/29/2013
EVENT NUMBERS
4948849484494804948149482
Agreement State
Event Number: 49488
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GB BIOSCIENCES CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: 03521
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Licensee: GB BIOSCIENCES CORPORATION
Region: 4
City: HOUSTON State: TX
County:
License #: 03521
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2013
Notification Time: 15:46 [ET]
Event Date: 10/29/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2013
Notification Time: 15:46 [ET]
Event Date: 10/29/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - NUCLEAR GAUGE SHUTTER STUCK IN THE OPEN POSITION
The following information was obtained from the State of Texas via email:
"On October 30, 2013, the Agency [Texas Department of Health] was notified by the licensee that while conducting routine maintenance checks on a Texas Nuclear model 5196 nuclear gauge containing a 20 milliCurie cesium137 source, the shutter was found stuck in the open position. The licensee lubricated the operating shaft and attempted to close and reopen the shutter. While attempting to reopen the shutter, the operating rod for the shutter broke. The licensee determined the gauge is in the open position, which is the normal operating position for the gauge. The licensee has contacted the gauge manufacturer and will either repair or replace the gauge. No individual received any additional exposure as a result of this event. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."
Texas Incident #: I-9132
The following information was obtained from the State of Texas via email:
"On October 30, 2013, the Agency [Texas Department of Health] was notified by the licensee that while conducting routine maintenance checks on a Texas Nuclear model 5196 nuclear gauge containing a 20 milliCurie cesium137 source, the shutter was found stuck in the open position. The licensee lubricated the operating shaft and attempted to close and reopen the shutter. While attempting to reopen the shutter, the operating rod for the shutter broke. The licensee determined the gauge is in the open position, which is the normal operating position for the gauge. The licensee has contacted the gauge manufacturer and will either repair or replace the gauge. No individual received any additional exposure as a result of this event. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."
Texas Incident #: I-9132
Agreement State
Event Number: 49484
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNIVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DARREN PERRERO
HQ OPS Officer: JOHN SHOEMAKER
Licensee: LOYOLA UNIVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DARREN PERRERO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/30/2013
Notification Time: 14:36 [ET]
Event Date: 10/29/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2013
Notification Time: 14:36 [ET]
Event Date: 10/29/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE
ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE TO A PATIENT
The following report was received from the Illinois Emergency Management Agency via e-mail:
"On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated.
"As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days."
The cause of this event was equipment failure.
Illinois Item Number: IL13032
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 report was received from the Illinois Emergency Management Agency via e-mail:
"On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated.
"As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days."
The cause of this event was equipment failure.
Illinois Item Number: IL13032
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: 49480
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CHRIS WEICHLER
HQ OPS Officer: DONG HWA PARK
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: CHRIS WEICHLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/29/2013
Notification Time: 05:01 [ET]
Event Date: 10/29/2013
Event Time: 05:00 [EDT]
Last Update Date: 10/30/2013
Notification Time: 05:01 [ET]
Event Date: 10/29/2013
Event Time: 05:00 [EDT]
Last Update Date: 10/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)
PAUL KROHN (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
MAIN STACK RADIATION MONITORS REMOVED FROM SERVICE
"At 0500 [EDT] Tuesday, October 29, the Peach Bottom Atomic Power Station (PBAPS) main stack radiation monitors will be removed from service for planned preventative maintenance activities on the flow elements. This maintenance is scheduled to be worked continuously until completion to minimize out of service time. The planned main stack radiation monitor outage is scheduled to be completed within 13 hours. Periodic gas sampling will be performed in accordance with the offsite dose calculation manual while the monitors are out of service.
"The NRC Resident Inspector has been notified.
"There are no follow-up written reports required for this event."
* * * UPDATE ON 10/30/13 AT 0216 EDT FROM BOB RAUCCI TO DONG PARK * * *
"This is an update to notification #49480. The out of service duration has been extended from the original estimated 13 hours due to work scope taking longer than expected with fatigue rule compliance requirements. The radiation monitor maintenance has been completed and the components have been restored to service, however, the post maintenance testing will be delayed until this morning (10/30/13) when the necessary component expert resource is next available. Periodic gas sampling remains in effect in accordance with the Off Site Dose Calculation Manual."
The licensee will notify the NRC Resident Inspector.
Notified R1DO (Krohn).
"At 0500 [EDT] Tuesday, October 29, the Peach Bottom Atomic Power Station (PBAPS) main stack radiation monitors will be removed from service for planned preventative maintenance activities on the flow elements. This maintenance is scheduled to be worked continuously until completion to minimize out of service time. The planned main stack radiation monitor outage is scheduled to be completed within 13 hours. Periodic gas sampling will be performed in accordance with the offsite dose calculation manual while the monitors are out of service.
"The NRC Resident Inspector has been notified.
"There are no follow-up written reports required for this event."
* * * UPDATE ON 10/30/13 AT 0216 EDT FROM BOB RAUCCI TO DONG PARK * * *
"This is an update to notification #49480. The out of service duration has been extended from the original estimated 13 hours due to work scope taking longer than expected with fatigue rule compliance requirements. The radiation monitor maintenance has been completed and the components have been restored to service, however, the post maintenance testing will be delayed until this morning (10/30/13) when the necessary component expert resource is next available. Periodic gas sampling remains in effect in accordance with the Off Site Dose Calculation Manual."
The licensee will notify the NRC Resident Inspector.
Notified R1DO (Krohn).
Power Reactor
Event Number: 49481
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RYAN HAMILTON
HQ OPS Officer: JOHN SHOEMAKER
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RYAN HAMILTON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/29/2013
Notification Time: 11:45 [ET]
Event Date: 10/29/2013
Event Time: 05:56 [EDT]
Last Update Date: 10/29/2013
Notification Time: 11:45 [ET]
Event Date: 10/29/2013
Event Time: 05:56 [EDT]
Last Update Date: 10/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)
PAUL KROHN (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 |
UNPLANNED LOSS OF TEN AREA RADIATION MONITORS IMPACTING EMERGENCY ASSESSMENT CAPABILITY
"At 0556 EDT, [on 10/29/13], Nine Mile Point Unit 1 experienced an unplanned loss of ten area radiation monitors due to a loss of the associated power supply. These monitors are located throughout the station. Compensatory local monitoring was established in the affected areas until the area radiation monitors could be restored to service. The cause of the loss of the power supply was determined to be a blown fuse. The fuse was replaced and the power supply was restored at 1040 EDT. All area radiation monitors are restored. Post maintenance testing is in progress.
"The condition is reportable as a major loss of emergency assessment capability in accordance with 10CFR50.72(b)(3)(xiii). The NRC Resident Inspector has been notified.
"An update will be provided once the area radiation monitors have been restored to functional status."
* * * UPDATE FROM RYAN C. HAMILTON TO PETER J. SNYDER AT 1545 EDT ON 10/29/13 * * *
"Post maintenance testing is complete and the affected area radiation monitors are declared functional as of 1440 [EDT] on 10/29/13."
Notified R1DO (Krohn).
"At 0556 EDT, [on 10/29/13], Nine Mile Point Unit 1 experienced an unplanned loss of ten area radiation monitors due to a loss of the associated power supply. These monitors are located throughout the station. Compensatory local monitoring was established in the affected areas until the area radiation monitors could be restored to service. The cause of the loss of the power supply was determined to be a blown fuse. The fuse was replaced and the power supply was restored at 1040 EDT. All area radiation monitors are restored. Post maintenance testing is in progress.
"The condition is reportable as a major loss of emergency assessment capability in accordance with 10CFR50.72(b)(3)(xiii). The NRC Resident Inspector has been notified.
"An update will be provided once the area radiation monitors have been restored to functional status."
* * * UPDATE FROM RYAN C. HAMILTON TO PETER J. SNYDER AT 1545 EDT ON 10/29/13 * * *
"Post maintenance testing is complete and the affected area radiation monitors are declared functional as of 1440 [EDT] on 10/29/13."
Notified R1DO (Krohn).
Power Reactor
Event Number: 49482
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAN HAUTALA
HQ OPS Officer: JOHN SHOEMAKER
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAN HAUTALA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/29/2013
Notification Time: 13:10 [ET]
Event Date: 10/29/2013
Event Time: 06:05 [MST]
Last Update Date: 10/29/2013
Notification Time: 13:10 [ET]
Event Date: 10/29/2013
Event Time: 06:05 [MST]
Last Update Date: 10/29/2013
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):
JAMES DRAKE (R4DO)
JAMES DRAKE (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | N | 0 | Defueled | 0 | Defueled |
OFFSITE NOTIFICATION DUE TO EMPLOYEE FATALITY
"At approximately 0530 MST on October 29, 2013, an Arizona Public Service Company (APS) employee developed a personal medical condition in the Owner Controlled Area prior to entering the Protected Area at the Palo Verde Nuclear Generation Station (PVNGS). PVNGS Emergency Medical Technicians responded and transported the individual to an offsite emergency trauma center. Upon arrival at the trauma center, medical personnel declared the individual deceased at 0650 [on 10/29/13].
"The fatality was not work related and the individual was outside of the Radiological Controlled Area. No radioactive material or contamination was involved. No news release by APS is planned. Notifications to the Arizona Division of Occupational Safety and Health, and the Maricopa County Sheriff's Office are planned.
"The NRC Resident Inspectors have been notified."
"At approximately 0530 MST on October 29, 2013, an Arizona Public Service Company (APS) employee developed a personal medical condition in the Owner Controlled Area prior to entering the Protected Area at the Palo Verde Nuclear Generation Station (PVNGS). PVNGS Emergency Medical Technicians responded and transported the individual to an offsite emergency trauma center. Upon arrival at the trauma center, medical personnel declared the individual deceased at 0650 [on 10/29/13].
"The fatality was not work related and the individual was outside of the Radiological Controlled Area. No radioactive material or contamination was involved. No news release by APS is planned. Notifications to the Arizona Division of Occupational Safety and Health, and the Maricopa County Sheriff's Office are planned.
"The NRC Resident Inspectors have been notified."