Event Notification Report for April 04, 2014

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following was received from the State of Arizona via email:

"On May 22, 2014, the Agency was notified of a medical event that occurred on April 4, 2014 involving Y-90 labeled SIR Spheres.

"On April 4, 2014, an adult liver tumor patient was treated with an injection of SIR Spheres. The patient was prescribed 59.4 Gy to the liver, but instead, the actual dose to the liver was approximately 39 Gy. It was determined that the error occurred in the step of transferring the dose from the delivery vial to the dosing vial. The step of drawing up the sterile fluid was inadvertently omitted by the nuclear medicine technologist working alone which led to much less than the expected activity/sphere being transferred to the dosing vial. Only after the completion of the procedure was the large amount of residual activity detected and noted. The physicians noted that physiologic factors can affect the amount of spheres reaching the tumor so the discrepancy of the dose delivered apparently was not alarming or significant to them. The RSO discovered the medical event during a records review and recognized that the patient only received 63% of the prescribed dose."

Arizona First Notice Number: 14-013

WIDE RANGE GASEOUS MONITORING SYSTEM REMOVED FROM SERVICE FOR GREATER THAN 72 HOURS

"Nine Mile Point Unit 2 Ventilation Wide Range Gaseous Monitoring System was removed from service on 4/1/2014 at 1140 EDT to support isolation of the Unit 2 Reactor Building Ventilation during a Division 2 electrical bus outage. The monitoring system will be out of service for greater than 72 hours due to the planned maintenance window.

"NMP2 is in Mode 5, refueling. Compensatory actions remain in effect in accordance with the Off-Site Dose Calculation Manual. Expected return to service is 4/5/14.

"This event is being reported in accordance with 10 CFR 50.72 (b)(3)(xiii) due to a loss of assessment capability."

The licensee notified the NRC Resident Inspector.

STACK RADIATION MONITOR REMOVED FROM SERVICE FOR PRE-PLANNED MAINTENANCE

The Millstone Station Stack Radiation Monitor, RM-8169 was removed from service for pre-planned maintenance. This is reportable as a loss of assessment capability in accordance with 10 CFR 50.72 (b)(3)(xiii).

RM-8169 was restored following pre-planned maintenance at 1150 EDT on 4/4/2014.

The licensee notified the NRC Resident Inspector and applicable State and local agencies.

CRITICALITY ACCIDENT EVACUATION ALARM NOT AUDIBLE IN CERTAIN AREAS OUTSIDE THE MATERIAL HANDLING AREA

"At approximately 1315 hours (Eastern Daylight Time) on April 4, 2014, while testing the audibility of the criticality accident evacuation alarm in the Building locker room, a report was made that the alarm could not be heard in an office trailer restroom. Subsequent testing confirmed the evacuation alarm could not be heard in the office trailer restroom when the fan was running. Safety management personnel were notified of the problem and other restrooms were tested. Testing revealed that the alarm was not able to be heard in three (3) additional office trailer restrooms. All affected restrooms were posted with signs indicating the areas are not to be occupied pending resolution of the audibility issue. It should be noted that the restrooms are located outside of the material processing areas.

"The licensee notified the NRC Resident Inspector."

See similar event EN #49848.

AGREEMENT STATE REPORT - CAMERA SOURCE DISCONNECT

The following information was received by facsimile from the State of Texas:

"On April 14, 2014, the Agency [Texas Department of State Health Services] was notified by the licensee's Corporate Radiation Safety Officer (CRSO) that one of their radiography crews had experienced source disconnect while using an INC IR 100 exposure device. The device contains a 70 curie iridium - 192 source. The CRSO stated the radiographers had completed a shot and noted the dose rates on the camera had not returned to normal after retracting the source. The radiographers increased the barriers around the exposure device and contacted their supervisor for assistance. The CRSO stated the source had been recovered by an individual listed on their license to retrieve sources. The CRSO stated he did not believe any individual received an exposure which exceeded any limits. The CRSO stated no member of the general public received any exposure. The CRSO stated he had just learned of the event and was beginning his investigation and would provide the Agency with additional information as it was obtained. This Agency will provide additional information as it is received in accordance with SA-300."

Texas Incident: I-9178

SEISMIC MONITOR DECLARED NON-FUNCTIONAL DUE TO SPURIOUS ALARM

"At 1453 CDT on April 04, 2014, the station's Seismic Monitor generated a seismic event alarm that was determined to be invalid based upon no recorded readings above alarm setpoint, no seismic activity being felt on site, and no activity detected by National Earthquake Information Center or Monticello Nuclear Generating Plant. The monitor was declared non-functional since it would not generate a control board seismic event alarm during an actual event until the invalid event was reset. This monitor has no credited compensatory measure that will allow timely classification of two Emergency Action Levels (EALs), NUE (Notification of Unusual Event) and Alert classifications when out of service. This results in a Loss of Emergency Assessment Capability while the Seismic Monitor is out of service. This is a reportable condition in accordance with 10 CFR 50.72(b)(3)(xiii).

"Maintenance has reset the alarm and has evaluated the monitor's performance. The alarm has been determined to be spurious. The monitor is working properly and will generate a control board alarm during an actual event, as determined by observed normal operation and the lack of any self-diagnostic error messages. At 1900 CDT on April 04, 2014 the monitor was declared functional and returned to service.

"There was no seismic activity during the out of service period indicated by the local seismic monitor display and no reports of seismic activity were reported to the site by National Earthquake Information Center or Monticello Nuclear Generating Plant. This event did not adversely affect the safe operation of the plant or health and safety of the public.

"The licensee has notified the NRC Resident Inspector."

AGREEMENT STATE REPORT - SCRAP FACILITY GATE ALARM

"On 04/04/14 at approximately 1430 MDT, the Colorado Radiation Program received phone notification of a scrap load that had been rejected at a recycling facility in Englewood, CO due to a gate radiation alarm. Scrap facility personnel performed surveys around the container using hand held survey instruments. Surveys indicated readings up to a maximum of 120 microrem/hour (Ludlum Model 3). Recycling facility staff indicated that the load would not be returned to the shipper until the following week and that the load/roll-off container was segregated onsite. The Colorado Radiation Program issued a DOT special permit and the scrap metal was returned to the originator, Baker-Hughes (Colorado License No. 678-01; 285 County Road 27, Brighton, CO 80603) on or about 04/11/14.

"Preliminary communications with Baker-Hughes personnel indicated that it performed well fracking work in mid-March 2014 and worked with another Colorado licensee - well logging tracer company, Protechnics (Colorado License No. 545-01; 703 Greenway Drive, Fruita, CO 81521). Baker-Hughes is not authorized for tracer material use. Baker-Hughes requested that Protechnics perform surveys on the rejected scrap load to determine whether the contamination was naturally occurring radioactive material, or tracer material. Protechnics performed radiological surveys on or about 04/15/14 at the Baker-Hughes facility and determined that a small amount of tracer material remained in one component (a manifold removed from the pumping truck) of the scrap load. Protechnics identified the tracer material as Iridium-192. The tracer material combined with approximately 10 lbs. of fracking sand was removed/decontaminated from the scrap component and was packaged by Protechnics and returned to their facility in Fruita, CO for decay in storage. Protechnics estimated the activity of Ir-192 tracer material in the component to be approximately 0.015 mCi. After receiving a preliminary written report from Protechnics on 04/16/14, Colorado Radiation Program staff performed phone interviews of Baker-Hughes personnel and Protechnics personnel.

"Colorado Radiation Program staff performed on-site verification surveys of the scrap load (post-decontamination) on 04/21/14. Surveys indicated that no radiation levels above instrument background were detected on the remaining decontaminated scrap.

"The Colorado Radiation Program is continuing to investigate the incident to determine further actions."