Event Notification Report for May 22, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/21/2014 - 05/22/2014
EVENT NUMBERS
50135501305013150132
Agreement State
Event Number: 50135
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NEBRASKA METHODIST HOSPITAL
Region: 4
City: LINCOLN State: NE
County:
License #: 01-07-02
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DANIEL MILLS
Licensee: NEBRASKA METHODIST HOSPITAL
Region: 4
City: LINCOLN State: NE
County:
License #: 01-07-02
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/23/2014
Notification Time: 16:05 [ET]
Event Date: 05/22/2014
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2014
Notification Time: 16:05 [ET]
Event Date: 05/22/2014
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISCALCULATION
The following was received from the State of Nebraska via fax:
"At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem."
Nebraska Item Number: NE140004
* * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *
The following was received from the State of Nebraska via email:
"In a letter dated June 3, 2014, the RSO/Medical Physicist from Nebraska Methodist Hospital updated the information for this incident. The implanted dose was 184 Gray. The dose to the organ at risk (rectum) is as follows: Only a small percentage of the entire organ (rectum) was imaged and contoured, in the plan that was 12cc. An estimate of the increased dose ranges from 16 Gray in the highest dose regions comprising 90% of the contoured volume and 27 Gray in the highest dose regions comprising 30% of the contoured volume.
"The patient was informed within 24 hours of the discovery of the misadministration."
Notified R4DO (Hay) and FSME Event Resource via email.
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 Nebraska via fax:
"At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem."
Nebraska Item Number: NE140004
* * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *
The following was received from the State of Nebraska via email:
"In a letter dated June 3, 2014, the RSO/Medical Physicist from Nebraska Methodist Hospital updated the information for this incident. The implanted dose was 184 Gray. The dose to the organ at risk (rectum) is as follows: Only a small percentage of the entire organ (rectum) was imaged and contoured, in the plan that was 12cc. An estimate of the increased dose ranges from 16 Gray in the highest dose regions comprising 90% of the contoured volume and 27 Gray in the highest dose regions comprising 30% of the contoured volume.
"The patient was informed within 24 hours of the discovery of the misadministration."
Notified R4DO (Hay) and FSME Event Resource via email.
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: 50130
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: STEVE NICOLAOS
HQ OPS Officer: JEFF ROTTON
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: STEVE NICOLAOS
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/22/2014
Notification Time: 09:31 [ET]
Event Date: 05/22/2014
Event Time: 02:10 [EDT]
Last Update Date: 05/22/2014
Notification Time: 09:31 [ET]
Event Date: 05/22/2014
Event Time: 02:10 [EDT]
Last Update Date: 05/22/2014
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):
HAROLD GRAY (R1DO)
HAROLD GRAY (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 65 | Power Operation | 65 | Power Operation |
UNPLANNED ISOLATION OF REACTOR BUILDING VENTILATION RADIATION MONITOR
"At 0210 [EDT] on May 22, 2014, Nine Mile Point Unit 2, the reactor building vent radiation monitor (Vent WRGMS) was removed from service due to a problem with the check source.
"The unplanned isolation of Vent WRGMS is a 8-hour report for 10 CFR 50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability.
"Until the equipment is restored, Chemistry will perform sampling requirements per the ODCM.
"The NRC Resident Inspector has been notified."
The licensee notified the State of New York Public Service Commission.
"At 0210 [EDT] on May 22, 2014, Nine Mile Point Unit 2, the reactor building vent radiation monitor (Vent WRGMS) was removed from service due to a problem with the check source.
"The unplanned isolation of Vent WRGMS is a 8-hour report for 10 CFR 50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability.
"Until the equipment is restored, Chemistry will perform sampling requirements per the ODCM.
"The NRC Resident Inspector has been notified."
The licensee notified the State of New York Public Service Commission.
Power Reactor
Event Number: 50131
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: DANIEL BACKUS
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: DANIEL BACKUS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/22/2014
Notification Time: 09:34 [ET]
Event Date: 05/22/2014
Event Time: 07:08 [CDT]
Last Update Date: 05/22/2014
Notification Time: 09:34 [ET]
Event Date: 05/22/2014
Event Time: 07:08 [CDT]
Last Update Date: 05/22/2014
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):
STEVE ORTH (R3DO)
STEVE ORTH (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
PLANNED MAINTENANCE ON THE AUXILIARY BUILDING SERVICE WATER RETURN MONITOR
"On May 22, 2014 at 0708 CDT, Kewaunee Power Station rendered the Auxiliary Building Service Water Return Monitor (R-20) nonfunctional for planned maintenance. R-20 is used for Emergency Action Level (EAL) classifications of an unplanned release of liquid radioactivity to the environment that would result in an Alert or Unusual Event and is being conservatively reported under 10CFR50.72(b)(3)(xiii) as a loss of emergency assessment capability.
"R-20 is planned to be restored to functional by 1530 CDT today, 05/22/2014.
"The NRC Regional Inspector has been notified."
"On May 22, 2014 at 0708 CDT, Kewaunee Power Station rendered the Auxiliary Building Service Water Return Monitor (R-20) nonfunctional for planned maintenance. R-20 is used for Emergency Action Level (EAL) classifications of an unplanned release of liquid radioactivity to the environment that would result in an Alert or Unusual Event and is being conservatively reported under 10CFR50.72(b)(3)(xiii) as a loss of emergency assessment capability.
"R-20 is planned to be restored to functional by 1530 CDT today, 05/22/2014.
"The NRC Regional Inspector has been notified."
Power Reactor
Event Number: 50132
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM STRICKLAND
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM STRICKLAND
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/23/2014
Notification Time: 01:01 [ET]
Event Date: 05/22/2014
Event Time: 21:50 [CDT]
Last Update Date: 05/23/2014
Notification Time: 01:01 [ET]
Event Date: 05/22/2014
Event Time: 21:50 [CDT]
Last Update Date: 05/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
STEVE ORTH (R3DO)
STEVE ORTH (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
BOTH HPCI SECONDARY CONTAINMENT AIRLOCK DOORS OPEN SIMULTANEOUSLY
"On May 22, 2014, at 2150 hours, the Shift Manager was notified that both HPCI Secondary Containment interlock doors were open simultaneously. The doors were immediately closed and Secondary Containment pressure remained negative.
"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2 given two doors in a single access opening were open. As a result, entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to Secondary Containment being inoperable.
"This event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Resident Inspector has been notified."
"On May 22, 2014, at 2150 hours, the Shift Manager was notified that both HPCI Secondary Containment interlock doors were open simultaneously. The doors were immediately closed and Secondary Containment pressure remained negative.
"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.2 given two doors in a single access opening were open. As a result, entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to Secondary Containment being inoperable.
"This event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Resident Inspector has been notified."