Event Notification Report for August 14, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/13/2014 - 08/14/2014
EVENT NUMBERS
50372503705036850364
Agreement State
Event Number: 50372
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: OHIO STATE UNIVERSITY MEDICAL CENTER
Region: 3
City: COLUMBUS State: OH
County: FRANKLIN
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DANIEL MILLS
Licensee: OHIO STATE UNIVERSITY MEDICAL CENTER
Region: 3
City: COLUMBUS State: OH
County: FRANKLIN
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/15/2014
Notification Time: 14:53 [ET]
Event Date: 08/14/2014
Event Time: 00:00 [EDT]
Last Update Date: 08/15/2014
Notification Time: 14:53 [ET]
Event Date: 08/14/2014
Event Time: 00:00 [EDT]
Last Update Date: 08/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE TO LIVER
The following was received from the State of Ohio via email:
"The licensee prepared and delivered a therapeutic dose of TheraSpheres to a patient's liver on August 14, 2014. The written directive was for 120 Gy to the liver with 27 mCi of Y-90 TheraSpheres. On August 15, 2014, the licensee discovered that 20% of the dose that was supposed to be administered to the patient was still in the bottom of the vial. Although the licensee prepared the vial in accordance with the manufacturer's instructions, 20% of the TheraSpheres remained in the bottom of the vial and did not go into suspension.
"The patient and referring physician have been notified.
"The Bureau [Ohio Bureau of Radiation Protection] will be conducting a follow-up investigation regarding this event."
The patient received 96 Gy to the liver instead of the prescribed 120 Gy.
Ohio incident # OH140010
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:
"The licensee prepared and delivered a therapeutic dose of TheraSpheres to a patient's liver on August 14, 2014. The written directive was for 120 Gy to the liver with 27 mCi of Y-90 TheraSpheres. On August 15, 2014, the licensee discovered that 20% of the dose that was supposed to be administered to the patient was still in the bottom of the vial. Although the licensee prepared the vial in accordance with the manufacturer's instructions, 20% of the TheraSpheres remained in the bottom of the vial and did not go into suspension.
"The patient and referring physician have been notified.
"The Bureau [Ohio Bureau of Radiation Protection] will be conducting a follow-up investigation regarding this event."
The patient received 96 Gy to the liver instead of the prescribed 120 Gy.
Ohio incident # OH140010
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: 50370
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEREMY COBBS
HQ OPS Officer: JEFF ROTTON
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEREMY COBBS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/15/2014
Notification Time: 01:19 [ET]
Event Date: 08/14/2014
Event Time: 16:31 [PDT]
Last Update Date: 08/15/2014
Notification Time: 01:19 [ET]
Event Date: 08/14/2014
Event Time: 16:31 [PDT]
Last Update Date: 08/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(B) - POT RHR INOP
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
JACK WHITTEN (R4DO)
JACK WHITTEN (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 63 | Power Operation |
UNIT 2 TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO MULTIPLE INOPERABLE EMERGENCY DIESEL GENERATORS
"While performing scheduled maintenance on Unit 2 Emergency Diesel Generator (EDG) 2-2, Diablo Canyon Power Plant (DCPP) identified a failed capscrew on engine cylinder 1L. As part of subsequent inspections to determine whether a similar condition existed on any of the other Unit 1 or Unit 2 EDGs, a degraded capscrew was identified on EDG 2-3 cylinder 8L at 1631 PDT on 08/14/2014. No capscrew issues were identified on the Unit 1 EDGs or on Unit 2 EDG 2-1. Although all operational tests of the diesels up to the time of discovery were satisfactorily performed with no indication of degraded performance, the EDG 2-3 was declared inoperable.
"Because two Unit 2 EDGs were inoperable concurrently, this is being reported as a condition that could have prevented fulfillment of a safety function per 10 CFR 50.72(b)(3)(v). Per the requirements of TS 3.8.1, with two EDGs inoperable, a plant shutdown was commenced at 2031 PDT on 08/14/2014. Therefore, this condition is also being reported in accordance with 10 CFR 50.72(b)(2)(i).
"Offsite power remained available throughout this condition. EDG 2-2 remains out of service as part of its scheduled maintenance window.
"This condition did not result in any adverse impact on the health and safety of the public.
"A press release is planned.
"The licensee informed the NRC Resident Inspector."
The licensee also reported event notifications for 10 CFR 50.72(b)(3)(v)(C) - Control of Rad Release and 10 CFR 50.72(b)(3)(v)(D) - Accident Mitigation.
The licensee plans to continue the shutdown to Mode 3 and is developing plans to return one of the two inoperable EDGs to operable status by the time the unit reaches Mode 5.
"While performing scheduled maintenance on Unit 2 Emergency Diesel Generator (EDG) 2-2, Diablo Canyon Power Plant (DCPP) identified a failed capscrew on engine cylinder 1L. As part of subsequent inspections to determine whether a similar condition existed on any of the other Unit 1 or Unit 2 EDGs, a degraded capscrew was identified on EDG 2-3 cylinder 8L at 1631 PDT on 08/14/2014. No capscrew issues were identified on the Unit 1 EDGs or on Unit 2 EDG 2-1. Although all operational tests of the diesels up to the time of discovery were satisfactorily performed with no indication of degraded performance, the EDG 2-3 was declared inoperable.
"Because two Unit 2 EDGs were inoperable concurrently, this is being reported as a condition that could have prevented fulfillment of a safety function per 10 CFR 50.72(b)(3)(v). Per the requirements of TS 3.8.1, with two EDGs inoperable, a plant shutdown was commenced at 2031 PDT on 08/14/2014. Therefore, this condition is also being reported in accordance with 10 CFR 50.72(b)(2)(i).
"Offsite power remained available throughout this condition. EDG 2-2 remains out of service as part of its scheduled maintenance window.
"This condition did not result in any adverse impact on the health and safety of the public.
"A press release is planned.
"The licensee informed the NRC Resident Inspector."
The licensee also reported event notifications for 10 CFR 50.72(b)(3)(v)(C) - Control of Rad Release and 10 CFR 50.72(b)(3)(v)(D) - Accident Mitigation.
The licensee plans to continue the shutdown to Mode 3 and is developing plans to return one of the two inoperable EDGs to operable status by the time the unit reaches Mode 5.
Agreement State
Event Number: 50368
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COLORADO STATE UNIVERSITY
Region: 4
City: FORT COLLINS State: CO
County:
License #: CO 002-19
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: DANIEL MILLS
Licensee: COLORADO STATE UNIVERSITY
Region: 4
City: FORT COLLINS State: CO
County:
License #: CO 002-19
Agreement: Y
Docket:
NRC Notified By: JAMES GRICE
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/14/2014
Notification Time: 17:16 [ET]
Event Date: 08/14/2014
Event Time: 14:45 [MDT]
Last Update Date: 08/14/2014
Notification Time: 17:16 [ET]
Event Date: 08/14/2014
Event Time: 14:45 [MDT]
Last Update Date: 08/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VIVIAN CAMPBELL (R4DO)
FSME EVENTS RESOURCE (EMAI)
VIVIAN CAMPBELL (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - INOPERABILITY OF THE ACCESS CONTROL SYSTEM
The following was received from the State of Colorado via email:
"CDPHE [Colorado Department of Public Health] received telephone notification of an inoperability of the access control system on 8/14/2014 at approximately 1445 [MDT]. Colorado State University, a research licensee, reported that a radiation monitor provided to detect the presence of high radiation levels in the radiation room of a panoramic irradiator was alarming when there was no [abnormal] radiation level present. One of the irradiator users noticed the audible alarm when their work was complete and they were leaving the area. The RSO responded and suspected a stuck source. Using a hand held radiation detection instrument, the irradiator door was opened and the irradiator room was entered. As the RSO entered the room there was no indication of radiation levels above what was expected when the source is in its shielded position, and as a result, it was determined that the source was in its shielded position. The room radiation monitor was reset but shortly after again alarmed without any [abnormal] radiation field present. The irradiator has been taken out of service and the monitor has been removed for repair."
Colorado event report ID: CO14-I14-22
The following was received from the State of Colorado via email:
"CDPHE [Colorado Department of Public Health] received telephone notification of an inoperability of the access control system on 8/14/2014 at approximately 1445 [MDT]. Colorado State University, a research licensee, reported that a radiation monitor provided to detect the presence of high radiation levels in the radiation room of a panoramic irradiator was alarming when there was no [abnormal] radiation level present. One of the irradiator users noticed the audible alarm when their work was complete and they were leaving the area. The RSO responded and suspected a stuck source. Using a hand held radiation detection instrument, the irradiator door was opened and the irradiator room was entered. As the RSO entered the room there was no indication of radiation levels above what was expected when the source is in its shielded position, and as a result, it was determined that the source was in its shielded position. The room radiation monitor was reset but shortly after again alarmed without any [abnormal] radiation field present. The irradiator has been taken out of service and the monitor has been removed for repair."
Colorado event report ID: CO14-I14-22
Power Reactor
Event Number: 50364
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: DAMON HESSIG
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: DAMON HESSIG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/14/2014
Notification Time: 08:58 [ET]
Event Date: 08/14/2014
Event Time: 07:55 [CDT]
Last Update Date: 08/14/2014
Notification Time: 08:58 [ET]
Event Date: 08/14/2014
Event Time: 07:55 [CDT]
Last Update Date: 08/14/2014
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):
CHRISTINE LIPA (R3DO)
CHRISTINE LIPA (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 89 | Power Operation | 89 | Power Operation |
SERVICE WATER RADIATION MONITOR NONFUNCTIONAL FOR PLANNED MAINTENANCE
"The service water radiation monitor system will be rendered nonfunctional during planned preventive maintenance. As a result, this represents a loss of emergency assessment capability and is reportable per 10CFR50.72(b)(3)(xiii). The planned maintenance is expected to last 4 hours. During this time, plant parameters will be monitored and sampling will be performed which will support sustaining the health and safety of the public during this planned maintenance activity.
"The NRC Resident Inspector will be notified prior to removing the service water radiation monitor from service."
"The service water radiation monitor system will be rendered nonfunctional during planned preventive maintenance. As a result, this represents a loss of emergency assessment capability and is reportable per 10CFR50.72(b)(3)(xiii). The planned maintenance is expected to last 4 hours. During this time, plant parameters will be monitored and sampling will be performed which will support sustaining the health and safety of the public during this planned maintenance activity.
"The NRC Resident Inspector will be notified prior to removing the service water radiation monitor from service."