Event Notification Report for October 02, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/01/2015 - 10/02/2015
EVENT NUMBERS
51442514395144051476
Agreement State
Event Number: 51442
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: WAKE FOREST BAPTIST HEALTH
Region: 1
City: WINSTON-SALEM State: NC
County:
License #: 034-0158-8
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: WAKE FOREST BAPTIST HEALTH
Region: 1
City: WINSTON-SALEM State: NC
County:
License #: 034-0158-8
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/02/2015
Notification Time: 17:59 [ET]
Event Date: 10/02/2015
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2015
Notification Time: 17:59 [ET]
Event Date: 10/02/2015
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO INCORRECT LOCATION
The following report was received via e-mail:
"A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015.
"The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency [North Carolina Division of Health and Human Services] scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee.
"Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time."
North Carolina NMED #NC150026
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 via e-mail:
"A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015.
"The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency [North Carolina Division of Health and Human Services] scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee.
"Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time."
North Carolina NMED #NC150026
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: 51439
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: LAUREL KETCHAM
HQ OPS Officer: JOHN SHOEMAKER
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: LAUREL KETCHAM
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/02/2015
Notification Time: 10:27 [ET]
Event Date: 10/02/2015
Event Time: 09:05 [CDT]
Last Update Date: 10/03/2015
Notification Time: 10:27 [ET]
Event Date: 10/02/2015
Event Time: 09:05 [CDT]
Last Update Date: 10/03/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
NICK TAYLOR (R4DO)
MARC DEPAS (RA)
BILL DEAN (NRR)
BRIAN HOLIAN (NSIR)
ROB LEWIS (NSIR)
NICK TAYLOR (R4DO)
MARC DEPAS (RA)
BILL DEAN (NRR)
BRIAN HOLIAN (NSIR)
ROB LEWIS (NSIR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF UNUSUAL EVENT
At 0905 CDT on 10/02/15, Ft. Calhoun Station declared a Notification of Unusual Event based on criteria in the site security plan.
The licensee notified State and local agencies and the NRC Resident Inspector.
Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.
* * * UPDATE FROM LAUREL KETCHAM TO DANIEL MILLS AT 1214 EDT ON 10/02/15 * * *
At 1136 CDT, the Unusual Event was terminated based on the fact that criteria for entry into the site security plan no longer exists.
The licensee notified State and local agencies and the NRC Resident Inspector.
Notified R4DO (Taylor), R4RA (Dapas), NRR ET (Dean), NSIR ET (Holian), NSIR (Lewis, Stapleton), ILTAB (Johnson), IRD MOC (Gott).
Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.
At 0905 CDT on 10/02/15, Ft. Calhoun Station declared a Notification of Unusual Event based on criteria in the site security plan.
The licensee notified State and local agencies and the NRC Resident Inspector.
Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.
* * * UPDATE FROM LAUREL KETCHAM TO DANIEL MILLS AT 1214 EDT ON 10/02/15 * * *
At 1136 CDT, the Unusual Event was terminated based on the fact that criteria for entry into the site security plan no longer exists.
The licensee notified State and local agencies and the NRC Resident Inspector.
Notified R4DO (Taylor), R4RA (Dapas), NRR ET (Dean), NSIR ET (Holian), NSIR (Lewis, Stapleton), ILTAB (Johnson), IRD MOC (Gott).
Notified DHS SWO, DHS NICC, FEMA, and Nuclear SSA via email.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 51440
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: CHRIS ROBINSON
HQ OPS Officer: MARK ABRAMOVITZ
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: CHRIS ROBINSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/02/2015
Notification Time: 14:50 [ET]
Event Date: 10/02/2015
Event Time: 08:25 [EDT]
Last Update Date: 11/20/2015
Notification Time: 14:50 [ET]
Event Date: 10/02/2015
Event Time: 08:25 [EDT]
Last Update Date: 11/20/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
STEVE ORTH (R3DO)
STEVE ORTH (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
LOOSE SAFETY RELIEF VALVE DISCHARGE FLANGE BOLTS
"On October 2nd, at approximately 0825 EDT, maintenance technicians were performing as-found torque checks on the discharge flange of the 'B' Safety Relief Valve (SRV). 12 of the 16 bolts were not adequately torqued. The 'B' Safety Relief Valve is credited for Remote Shutdown. The as-found condition of inadequate torque potentially impacts the seismic qualification of the 'B' SRV.
"An investigation and extent of condition review is ongoing. The NRC Resident Inspector has been notified."
Before the outage, there were no abnormal indications of leakage as indicated by a rise in drywell temperature or pressure. The SRVs had been cycled under pressure with no abnormal indications.
The four bolts that were tight were in a diagonal pattern. The looses bolts were described as "finger tight." The licensee is determining the actions to take regarding the remaining 14 SRVs.
* * * RETRACTION FROM STEVE WARD TO DONALD NORWOOD AT 1552 EST ON 11/20/2015 * * *
"As part of the event investigation and extent of condition review, the as-found torque values of the inlet and outlet Safety Relief Valve (SRV) flange connections were measured and an engineering evaluation of the as-found condition was performed. The evaluation confirmed that all 15 SRVs would have remained operable during a design basis earthquake. Any potential discharge flange connection leakage during SRV operation would be bounded by the design basis Loss of Coolant Accident analysis described in the UFSAR.
"Subsequent investigation activities of the as-found condition of SRV 'B' determined that the four tight bolts were not oriented in a diagonal pattern across the discharge flange as originally reported. This information is provided only to clarify previously reported information and does not affect the original basis for reporting or the current basis for retraction."
The licensee notified the NRC Resident Inspector.
Notified R3DO (McCraw).
"On October 2nd, at approximately 0825 EDT, maintenance technicians were performing as-found torque checks on the discharge flange of the 'B' Safety Relief Valve (SRV). 12 of the 16 bolts were not adequately torqued. The 'B' Safety Relief Valve is credited for Remote Shutdown. The as-found condition of inadequate torque potentially impacts the seismic qualification of the 'B' SRV.
"An investigation and extent of condition review is ongoing. The NRC Resident Inspector has been notified."
Before the outage, there were no abnormal indications of leakage as indicated by a rise in drywell temperature or pressure. The SRVs had been cycled under pressure with no abnormal indications.
The four bolts that were tight were in a diagonal pattern. The looses bolts were described as "finger tight." The licensee is determining the actions to take regarding the remaining 14 SRVs.
* * * RETRACTION FROM STEVE WARD TO DONALD NORWOOD AT 1552 EST ON 11/20/2015 * * *
"As part of the event investigation and extent of condition review, the as-found torque values of the inlet and outlet Safety Relief Valve (SRV) flange connections were measured and an engineering evaluation of the as-found condition was performed. The evaluation confirmed that all 15 SRVs would have remained operable during a design basis earthquake. Any potential discharge flange connection leakage during SRV operation would be bounded by the design basis Loss of Coolant Accident analysis described in the UFSAR.
"Subsequent investigation activities of the as-found condition of SRV 'B' determined that the four tight bolts were not oriented in a diagonal pattern across the discharge flange as originally reported. This information is provided only to clarify previously reported information and does not affect the original basis for reporting or the current basis for retraction."
The licensee notified the NRC Resident Inspector.
Notified R3DO (McCraw).
Agreement State
Event Number: 51476
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOURCE PRODUCTION AND EQUIPMENT COMPANY, INC.
Region: 4
City: ST. ROSE State: LA
County:
License #: LA-2966-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JEFF ROTTON
Licensee: SOURCE PRODUCTION AND EQUIPMENT COMPANY, INC.
Region: 4
City: ST. ROSE State: LA
County:
License #: LA-2966-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/16/2015
Notification Time: 14:19 [ET]
Event Date: 10/02/2015
Event Time: 15:00 [CDT]
Last Update Date: 10/16/2015
Notification Time: 14:19 [ET]
Event Date: 10/02/2015
Event Time: 15:00 [CDT]
Last Update Date: 10/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
LOUISIANA AGREEMENT STATE REPORT - RADIATION WORKERS CONTAMINATED WHILE WORKING IN HOT CELL
The following information was received from the State of Louisiana via email:
"On October 02, 2015, around 1500 CDT, Source Production & Equipment Company [SPEC] was manufacturing a 30 Curie sealed Co-60 source within Hot Cell Number 2. During the welding process of double encapsulating the sealed source the welder malfunctioned. Two radiation workers within Hot Cell Number 2, behind the room divider, attempted to grind off the ruined outer encapsulation.
"The result was two workers inhaled Co-60 material. Nasal swipes indicated 11,743 cpm on the highest wipe. It was initially calculated internal exposure of around 200 mRem.
"The event was basically contained to Hot Cell Number 2 except for some footprints outside the cell which were remediated. The Hot Cell is currently restricted because of contamination.
"The workers have had two whole body scans on 10/07/15 and 10/12/15 with a third scan planned for 10/19/15.
"Currently internal exposure from inhalation has been calculated to be 373 mRem from 2.3 microCi of Co-60. The other worker's calculated exposure was 80 mRem from 0.42 microCi of Co-60.
"SPEC has enacted a policy in regards to this event to no longer allow reworking a ruined source during manufacturing by grinding on it. They will just retire/dispose of that source and get a new source to work with."
The licensee is also collecting bioassay samples from both workers for analysis.
LA Event Report ID NO.: LA150017
The following information was received from the State of Louisiana via email:
"On October 02, 2015, around 1500 CDT, Source Production & Equipment Company [SPEC] was manufacturing a 30 Curie sealed Co-60 source within Hot Cell Number 2. During the welding process of double encapsulating the sealed source the welder malfunctioned. Two radiation workers within Hot Cell Number 2, behind the room divider, attempted to grind off the ruined outer encapsulation.
"The result was two workers inhaled Co-60 material. Nasal swipes indicated 11,743 cpm on the highest wipe. It was initially calculated internal exposure of around 200 mRem.
"The event was basically contained to Hot Cell Number 2 except for some footprints outside the cell which were remediated. The Hot Cell is currently restricted because of contamination.
"The workers have had two whole body scans on 10/07/15 and 10/12/15 with a third scan planned for 10/19/15.
"Currently internal exposure from inhalation has been calculated to be 373 mRem from 2.3 microCi of Co-60. The other worker's calculated exposure was 80 mRem from 0.42 microCi of Co-60.
"SPEC has enacted a policy in regards to this event to no longer allow reworking a ruined source during manufacturing by grinding on it. They will just retire/dispose of that source and get a new source to work with."
The licensee is also collecting bioassay samples from both workers for analysis.
LA Event Report ID NO.: LA150017