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Event Notification Report for August 26, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2010 - 08/26/2010

** EVENT NUMBERS **


46189 46193 46200 46204 46205 46206

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General Information or Other Event Number: 46189
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2010
Notification Time: 16:56 [ET]
Event Date: 08/18/2010
Event Time: [CDT]
Last Update Date: 08/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK VALOS (R3DO)
MARK DELLIGATTI (FSME)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTRIUM-90 UNDER DOSE

The following information was obtained from the State of Illinois via email:

"On the afternoon of August 18, [REDACTED], the licensee's Radiation Safety Officer [RSO] called the Agency [Illinois Emergency Management Agency] to report a medical event in accordance with 32 Ill. Adm. Code 336.1080. The licensee was conducting a treatment involving the use of colloidal Y-90 'SIR-Spheres' under consultation with the manufacturer's representative. A dose of 15.4 milliCi was prescribed by the authorized user and the entire volume of material appeared to be delivered without any unexpected complications, including a complete repeated flushing of the delivery line. However, measurements of the associated tubing, vial and other contaminated items in accordance with accepted procedures showed a notable quantity of Y-90 remained. It was subsequently determined that the dose received was less than 80% of the intended dose. [The RSO] contacted the Agency within the prescribed notification period after verifying the measurements and calculations. The Medical Center also notified the attending physician and the patient the same day. Estimates are that 72% [11.1 milliCi] of the intended dose was delivered.

"[The RSO] was advised of the regulatory reporting requirements and was beginning preparations for providing that information. Initially, it is believed that the underdose will not have any adverse effect on the patient. The prescribed treatment was intended as a palliative measure for liver tumors secondary to colon cancer. [The RSO] was asked to obtain the opinion of the manufacturer's rep as to the cause of the underdose and any recommended corrective actions the manufacturer suggests in these treatments. [The RSO] was also requested to provide the initial corrective action the hospital intends to take for this and subsequent treatments.

"A separate conversation was held with the authorized physician user [REDACTED] who attended and oversaw the patient treatment. [The physician] advised that there were no spills, leaks, adverse patient reactions or shunting of the dose outside of the hepatic artery that led to the underdose. Comments from all involved at the time of the treatment, including the manufacturer's representative, was that the administration of the palliative treatment was as good as could be expected and there were no visual indications that any anomalies were present in delivery of the dose. Patient will undergo PET and CT scans in 6 weeks and 12 weeks respectively to determine if any additional actions are warranted such as making up the difference in dose, conducting a repeat of the treatment or if taking no action at all is appropriate. The overriding issue will be the patient's general quality of life. At this point, preliminary indications are that no changes in procedures or processes are necessary and that general delivery system design, coupled with characteristics of material to be administered, resulted in the unintended coagulation and accumulation of microspheres either within the Sir-Sphere three way stopcock or the microcatheter despite routine agitation of the suspension delivery vial."

Illinois Case Number: IL10055

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.

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General Information or Other Event Number: 46193
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA - STANFORD
Region: 4
City: STANFORD State: CA
County:
License #: 0676-43
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2010
Notification Time: 21:00 [ET]
Event Date: 08/16/2010
Event Time: [PDT]
Last Update Date: 08/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
MARK DELLIGATTI (FSME)
ILTAB VIA EMAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received from the State of California via email:

"On 08/20/10, the ARSO at Stanford University called and informed RHB [California Department of Public Health - Radiologic Health Branch] of the following:

"On 8/16/10, it was discovered that one of our Contractors, Vance Brown, lost control of 28 signs they removed from two buildings (Building 05-600 Moore South (row 475) and Building 05-610 Moore North (row 493). The signs were placed into a plastic bin and Vance Brown cannot determine what happened to them.

"Representatives from Vance Brown and Redwood City Electric, the electrical subcontractor who removed the signs, conducted an investigation to determine the fate of the signs. They determined that while the signs had been removed and stored properly awaiting disposal by EH&S [Stanford University Environmental Health and Safety], they vanished from the secured construction site at an undetermined time between 6/28/2010 and 8/16/10.

"EH&S met with representatives from Vance Brown and Redwood City Electric on 8/19/10. Several avenues were explored during the meeting. Vance Brown explained that the site was broken into on 7/29/2010 and several tools and other valuables were stolen. Vance Brown filed a police report, but did not notice the signs missing at that time. Vance Brown and Redwood City Electric also questioned their employees, reviewed truck logs, and looked through both construction site storage containers and their off-site warehouses.

"Stanford EH&S has also conducted an internal investigation to determine if any Stanford employees had picked up the signs. None had. Stanford EH&S also queried the waste hauler used by Redwood City Electric (Quick Light Recycle) who stated they had not picked up the signs.

"At this time Vance Brown and Stanford EH&S has exhausted potential locations for the plastic bin of 28 tritium exit signs and considers them to be lost and/or missing. "

California Report No.: 5010-082010

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 46200
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: SHIVE-HATTERY INC
Region: 3
City: CAMANCHE State: IA
County:
License #: 0174152PG
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: JOE O'HARA
Notification Date: 08/23/2010
Notification Time: 16:21 [ET]
Event Date: 08/20/2010
Event Time: [CDT]
Last Update Date: 08/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT - TROXLER MOISTURE DENSITY GAUGE MODEL 3411B DAMAGED AT CONSTRUCTION SITE

The following was received from the State of Iowa via e-mail:

"The licensee reported [to the IDPH (Iowa Department of Public Health)] on Saturday, August 21, 2010 of an event that occurred the previous day. A Troxler, model 3411B moisture/density gauge was run over at a temporary job site in Camanche, Iowa by a large dump truck. The construction vehicle was backing up and the driver did not see the gauge or the gauge user. The licensee's RSO reported the following to IDPH on August 23, 2010. The source rod was severed from the handle at the upper weld. The index rod was bent, and two of the faceplate screws were bent. The source rod was lifted up by hand and brought back into the gauge (safe position, with the exception that the source rod could pull completely out the top of the gauge). The bottom shutter closed as usual. No physical damage to the source rod was evident on the bottom half of the source rod. A leak test was completed on the gauge and the swabs were overnighted to Qal-Tek Associates (3998 Commerce Cr. Idaho Falls,
Idaho 83401) on Friday night. Once the results are known, delivery of the gauge will be made to Qal-Tek to repair the gauge or dispose of as required. Direction will be given to us [IDPH] from Qal-Tek based on the leak test results. They are a certified disposal site. A survey was conducted on the soil surrounding the site of the accident. Based on a background radiation check 200' away from the site, no change in reading was observed at the actual accident site. The survey meter was also used to check the gauge itself compared to another gauge with a current leak test that had passed, and no change in reading was observed. The gauge is stored in a metal storage container on the jobsite in Camanche, Iowa. The windows are barred shut. The gauge is locked in its case to the inside of the storage container, and the container is locked shut at all times. Only the authorized user has access to this container. The gauge's source rod is duct taped to the index rod, and will have a ubolt binding the source rod to the index rod to prevent movement of the source rod from the gauge."

The Troxler gauge contained .009 Curies Cs-137 and .044 Curies Am-241/Be.

Item Number: IA100003

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Power Reactor Event Number: 46204
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: DON GRANT
HQ OPS Officer: PETE SNYDER
Notification Date: 08/25/2010
Notification Time: 08:47 [ET]
Event Date: 08/25/2010
Event Time: 08:45 [EDT]
Last Update Date: 08/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF SEVERAL DISPLAY SYSTEMS DUE TO PLANNED COMPUTER MODIFICATIONS

"At 0845 hours EDT, on August 25, 2010, the Emergency Response Facility Information System (ERFIS) computer system was removed from service to perform a planned modification of the ERFIS. This modification will remove obsolete software and hardware related to the Emergency Response Data System, which has been replaced by an upgraded system. The expected duration of ERFIS inoperability is approximately 3 hours. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, and the Inadequate Core Cooling Monitor (ICCM). The loss of ERFIS requires alternate methods, as described in plant procedures, to be used for the above-described functions. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still be made, if required, during the time that the ERFIS Computer system is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As previously stated, alternate means remained available to assess plant conditions, make notifications, and accomplish required communications, as necessary. An additional message will be provided when the ERFIS is restored. It should also be noted that during the period of ERFIS inoperability, it is likely that the system could be restored within one hour to support Emergency Response Facility activation. This report is provided to conservatively cover the possibility that restoration within one hour may not be able to be accomplished if facility activation were to occur.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM DON GRANT TO JOE O'HARA AT 1454 ON 8/25/10 * * *

"At 1430, the ERFIS system was returned to service."

The NRC Resident Inspector has been notified.

Notified the R2DO(Franke)

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Other Nuclear Material Event Number: 46205
Rep Org: ARCELORMITTAL BURNS HARBOR
Licensee: ARCELORMITTAL BURNS HARBOR
Region: 3
City: BURNS HARBOR State: IN
County:
License #: 13-32670-01
Agreement: N
Docket:
NRC Notified By: CHRIS SARVANIDIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/25/2010
Notification Time: 09:50 [ET]
Event Date: 08/24/2010
Event Time: 10:15 [EDT]
Last Update Date: 08/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

LEVEL DETECTION GAUGE SHUTTER CONTROL ROD DISENGAGED

"After completion of casting operations at our #1 Slab Caster, a trained worker proceeded to the mould strand area to remove the Berthold Co-60 rod source from the mould and place it in proper storage. The source is 3.97 mCi and is used to measure mould level of liquid steel. After properly securing the source into its shielded source holder, the trained worker began transporting the holder to the storage cabinet. During transport, the holder fell over and hit the ground. When it hit the ground, the steel 'D' arm (for lifting the holder) structure on the outside of the holder was bent.

"Also, the device is designed such that the source insertion/removal rod is stored on the outside of the holder. It actually slides through openings on the 'D' arm and screws into the shutter door when in the closed position. After the fall, the threaded portion of the shutter door which receives the insertion rod broke. I immediately removed the rod and replaced it with a positive lock.

"During this event, the source rod and its shielding were not compromised and there was no exposure to employees. Also, we are making immediate modifications to the transporting device to prevent this from recurring."

The shutter was closed throughout this event.

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Power Reactor Event Number: 46206
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: STAN PAUL
HQ OPS Officer: PETE SNYDER
Notification Date: 08/25/2010
Notification Time: 10:38 [ET]
Event Date: 08/25/2010
Event Time: 08:30 [EDT]
Last Update Date: 08/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PAMELA HENDERSON (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

Event Text

OFFSITE NOTIFICATION - RELEASE OF HYDROGEN GAS IN EXCESS OF THE REPORTABLE QUANTITY OF TEN POUNDS

"On August 25, 2010 [the licensee] made a notification to] the Massachusetts Department of Environmental Protection and the Plymouth Massachusetts Fire Department in accordance with 310CMR40.300, Massachusetts Contingency Plan Notification of Oil and Hazardous Material; Identification and Listing of Oil and Hazardous Material. [The licensee made the notification] due to a release of hydrogen gas to the environment exceeding the reportable quantity of ten pounds via the designed system release path. The release occurred when restoration of a system vacuum pump following planned maintenance resulted in higher than normal system makeup rates. Combustible gas sampling of equipment areas confirmed that the excess hydrogen gas had been released to the environment via a remote roof vent designed to continuously exhaust [hydrogen] removed from the seal oil system by the vacuum pump. The release of hydrogen gas was secured when the vacuum pump was removed from service. The estimated quantity of hydrogen gas released was approximately twenty pounds. This event posed no danger to the health and safety of plant personnel or members of the general public.

"The NRC Senior Resident Inspector is on-site and has been notified."

The licensee is investigating the cause of the excessive makeup rate.

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Thursday, March 29, 2012