Event Notification Report for November 10, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/09/2011 - 11/10/2011
EVENT NUMBERS
4743547427474284742947430
Agreement State
Event Number: 47435
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 11/14/2011
Notification Time: 18:49 [ET]
Event Date: 11/10/2011
Event Time: 07:00 [EST]
Last Update Date: 11/14/2011
Notification Time: 18:49 [ET]
Event Date: 11/10/2011
Event Time: 07:00 [EST]
Last Update Date: 11/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN CARUSO (R1DO)
ANDREW PERSINKO (FSME)
JOHN CARUSO (R1DO)
ANDREW PERSINKO (FSME)
AGREEMENT STATE REPORT - UNDERDOSAGE OF THERASPHERES
The following report was received via facsimile:
"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 36%, which is reportable under 10CFR35.3045 (a) (1) (ii).
"Notifications: On November 11, 2011, at 0849, the Department's [Pennsylvania Department of Environmental Protection] Southeast Regional Office received notification via email about the ME.
"Event Description: The patient was being treated with MDS Nordion Y-90 TheraSpheres« for disease of the liver and received only 36% of the intended dose. The licensee has notified the patient. No more information is available at this time.
"Cause of the Event: Is unknown at this time and is currently under investigation.
"Actions: The licensee will be submitting a written report within 15 days. The department [Pennsylvania Bureau of Radiation Protection] has planned a reactive inspection for November 17, 2011."
PA Event Report Identification Number: PA110036
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 facsimile:
"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 36%, which is reportable under 10CFR35.3045 (a) (1) (ii).
"Notifications: On November 11, 2011, at 0849, the Department's [Pennsylvania Department of Environmental Protection] Southeast Regional Office received notification via email about the ME.
"Event Description: The patient was being treated with MDS Nordion Y-90 TheraSpheres« for disease of the liver and received only 36% of the intended dose. The licensee has notified the patient. No more information is available at this time.
"Cause of the Event: Is unknown at this time and is currently under investigation.
"Actions: The licensee will be submitting a written report within 15 days. The department [Pennsylvania Bureau of Radiation Protection] has planned a reactive inspection for November 17, 2011."
PA Event Report Identification Number: PA110036
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: 47427
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN KOWALSKI
HQ OPS Officer: VINCE KLCO
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN KOWALSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/10/2011
Notification Time: 00:59 [ET]
Event Date: 11/10/2011
Event Time: 01:00 [CST]
Last Update Date: 11/10/2011
Notification Time: 00:59 [ET]
Event Date: 11/10/2011
Event Time: 01:00 [CST]
Last Update Date: 11/10/2011
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):
JOHN GIESSNER (R3DO)
JOHN GIESSNER (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 |
TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED MAINTENANCE
"'This telephone notification is provided in accordance with 10CFR50.72(b)(3)(xiii), loss of emergency assessment capability.
"On 11-10-11 at 0100 Central Standard Time, the Technical Support Center Emergency Diesel Generator and Technical Support Center regular lighting will be taken Out of Service to support a scheduled temporary power supply return to normal configuration. The temporary power had been in place since the last refueling outage in support of planned bus maintenance. The Technical Support Center Emergency Diesel Generator and regular lighting are scheduled to be restored at 1100 [CST] on 11-10-11.
"The licensee has notified the Senior Resident Inspector of this scheduled work."
"'This telephone notification is provided in accordance with 10CFR50.72(b)(3)(xiii), loss of emergency assessment capability.
"On 11-10-11 at 0100 Central Standard Time, the Technical Support Center Emergency Diesel Generator and Technical Support Center regular lighting will be taken Out of Service to support a scheduled temporary power supply return to normal configuration. The temporary power had been in place since the last refueling outage in support of planned bus maintenance. The Technical Support Center Emergency Diesel Generator and regular lighting are scheduled to be restored at 1100 [CST] on 11-10-11.
"The licensee has notified the Senior Resident Inspector of this scheduled work."
Non-Agreement State
Event Number: 47428
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: PETE SNYDER
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: PETE SNYDER
Notification Date: 11/10/2011
Notification Time: 20:10 [ET]
Event Date: 11/10/2011
Event Time: 11:10 [YST]
Last Update Date: 11/10/2011
Notification Time: 20:10 [ET]
Event Date: 11/10/2011
Event Time: 11:10 [YST]
Last Update Date: 11/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL HAY (R4DO)
ANDREW PERSINKO (FSME)
MICHAEL HAY (R4DO)
ANDREW PERSINKO (FSME)
RADIOGRAPHY CAMERA SOURCE FAILS TO COMPLETELY RETRACT
"On November 10th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6774).
"During the shift, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated.
"The 2 mR/hr boundary was reconfirmed and the Foreman and Supervisor were notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the Permanent Storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service.
"Exposure Device: Industrial Nuclear IR-100
"Device S/N: 6774
"Source S/N: 70129B
"Source Activity: 63.4 curies
"Source Type: Ir-192
"Source Model # QSA 87703
"There was no exposure to the crew or the general public during this incident."
See similar events: 47418, 46533, 46323, 46233, 46052, 46051, 45669, 45648, 45609, 45544, 45524, 45496, 45469, 45384.
"On November 10th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6774).
"During the shift, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated.
"The 2 mR/hr boundary was reconfirmed and the Foreman and Supervisor were notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the Permanent Storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service.
"Exposure Device: Industrial Nuclear IR-100
"Device S/N: 6774
"Source S/N: 70129B
"Source Activity: 63.4 curies
"Source Type: Ir-192
"Source Model # QSA 87703
"There was no exposure to the crew or the general public during this incident."
See similar events: 47418, 46533, 46323, 46233, 46052, 46051, 45669, 45648, 45609, 45544, 45524, 45496, 45469, 45384.
Power Reactor
Event Number: 47429
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: RICHARD GARCIA
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: RICHARD GARCIA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/10/2011
Notification Time: 21:54 [ET]
Event Date: 11/10/2011
Event Time: 14:39 [PST]
Last Update Date: 11/12/2011
Notification Time: 21:54 [ET]
Event Date: 11/10/2011
Event Time: 14:39 [PST]
Last Update Date: 11/12/2011
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):
MICHAEL HAY (R4DO)
MICHAEL HAY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF TECHNICAL SUPPORT CENTER EMERGENCY FILTRATION SYSTEM DURING MAINTENANCE
"At 1439 PST on 11-10-2011, while performing maintenance on the Technical Support Center (TSC) emergency filtration system, it was discovered that replacement gaskets required to restore the system were undersized and that the system could not be restored. Specifically the replacement gaskets were determined to be too small. All spare gaskets onsite were examined and determined to suffer from the same undersized condition. Prior to discovery of the undersized gaskets, the maintenance plan allowed for prompt system restoration in the event of an emergency.
"The current lack of a suitable replacement gasket has resulted in a condition which represents a major loss of emergency preparedness capability per 10 CFR 50.72(b)(3)(xiii) in that TSC habitability might not be sustainable during certain events due to the inability of the filtration system to maintain a habitable atmosphere. Station procedures provide instructions to relocate the TSC if monitoring during an emergency event indicates that habitability cannot be maintained. Compensatory measures are being developed (while the restoration work is ongoing) to heighten awareness of responsible TSC staff following ERO activation to monitor TSC habitability in accordance with procedures and to consider potential TSC relocation as necessary as described in the station emergency plan.
"Work is underway to return the TSC filtration system to functional status with a high priority."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM MICHAEL STODICK TO HOWIE CROUCH AT 2039 EST ON 11/12/11 * * *
"Maintenance work on the TSC emergency filtration system has been completed. A post functional test has been performed and it has been evaluated that the TSC emergency filtration system's function has been restored as of 1718 PST on 11/12/2011. The NRC Resident Inspector will be notified."
Notified R4DO (Hay).
"At 1439 PST on 11-10-2011, while performing maintenance on the Technical Support Center (TSC) emergency filtration system, it was discovered that replacement gaskets required to restore the system were undersized and that the system could not be restored. Specifically the replacement gaskets were determined to be too small. All spare gaskets onsite were examined and determined to suffer from the same undersized condition. Prior to discovery of the undersized gaskets, the maintenance plan allowed for prompt system restoration in the event of an emergency.
"The current lack of a suitable replacement gasket has resulted in a condition which represents a major loss of emergency preparedness capability per 10 CFR 50.72(b)(3)(xiii) in that TSC habitability might not be sustainable during certain events due to the inability of the filtration system to maintain a habitable atmosphere. Station procedures provide instructions to relocate the TSC if monitoring during an emergency event indicates that habitability cannot be maintained. Compensatory measures are being developed (while the restoration work is ongoing) to heighten awareness of responsible TSC staff following ERO activation to monitor TSC habitability in accordance with procedures and to consider potential TSC relocation as necessary as described in the station emergency plan.
"Work is underway to return the TSC filtration system to functional status with a high priority."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM MICHAEL STODICK TO HOWIE CROUCH AT 2039 EST ON 11/12/11 * * *
"Maintenance work on the TSC emergency filtration system has been completed. A post functional test has been performed and it has been evaluated that the TSC emergency filtration system's function has been restored as of 1718 PST on 11/12/2011. The NRC Resident Inspector will be notified."
Notified R4DO (Hay).
Power Reactor
Event Number: 47430
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BLAKE MITCHELL
HQ OPS Officer: VINCE KLCO
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BLAKE MITCHELL
HQ OPS Officer: VINCE KLCO
Notification Date: 11/11/2011
Notification Time: 10:01 [ET]
Event Date: 11/10/2011
Event Time: 12:00 [CST]
Last Update Date: 11/11/2011
Notification Time: 10:01 [ET]
Event Date: 11/10/2011
Event Time: 12:00 [CST]
Last Update Date: 11/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GEORGE HOPPER (R2DO)
GEORGE HOPPER (R2DO)
| 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 | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
SUPERVISOR ATTEMPTED TO SUBVERT THE FITNESS FOR DUTY PROCESS
This event is being reported because a non-licensed contractor employee's direct supervisor authorized the individual to return home instead of initiating a for cause Fitness For Duty test. Both the direct supervisor and the contractor employee had their unescorted access to the protected area terminated. Contact the Headquarters Operations Officer for additional details.
This event is being reported because a non-licensed contractor employee's direct supervisor authorized the individual to return home instead of initiating a for cause Fitness For Duty test. Both the direct supervisor and the contractor employee had their unescorted access to the protected area terminated. Contact the Headquarters Operations Officer for additional details.