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Event Notification Report for February 5, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/04/2013 - 02/05/2013

** EVENT NUMBERS **


48528 48699 48700 48702 48713

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 48528
Rep Org: STAMFORD HOSPITAL
Licensee: STAMFORD HOSPITAL
Region: 1
City: STAMFORD State: CT
County:
License #: 06-066-9702
Agreement: N
Docket:
NRC Notified By: SARAH BULL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2012
Notification Time: 12:31 [ET]
Event Date: 05/01/2012
Event Time: [EST]
Last Update Date: 02/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES DWYER (R1DO)
FSME RESOURCE (EMAI)

Event Text

MEDICAL EVENT - ACTUAL DOSE DIFFERED FROM PRESCRIBED DOSE

An NRC Region I Inspector (Abogundi) performed an inspection at the licensee facility and determined that a medical event occurred and should have been reported.

In May, 2011, a patient received prostate LDR (Low-Dose Rate brachytherapy) treatment using 86 Pd-103 seeds for a prescribed dose of 125 Gy. During post-treatment evaluation, it was determined that the patient received between 72% and 75% of prescribed dose. The prescribing physician was notified and will not be notifying the patient due to treatment success.

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.

* * * RETRACTION FROM SARAH BULL TO HOWIE CROUCH AT 1130 EST ON 2/4/13 * * *

After reviewing their reporting procedures and in consultation with their Regional NRC Inspector (Abogundi), the licensee determined that this event did not meet their activity-based (versus dose-based) reporting criteria. Based on this information, the licensee has retracted this event notification.

Notified R1DO (Powell) and FSME Resource via email.

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Agreement State Event Number: 48699
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: CRAIG JONES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2013
Notification Time: 11:01 [ET]
Event Date: 01/16/2013
Event Time: 14:00 [MST]
Last Update Date: 01/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME_EVENTS-RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - DOSE DIFFERENT FROM PRESCRIBED USING YTTRIUM-90 THERASPHERE TREATMENT

The following event report was received from the State of Utah Division of Radiation Control via facsimile:

"The Utah Division of Radiation Control was notified at 11:45 a.m. MST on Thursday, January 17, 2013 of a medical event associated with a radioembolization brachytherapy treatment of liver cancer. Notification was provided by the licensee's Radiation Safety Officer. This incident report is the initial notification to the NRC Operations Center.

"The licensee's radiation safety officer reported to the Division that the treatment plan prescribed 1.33 GBq of yttrium-90 for treatment of liver cancer. The patient received 0.798 GBq of yttrium associated with the TheraSphere product. After the administration of the dosage, a nuclear medicine technologist determined that the total prescribed dosage was not delivered to the patient, as radioactive material was found to remain in the dosage vial and the administration apparatus. The licensee is working with the manufacturer of the treatment delivery system to determine the cause of the medical event."

Utah Event Report ID : UT130001

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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Agreement State Event Number: 48700
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: HALLIBURTON ENERGY SERVICES, INC.
Region: 4
City: ROOSEVELT State: UT
County:
License #: G3-039
Agreement: Y
Docket:
NRC Notified By: CRAIG JONES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2013
Notification Time: 11:02 [ET]
Event Date: 01/22/2013
Event Time: 06:00 [MST]
Last Update Date: 01/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME_EVENTS_RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - PROCESS METER SOURCE SUBJECTED TO INTENSE FIRE AT WELL SITE

The following information was obtained from the State of Utah via facsimile:

"The Utah Division of Radiation Control was notified at 3:40 p.m. MST on January 22, 2013 of a fire at a natural gas well. Notification was provided by the licensee's Radiation Safety Officer. This incident report is the initial notification to the NRC Operations Center.

On January 22, 2013, a representative of Halliburton Energy Services, Inc. radiation safety called the Division to report a fire involving a natural gas well. The fire erupted about 6:00 a.m. that morning. The licensee was using a truck with a slurry densimeter (Sealed Source Device Registry Number NR-340-D-101-G) in-line after a chicksan on a down-hole pump. The truck was parked approximately 40 feet from the blowout preventer (well head). An 8.8 milliCurie cesium-137 sealed source (Gammatron GT-GHP) is contained within the slurry densimeter. As of Thursday afternoon, January 24, 2013, the fire continued to occasionally flare, but a Halliburton representative was able to gain brief access to the slurry densimeter. He reported to a Department of Environmental Quality representative (on-scene presence) that the sealed source is not leaking and the device containment housing was still intact. Fire control operations continue and efforts to drag the licensee's truck away from the drill rig may occur on Friday, January 25, 2013.

Utah Report No: UT130002

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Agreement State Event Number: 48702
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: ADVANCED INSPECTION TECHNOLOGIES
Region: 4
City: TULSA State: OK
County:
License #: OK-27588-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/28/2013
Notification Time: 16:32 [ET]
Event Date: 01/15/2013
Event Time: [CST]
Last Update Date: 01/28/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - ASSISTANT RADIOGRAPHER EXCEEDED ANNUAL EXPOSURE LIMIT

The following was received from the state of Oklahoma via email:

"On January 15 [the Oklahoma Department of Environmental Quality] was informed by the RSO for AIT [Advanced Inspection Technologies] that one of their radiographer assistants had exceeded the 5 R limit for exposure during calendar year 2012. This individual consistently had higher exposures than other employees at AIT and had failed to turn in his badge at the end of April, 2012, instead continuing to wear it through May. This resulted in a reading of 1075 mR on the April report, but this also included the month of May. His May badge was not used and showed a dose of only 19 mR when processed. This situation was discussed with the RSO during their routine inspection in June. At the end of October the assistant again failed to turn in his badge and wore it through November. At the beginning of October, his cumulative dose for the year was 4580 mR. The badge was sent in for processing at the end of November and Landauer contacted the licensee on January 15, 2013 to inform him that the exposure on the October badge was 1282 mR. This put his 2012 total at 5864 (the unused November badge showed 2 mR). The RSO submitted a written report of this incident to us [State of Oklahoma] on Jan. 22, 2013.

"On January 23, [the Oklahoma Department of Environmental Quality] spoke with the radiographer who the assistant radiographer worked with most often. The radiographer [was asked] if there had been any incidents which might have caused the high doses the assistant radiographer had received. The radiographer replied that there had been no 'major' incidents that he was aware of. [The radiographer was] then asked about any minor incidents and the radiographer replied that 'two or three times' they had retracted the source into the exposure device, however when they approached the device, their rate alarms went off (these are required to be set to alarm at a dose rate of 500 mR/hr). They then cranked the source out again and again tried to retract it, which was successful. The fact that they got close enough to the source to encounter a 500 mR/hr radiation field indicates that they were not performing the post-exposure surveys required by 10 CFR 34.49(b). The radiographer [was then asked] if he had reported these incidents to the RSO to which he replied that in all cases he had checked the direct-reading dosimeters of he and the assistant radiographer's and found that they indicated a dose of 10 mR or less. Therefore, he decided not to report them. He also stated that the need to keep up with the work load played a role in his decision. The radiographer could not remember specific dates or locations where this had occurred. On January 28, 2013, [the Oklahoma Department of Environmental Quality] spoke with the RSO again and informed him of the conversation with the radiographer. The RSO professed to have no knowledge of the 'incidents' described by the radiographer. The RSO [was requested] to perform another investigation into this incident, specifically focusing on whether this was an isolated incident or if this was representative of the overall culture at the facility, and that enforcement action [would be deferred] pending the results of his investigation. The RSO agreed to this stipulation. It should be noted that AIT is, in general, one of [the] better licensees when it comes to compliance with [the Oklahoma Department of Environmental Quality] regulations. Investigation into this incident is continuing. As the over-exposure did not occur within a period of 24 hours as stipulated by 10 CFR 20.2202(b)(1), [the Oklahoma Department of Environmental Quality] is treating this as a reportable event under 10 CFR 20.2203(a)(2)."

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Power Reactor Event Number: 48713
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JAMES KURAS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/04/2013
Notification Time: 16:46 [ET]
Event Date: 02/04/2013
Event Time: 13:40 [CST]
Last Update Date: 02/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DAVID PROULX (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

REACTOR COOLANT SYSTEM PRESSURE BOUNDARY LEAKAGE IDENTIFIED ON SEAL INJECTION LINE DRAIN VALVE

"Unit is shut down in Mode 4 and in process of cooling down to Mode 5 for a scheduled refueling outage. During a containment walkdown to inspect for boron leakage, personnel identified that Reactor Coolant Pump 'A' seal injection line drain valve has a crack in the socket weld on the upstream side of the valve with active leakage visible as a fine mist. This valve is part of the Reactor Coolant System pressure boundary. TS 3.4.13 requires that the unit be placed in Mode 5 prior to 0140 hours on 2/6/13. All Mode 4 required safety related equipment is operable.

"The NRC Resident Inspector has been notified."

The last primary leak rate test was conducted at 100% power and determined that there was 0.114 gpm of unidentified leakage. The leak location is inside the containment bio-shield and is not accessible at power.

Page Last Reviewed/Updated Tuesday, February 05, 2013
Tuesday, February 05, 2013