| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/23/2013 - 08/26/2013 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 49282 | Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: LEGACY MERIDIAN PARK MEDICAL CENTER
Region: 4
City: TUALATIN State: OR
County: WAHINGTON
License #: ORE 90293
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: VINCE KLCO | Notification Date: 08/15/2013
Notification Time: 14:05 [ET]
Event Date: 11/03/2011
Event Time: [PDT]
Last Update Date: 08/15/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT- DELIVERED PATIENT DOSE DIFFERENT THAN PRESCRIBED
The following information was received by email:
"Based on protocol, a dose of 120 Gy (1.79 GBq) was prescribed. Upon completion of the treatment, survey of the Nalgene waste container measured higher than expected. Ensuing calculations resulted in dose delivered to be 85 Gy (1.24 GBq); greater than 20% variation from prescribed dose. All drapes, towels, etc were surveyed with no evidence of radioactivity present, therefore assuring no contamination present. Contents of the waste container were measured separately to locate the source of residual activity. The readings indicated minimal activity in the Y -90 vial; readings of the patient delivery microcatheter were indicative of residual microspheres. The treatment protocol was followed with no variations of procedure. As is typical, 3 saline flushes were made of the catheter including several vigorous flushes to dislodge any microspheres as recommended by Nordion, the product manufacturer. No high pressure was detected at any point during infusion which would trigger the pressure valve and deliver saline in the overflow vial. There was no build up of particles in the hub of the delivery catheters as inspected throughout the procedure. Measurements over the length of the catheter revealed greatest activity in the proximal portion of the catheter with little-to-no activity in the tip. Nordion has been contacted. In the future, survey of the catheter prior to disconnecting it for disposal may help detect the build-up of particles."
Oregon Incident: 11-0037
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. |
| Agreement State | Event Number: 49283 | Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BAYFRONT MEDICAL CENTER
Region: 1
City: ST. PETERSBURG State: FL
County:
License #: 4374-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: DONG HWA PARK | Notification Date: 08/15/2013
Notification Time: 14:45 [ET]
Event Date: 08/07/2013
Event Time: [EDT]
Last Update Date: 08/15/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - VENTILATION PERFUSION LUNG SCAN ADMINISTERED INSTEAD OF CT LUNG SCAN
The following event report was received from the State of Florida via facsimile:
"Received notification of a medical event on 15 Aug 2013 at 10:30 am [EDT] from Bayfront Medical Center, license number 4374-1. Date of procedure was 7 Aug 2013. A patient was prescribed a CT lung scan by the physician. Technologist entered, by mistake, Ventilation Perfusion Lung Scan into the computer (9 mCi's of Xenon-133). Patient's physician was notified, patient was on a ventilator and was not able to communicate. [This incident was] assigned to the Tampa Office for investigation. No further action will be taken on this incident."
Florida Incident Number: FL13-056
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. |
| Agreement State | Event Number: 49284 | Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: CARESTREAM HEALTH, INC.
Region: 4
City: WHITE CITY State: OR
County:
License #: ORE-90879
Agreement: Y
Docket:
NRC Notified By: DARYL A. LEON
HQ OPS Officer: DONG HWA PARK | Notification Date: 08/15/2013
Notification Time: 15:46 [ET]
Event Date: 02/06/2013
Event Time: [PDT]
Last Update Date: 08/15/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN
The following information was received by email:
"Oregon Radiation Protection Services was notified by email on 2/20/13 at 11:28 a.m. [PDT], by Curtis Kreil, RSO, a representative of Carestream Health, Inc., of one tritium exit sign discovered missing during a 6-month radioactive material inventory check on 2/6/13. The sign was last inventoried on 8/1/12. A site-wide email alert was issued regarding the missing sign.
"Exit sign details are:
Manufacturer: SRB Technologies
Model: Betalux E
Serial Numbers: 258030
Radioactive material: H-3
Activity: Nominal 20 Ci (on 10/2/02), currently 11.2 Ci (2/20/13)
"Engineers and technicians are currently aware of the location of the [remaining] exit signs and monitor their presence. The licensee added discussion information into their Radiation Safety Training document regarding the exit signs and awareness of their location to assist in timely reporting of any future issues as a corrective action."
Oregon Incident: OR-13-0011
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 |
| Part 21 | Event Number: 49301 | Rep Org: MIRION TECHNOLOGIES CONAX NUCLEAR
Licensee: MIRION TECHNOLOGIES CONAX NUCLEAR
Region: 1
City: BUFFALO State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN MacDONALD
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/23/2013
Notification Time: 12:54 [ET]
Event Date: 08/23/2013
Event Time: [EDT]
Last Update Date: 08/23/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
| Person (Organization):
WAYNE SCHMIDT (R1DO)
ROBERT HAAG (R2DO)
LAURA KOZAK (R3DO)
PART 21 GROUP (NRR)
| Event Text PART-21 NOTIFICATION - UNQUALIFIED MATERIAL USED IN ELECTRICAL PENETRATION ASSEMBLIES
The following information was received via fax:
"Material supplied to MTCN [Mirion Technologies (Conax Nuclear)] by approved sub-suppliers audited to NCA-3800 by MTCN was considered to be ASME [American Society of Mechanical Engineers] qualified source material for Section II and Section III requirements. During triennial survey of MTCN by the ASME for renewal of our N Type Certificates of Authorization, it was identified by the ASME survey team that material supplied by two (2) MTCN approved sub-suppliers should be considered unqualified source material. At that time, MTCN's Quality Program did not Include the use of unqualified source material.
"Testing of the coupons for materials used with the basic components supplied to the operating plants is expected to be completed within the next 30 days."
The potentially defective components are electrical penetration headerplates, mounting weldment rings and weld neck flanges for mounting the electrical penetration assemblies.
The affected facilities are: Oconee, Ginna, Crystal River, Point Beach, Monticello, Cook, and Turkey Point.
Point of contact: John MacDonald 716-681-1973 |
| Part 21 | Event Number: 49302 | Rep Org: BALDOR ELECTRIC CO.
Licensee: BALDOR ELECTRIC CO.
Region: 1
City: FLOWERY BRANCH State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES THIGPEN
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/23/2013
Notification Time: 12:35 [ET]
Event Date: 08/23/2013
Event Time: [EDT]
Last Update Date: 08/23/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
| Person (Organization):
WAYNE SCHMIDT (R1DO)
ROBERT HAAG (R2DO)
LAURA KOZAK (R3DO)
GREG WERNER (R4DO)
PART 21 GROUP (NRR)
| Event Text PART-21 NOTIFICATION - MOTORS MAY HAVE A POINT FOR FOREIGN MATERIAL ENTRY
The following information was received via fax:
"This is a reportable 10CFR21 notification because some 1E motors in frame sizes 360, 400, and 440 may have been shipped by Baldor Electric, which contain an entry point for blast media to enter the motor during post shipment paint treatment preparations. During a recent inspection of a returned motor, some foreign materials were discovered inside the motor which appeared to consist of two types of blast media. One type of blast media found is used during the manufacturing process to clean the rotor end ring area before applying an end ring coating. This media is non-conductive and is typically cleaned away as part of the treatment process. The presence of blast media is a key inspection point at rotor final inspection. In mid 2008 this type of blast media was eliminated from Baldor processes and substituted with C02 blast media.
"The other blast media found inside the motor is not used during the motor manufacturing process at Baldor. It was a metallic bead media and used during a paint preparation process after leaving Baldor. The entry point of this material was found to be through a small window in the frame casting that normally is closed with weld after the stator is assembled into the frame. In this instance, one of the stator weld notches was aligned with one (of the two) small windows in the frame casting. This allowed the blast media to enter and travel along the OD [outside diameter] of the stator core weld notch and into the motor.
"Engineering and Quality reviewed all nuclear orders to verify the frame sizes that may have used the weld slot construction. The frames were determined to be 360, 400, and 440 during the time frame when the welds may not have been verified. The date range was established as 2002 thru 2013.
"The motors identified as possibly having this non-conformance should be inspected for the following:
a. The frame weld windows on identified 360,400 or 440 frame motors show no weld.
and
b. The stator core weld notch is visible in at least one (of the two) frame weld windows."
If both issues exist, then remediation is recommended.
Customers who have received these motors:
Areva, Inc.
David Brown Union Pumps Co.
Duke Energy Corp.
Enertech
First Energy
First Energy Service Co.
Flowserve Pump Division - Spain
Georgia Power
Howden North America Inc.
Limitorque
Spencer Turbine Co.
Taiwan Power Company
Westinghouse Electric Company
Point of Contact: James Thigpen, 678-947-7272 |
| Part 21 | Event Number: 49303 | Rep Org: WESTINGHOUSE ELECTRIC CORPORATION
Licensee: WESTINGHOUSE ELECTRIC CORPORATION
Region: 1
City: State: PA
County: CRANBERRY TOWNSHIP
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES GRESHAM
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/23/2013
Notification Time: 13:01 [ET]
Event Date: 08/23/2013
Event Time: [EDT]
Last Update Date: 08/23/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
| Person (Organization):
ROBERT HAAG (R2DO)
PART-21 GROUP (NRR)
| Event Text PART-21 NOTIFICATION - AP-1000 TIME RESPONSE FOR THE SAFETY ANALYSIS CANNOT BE DIRECTLY MEASURED
The following information was received via fax:
"Several technical specifications were identified in a Corrective Action Report (CAR) as having a time response surveillance requirement that cannot be directly measured due to logic pathways where overlap with another protective function occurs. Westinghouse is now determining what other reactor trip and engineered safeguards actuation system protective functions have a credited time response in the Safety Analysis for the AP1000 plant and therefore should be assigned a time response surveillance requirement in the Technical Specifications. The evaluation will address the safety implication of the items identified in the CAR as well as confirm that all other protective functions where a time response was credited in the safety analysis have a measurable surveillance requirement in the Techni.cal Specifications.
"The safety significance evaluation for the AP1000 plant is still in process and a determination of the potential to create a substantial safety hazard is not yet complete."
Affected licensees:
Summer Units 2 and 3
Vogtle Units 3 and 4
Levy Units 1 and 2
Harris Units 2 and 3
Lee Units 1 and 2
Turkey Points Units 6 and 7
Bellefonte Units 3 and 4
Point of contact: James Gresham 412-720-0754
Westinghouse letter: LTR-NRC-13-62 |
| Power Reactor | Event Number: 49304 | Facility: ZION
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARK BITTMAN
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/23/2013
Notification Time: 11:39 [ET]
Event Date: 08/22/2013
Event Time: 13:00 [CDT]
Last Update Date: 08/23/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
LAURA KOZAK (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Decommissioned | 0 | Decommissioned | | 2 | N | N | 0 | Decommissioned | 0 | Decommissioned | Event Text ALCOHOL FOUND IN THE RESTRICTED AREA
"The following significant FFD policy violations and programmatic failures must be reported to the NRC Ops Center within 24 hours by telephone after the licensee or other entity discover the violation.
"(1) The use, sale, distribution possession or presence of illegal drugs, or the consumption or presence of alcohol within a protected area.
"Ours [licensee] is a conservative decision to notify due to the fact that the contraband was found in the restricted area and NOT in the protected area.
"On 8/22/13 at approximately 1300 hours, an employee conducting demolition work on the 542 level of the Auxiliary Building discovered an old dust covered pint glass bottle of Jim Beam Bourbon Whiskey containing approximately 1 inch of brown liquid which, when opened, smelled of alcohol. The bottle was located in bus trays 12 to 15 feet above the floor. The employees retrieved the bottle and handed it to an individual on the ground. Radiation Protection [RP] personnel bagged the bottled due to it being in a contaminated area. The bottle was surveyed by RP and released to Security. The bottle was removed to the FFD Office and the liquid was disposed of in the toilet. The glass bottle was then disposed of offsite."
The licensee will notify the NRC Resident Inspector. |
| Power Reactor | Event Number: 49306 | Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MATT HUMMER
HQ OPS Officer: PETE SNYDER | Notification Date: 08/25/2013
Notification Time: 00:46 [ET]
Event Date: 08/24/2013
Event Time: 16:14 [PDT]
Last Update Date: 08/25/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
GREG WERNER (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 | Event Text MALFUNCTION OF STACK RADIATION MONITOR SUPPORTING EQUIPMENT
"At 1614 hours PDT on August, 24, 2013 the Reactor Building Stack Radiation Monitor - High Range and Reactor Building Stack Radiation Monitor - Intermediate Range detectors were declared non-functional due to a loss of supporting equipment. Corrective actions are being pursued to restore the affected monitors to functional status.
"To compensate for the loss of assessment capability due to the non-functioning Radiation Monitoring Equipment, an additional Health Physics (HP) Technician trained to acquire offsite dose assessment information on offsite releases is available. The additional personnel are pre-staged in support of the Radiation Monitoring System outage and will be mobilized in accordance with guidance in the compensatory measure instructions.
"This event is being reported as a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). A follow up notification will be made when the Equipment has been returned to service.
"The licensee has notified the NRC Resident Inspector." |
| Power Reactor | Event Number: 49307 | Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: GREG KNUDSON
HQ OPS Officer: VINCE KLCO | Notification Date: 08/26/2013
Notification Time: 01:05 [ET]
Event Date: 08/25/2013
Event Time: 18:18 [PDT]
Last Update Date: 08/26/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
GREG WERNER (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 | Event Text LOSS OF SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE
"Reactor Building (Secondary Containment) pressure increased to above the Technical Specification Surveillance requirement of 0,25 inches vacuum water gauge. This event is reportable as an event that could have prevented fulfillment of a safety function needed to control the release of radiation and mitigate the consequences of an accident. The Reactor Building differential pressure controller was placed in manual operation and Secondary Containment pressure was restored to normal (greater than 0.25 inches vacuum water gauge) returning Secondary Containment to operable status. Secondary Containment pressure was outside the allowable Technical Specification requirement for 4 minutes.
"There were no radiological releases associated with the event.
"No safety system actuations or isolations occurred."
The licensee notified the NRC Resident Inspector. | |