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Event Notification Report for September 3, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/30/2013 - 09/03/2013

** EVENT NUMBERS **


49297 49305 49316 49317

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Agreement State Event Number: 49297
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: GOOD SAMARITAN REGIONAL MEDICAL CENTER
Region: 4
City: CORVALIS State: OR
County:
License #: 90202
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/22/2013
Notification Time: 14:33 [ET]
Event Date: 08/21/2013
Event Time: 13:45 [PDT]
Last Update Date: 08/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN DOSE PRESCRIBED FOR ANOTHER PATIENT

The following was received from the State of Oregon via facsimile:

"The inpatient was having an Adenosine Myoview stress test. The Nuclear Medicine Technologist took the dose that was already in the dose calibrator (place there earlier by another Nuclear Medicine Technologist). It measured about the same activity as 99m-Tc Myoview would measure in the dose calibrator. The Nuclear Medicine Technologist gave the patient 37.4 millicuries of 99m-Tc DTPA (lung ventilation dose) instead of 30 millicuries of 99m-Tc Myoview. The route of administration for 99m-Tc DTPA is inhalation and the route of administration for 99m-Tc Myoview is intravenous. The 99m-Tc DTPA was intended for a different patient. The patient was informed of the mistake and the stress test will be repeated tomorrow (8/22/13). The ordering physician was also notified of the event. There were no adverse effects to the patient, just delayed the study.

"This will be reported at the next Radiation Safety Committee Meeting along with any actions that will be taken to prevent this in the future."

Oregon Event Number: 13-0031

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: 49305
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: THE CHILDREN'S HOSPITAL AT MONTEFIORE
Region: 1
City: BRONX State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/23/2013
Notification Time: 14:05 [ET]
Event Date: 05/10/2013
Event Time: [EDT]
Last Update Date: 08/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
PAMELA HENDERSON (FSME)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO FAMILY MEMBER

A family member may have received an exposure of 5,925 mrem while providing home care for the patient undergoing I-131 therapy administered on March 22, 2013. The patient was hospitalized from March 22 to March 29, 2013 and then discharged with at-home precautions.

During the patient's hospitalization visitors including family members were provided radiation badges to monitor exposure. The badges were subsequently processed by Landauer on May 5, 2013 which identified that a family member received 5,925 mrem effective dose equivalent during this period of hospitalization. The subject badge was reread on May 6, 2013 which confirmed the initial reading. The Children's Hospital was notified on May 10, 2013 of the results. A survey of the patient's room found little contamination.

Children's Hospital conducted an extensive investigation but could not definitively identify the cause for the high exposure level.

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Power Reactor Event Number: 49316
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ANGLE BRAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/01/2013
Notification Time: 23:34 [ET]
Event Date: 09/01/2013
Event Time: 16:10 [CDT]
Last Update Date: 09/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 98 Power Operation

Event Text

RECIRC PUMP RUNBACK AND POWER REDUCTION

"On September 1, 2013 at 1610 CST, Monticello Nuclear Generating Plant (MNGP) experienced a runback of 'A' Recirc pump from 87% speed to 82% speed. Operators took action to lock 'A' Recirc pump scoop tube. This runback resulted in a power reduction from 100% to 98% RTP [Rated Thermal Power]. Should a LOCA [Loss of Coolant Accident] occur with the resultant mismatch between total jet pump flows of the two loops greater than required limits, the core flow coastdown and resultant core response may not be bounded by the LOCA analyses. It has been determined that this is an unanalyzed condition as defined by 10CFR50.72(b)(3)(ii)(B).

"At 2123 CST on September 1, 2013, MNGP completed adjusting recirc flow speed on 'A' and 'B' Recirc pumps to match jet pump loop flows to within the required limits and is no longer in an unanalyzed condition. Both 'A' and 'B' Recirc scoop tubes remain locked pending investigation."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49317
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: WAYNE TIMOTHY
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/02/2013
Notification Time: 22:53 [ET]
Event Date: 09/02/2013
Event Time: 19:26 [MST]
Last Update Date: 09/03/2013
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
BOB HAGAR (R4DO)
MELANIE GALLOWAY (NRR)
TONY VEGEL (R4)
JENNIFER UHLE (NRR)
JANE MARSHALL (IRD)

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

UNUSUAL EVENT DECLARED DUE TO FIRE IN THE TURBINE BUILDING

"An Event Classification of Unusual Event (HU2.1) was declared at 1926 [MST] for the Palo Verde Nuclear Generating Station. At 1912, smoke was detected by a security officer by the 'A' train Main Feed pump. An Auxiliary Nuclear Operator investigated and identified a fire on lagging, with one foot flames behind the main standard 'A' train Main Feed pump. The fire team responded to the fire and is currently on scene. Fire was declared out at 1957.

"No reactor protection system (RPS) or engineered safety feature (ESF) actuations occurred and none were required. The event did not result in any challenges to the fission product barrier or result in any releases of radioactive materials. There were no adverse safety consequences, and this event did not adversely affect the safe operation of the plant or health and safety of the public. The 'A' Main Feed pump high vibration alarm was received, but the continued operation of the main feed pump is currently not in jeopardy."

While removing lagging, during the recovery process, the licensee had 2 reflash events. The flame was extinguished and the licensee continues to remove the oil soaked lagging for the 'A' Main Feed pump.

The licensee has notified the NRC Resident Inspector, State, and Local Authorities. The Tonophah Fire Department was contacted and did respond to the site.

Notified DHS SWO, FEMA, DHS NICC, and Nuclear SSA (email only).

* * * UPDATE FROM WAYNE TIMOTHY TO JOHN SHOEMAKER AT 0352 EDT ON 9/3/13 * * *

"PVNGS Unit 2 Terminated the Unusual Event HU2.1 on 9/3/13 at 0029 MST. The fire no longer constitutes a hazard to plant or personnel. 'A' Main Feed Pump is running and Unit 2 is operating at 100% power. The fire was extinguished at 1957 MST (per fire team advisor) and was declared extinguished by the incident commander at 2055 MST. A small oil vapor leak was identified coming from the high pressure bearing seal. Vapor extraction differential pressure was increased to eliminate the oil vapor leak. At 2134 MST, received a report of two reflash events while the Fire Department was removing additional lagging with no sustained flame or fire. All the affected lagging has been removed and the fire emergency was terminated at 2345 MST on 9/2/13."

The licensee updated event times to reflect MST.

The licensee has notified the NRC Resident Inspector, State, and Local Authorities.

Notified R4DO (Hagar), NRR (Galloway), IRD (Marshall), DHS SWO, FEMA, DHS NICC, and Nuclear SSA (email only).

Page Last Reviewed/Updated Tuesday, September 03, 2013
Tuesday, September 03, 2013