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Event Notification Report for September 4, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/03/2013 - 09/04/2013

** EVENT NUMBERS **


49182 49309 49310 49317 49318 49319

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 49182
Rep Org: ST ALPHONSUS REGIONAL MED CTR
Licensee: ST ALPHONSUS REGIONAL MED CTR
Region: 4
City: BOISE State: ID
County:
License #: 11-27306-01
Agreement: N
Docket:
NRC Notified By: TIM STACK
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/09/2013
Notification Time: 16:06 [ET]
Event Date: 12/20/2012
Event Time: [MDT]
Last Update Date: 09/03/2013
Emergency Class:
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVID PROULX (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

MEDICAL EVENT - DOSE DELIVERED TO OTHER SITE

On December 20, 2012, a patient was administered microspheres to treat the liver. On July 9, 2013 the administering facility learned that a biopsy identified microspheres in a slow healing gastric ulcer. The facility is assuming that the patient received a dose that exceeded the limits based on the presence of microspheres and the development of a gastric ulcer.

* * * RETRACTION ON 9/3/13 AT 1705 EDT FROM ERIC COLAIANNI TO DONG PARK * * *

Based on discussion with NRC Region 4 and after a review process, the licensee is retracting this report.

Notified R4DO (Gaddy).

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: 49309
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: NABORS COMPLETION & PRODUCTION SERVICES COMPANY
Region: 4
City: WILLISTON State: ND
County:
License #: 33-48830-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/27/2013
Notification Time: 16:27 [ET]
Event Date: 08/24/2013
Event Time: [MDT]
Last Update Date: 08/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE INVOLVED IN FIRE AT WELL SITE

The following information was received via facsimile:

"A fire started at a well site near Williston, ND on Saturday, August 24, 2013. At the time of the event, fracking activities were being performed utilizing a Thermo Fisher Scientific model 5190 nuclear density gauge containing a Cs-137 source attached to a blender. Personnel evacuation was immediately performed and notification was made to the local fire department. Local fire department personnel arrived on-site and established control of the scene. The fire was extinguished later that night. Local fire department personnel restricted access to the site until Sunday morning. At that time, licensee personnel on-site were allowed to approach the gauge from a safe distance working their way towards the gauge while continually monitoring a radiation survey instrument (Ludlum Model 3). As the observed readings were higher than expected, it was believed the lead shielding had melted inside the steel casing and shifted to the lower area within the casing. The steel casing remained intact. After the initial assessment, licensee personnel maintained continual surveillance while site security personnel prohibited access within the public dose boundary set by the licensee. The licensee dispatched their Radiation Compliance Coordinator for further evaluation.

"The licensee's Radiation Compliance Coordinator arrived in Williston late Sunday night. Early Monday morning he arrived on site to perform more complete radiation surveys and leak testing of the involved gauge. The highest radiation levels noted around the gauge were 2.6 R/hr at the surface and 20 mR/hr at 1 meter. Wipe tests were collected and sent to Applied Health Physics of Bethel, PA for analysis. The results of the first two wipe samples demonstrated no evidence of contamination.

"The licensee contacted the manufacturer regarding disposal of the damaged gauge. The manufacturer, not willing to accept receipt of the gauge, suggested the licensee contact a waste broker for final disposal. The licensee subsequently contacted Applied Health Physics (AHP). AHP plans to cut out the gauge and package it in a lead lined 55 gallon steel drum for transport, and ship the container for final disposal. AHP is scheduled to perform this activity on Thursday, August 29, 2013.

"Licensee and site security personnel will continue to maintain surveillance and control of the site until the disposal personnel arrive."

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Agreement State Event Number: 49310
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TULANE UNIVERSITY HOSPITAL
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-3325-LO1
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/27/2013
Notification Time: 18:00 [ET]
Event Date: 08/22/2013
Event Time: [CDT]
Last Update Date: 08/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - THERAPY DOSE APPLIED TO WRONG LOCATION

The following report was received via e-mail from the Louisiana Department of Environmental Quality:

"On 08/27/2013, the RSO for Tulane University Hospital called to notify the Department that their facility had a Medical Event involving [exposure to unintended tissue greater than] 50 Rem. The event was discovered on 08/27/2013 when an application was not able to be applied to the intended tissue. The HDR source had 'dog legged' into the bowel area when it was intended to apply the radiation dose to the cervical area. The films were pulled for the application on 08/22/2013 and revealed that the application had 'dog legged' also. The cervical tissue did not receive the initial intended dose.

"The HDR [High Dose Rate Brachytherapy Afterloader] unit was a Nucletron Micro-Selectron, loaded with [an] Ir-192 [source]. The therapy dose was 8.4 Gray [840 rads] given in fractions. The patient is to receive the entire corrected therapy dose prescribed.

"This is believed to be (under investigation) a positioning problem and not an equipment malfunction.

"The patient's physician has been notified. However, the patient was heavily sedated and has not been notified.

"Updates will be made when additional information is available."

Louisiana Report ID: LA-130001

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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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 Tonopah 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).

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Power Reactor Event Number: 49318
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CHRIS GIAMBRONE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/03/2013
Notification Time: 14:10 [ET]
Event Date: 09/03/2013
Event Time: 06:46 [EDT]
Last Update Date: 09/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
TODD JACKSON (R1DO)

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

SECONDARY CONTAINMENT ACCESS AIR LOCK DOORS OPENED SIMULTANEOUSLY RESULTING IN MOMENTARY DEGRADATION

"During planned maintenance activities, station personnel simultaneously opened the inner and outer airlock doors from unit 2 reactor enclosure to the U2 reactor enclosure HVAC room, resulting in a lowering of reactor enclosure delta pressure to below the tech spec minimum required value. The airlock doors were closed within approximately 5 seconds and reactor enclosure delta pressure recovered to greater than the tech spec minimum required value within approximately 20 seconds.

"Unit 2 secondary containment was declared inoperable for the time that reactor enclosure delta pressure was below the tech spec minimum required value, and was declared operable when reactor enclosure delta pressure recovered to greater than the tech spec minimum required value. Total Limiting Condition of Operation time was approximately 20 seconds."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49319
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: AARON MICHALSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/04/2013
Notification Time: 04:13 [ET]
Event Date: 09/04/2013
Event Time: 04:05 [EDT]
Last Update Date: 09/04/2013
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
1 N Y 100 Power Operation 100 Power Operation
2 N Y 99 Power Operation 99 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10CFR50.72(b)(3)(xiii) because the work activity affects the functionality of an emergency response facility.

"Planned maintenance activities are being performed on 09/04/13 to the Technical Support Center (TSC) HVAC. The work includes performance of planned outside air intake valve electrical repair. The planned work activity duration is approximately 12 hours.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures. The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency.

"The NRC Resident Inspector has been notified. This event poses no threat to the public or station employees."

Page Last Reviewed/Updated Wednesday, September 04, 2013
Wednesday, September 04, 2013