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Event Notification Report for September 5, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/04/2013 - 09/05/2013

** EVENT NUMBERS **


49297 49309 49310 49319

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 09/04/2013
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

* * * RETRACTION ON 9/4/13 AT 1310 EDT FROM RICK WENDT TO DONG PARK * * *

"This item is ready for closure. Incident closed. Not a reportable event."

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: 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 Thursday, September 05, 2013
Thursday, September 05, 2013