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Event Notification Report for September 17, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/16/2013 - 09/17/2013

** EVENT NUMBERS **


49329 49330 49331 49333 49345 49349 49351

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Agreement State Event Number: 49329
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GLOBAL X-RAY & TESTING CORPORATION
Region: 4
City: HOUMA State: LA
County:
License #: LA-0577-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 15:11 [ET]
Event Date: 01/28/2012
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

"Individual badge received 3.491 REM through September 2012. His exposure for October wear period was 0.565 REM, which gave him a total of 4.056 REM through October 2012. On 01/02/2013, November badge results came back 1.040 REM. On 01/10/2013, the December badge results came back with 0.043 REM. Making the annual exposure for the individual 5.139 REM for 2012."

LA Event Report ID No. LA130002

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Agreement State Event Number: 49330
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BAYOU INSPECTION SERVICES INC.
Region: 4
City: AMELIA State: LA
County:
License #: LA-7112-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:51 [ET]
Event Date: 07/19/2013
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

"Dosimetry badge result were reported to the licensee around July 19, 2013 with an individual's badge having received a total annual occupational dose exposure exceeding 7,437 mrem. 2013 badge history results showed exposures for the following months: January - 538 mrem, February - 410 mrem, March - 287 mrem, April 367 mrem, May 2,412 - mrem, and June - 3,423 mrem."

LA Event Report ID No. LA130003

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Agreement State Event Number: 49331
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-213-27
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:29 [ET]
Event Date: 09/06/2013
Event Time: [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG SITE

The following information was received from the State of Minnesota via email:

"The planned/prescribed dose that was to be delivered to a patient's tumor volume was 400cGy (4Gy) on this fraction. Due to medical event, [approximately] 0cGy (0Gy) was delivered to the tumor volume during HDR treatment fraction #2 of 6. The prescribed fraction dose of 400cGy (4Gy) was unintentionally delivered 5.4cm superiorly to the tumor volume in the patient's small bowel/external bladder wall region.

"The HDR remote afterloader at Abbott-Northwestern being used/in use during this patient's treatment is a Nucletron/Elekta V2 mHDR, serial number 31823; mHDR Ir-192 source #D36E-6829. The Ir-192 source activity at time of above medical event was 6.407 Ci.

"Abbott-Northwestern Radiation Oncology is actively investigating the cause of the above medical event, corrective action(s) to implement to prevent such an event from happening in the future, and any medical follow-up/expected implications to the patient from the above medical event. These items will be detailed in Abbott-Northwestern's full written report to be submitted within 15 days of discovery.

"MDH [Minnesota Department of Health] will submit more information as it becomes available."

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: 49333
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: LOYOLA UNIVERSITY MEDICAL CENTER
Region: 3
City: MAYWOOD State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/09/2013
Notification Time: 14:08 [ET]
Event Date: 09/07/2013
Event Time: [CDT]
Last Update Date: 09/09/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE HAD EXTERNAL CONTAMINATION

The following information was obtained from the State of Illinois via email:

"Saturday morning a call was received by the Illinois Emergency Management Agency [IEMA] from the RSO at Loyola University Medical Center reporting exterior contamination on one of two packages received from their radiopharmacy, Cardinal Health, that same morning. Staff at Loyola confirmed the presence of contamination with a second wipe which measured less than 15,000 dpm. The contaminant was verified as Tc-99m by Loyola staff. The package involved contained 6 doses of Tc-99m to be used for imaging that morning. Smears taken of the interior of the package and on each shielded syringe showed no removable contamination present. Smears on the exterior of the black nylon shipping package showed contamination only on the bottom of the package and on no other surfaces. The maximum measured dose rate from the empty package near the surface of the contaminated package was less than 500 microRem/h. The second package which had arrived at the same time as the first showed no contamination or unexpected radiation levels.

"The pharmacist at Cardinal Health was subsequently contacted by the Agency [IEMA] that same morning. The responsible pharmacist confirmed he'd been notified by the RSO of Loyola University Medical Center immediately at the time of discovery of the event. The pharmacy's courier vehicle made one other delivery to an area hospital before reaching Loyola and then proceeded to a third hospital. Both other facilities were contacted by Cardinal and told to be on the lookout for potential exterior contamination should cross contamination be involved. The pharmacist indicated that neither facility reported any noted contamination. The pharmacist noted that the couriers for all packages from their facility in Glendale Heights are Cardinal employees using Cardinal vehicles. Once the vehicle returned to Glendale Heights, surveys of the vehicle were completed and no removable contamination or elevated levels were detected. During the interim, a survey of the radiopharmacy was also conducted with no contamination found in the package preparation areas.

"Based on this information and past inspection results of both facilities, it appears this event is an isolated instance where incomplete/inadequate surveys were conducted to evaluate the potential hazard present and assure that packages offered for transport are free of contamination in excess of the limits."

Illinois Item Number: IL13026

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Power Reactor Event Number: 49345
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2013
Notification Time: 11:53 [ET]
Event Date: 09/16/2013
Event Time: 07:00 [EDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
SCOTT SHAEFFER (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

Event Text

OFF-SITE NOTIFICATION TO SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL (SCDHEC)

"At approximately 0700 [EDT] on 9/16/13, site personnel discovered a sewer lift station, in the owner controlled area, overflowing. The overflow entered a nearby storm drain that discharges into Outfall 13. The estimated release volume is between 500-1000 gallons. The release has been stopped. At 1045 an initial notification was made to SCDHEC. A pump failure is suspected to be the cause of the back-up and subsequent overflow. Repair and clean-up is in process.

"The NRC Residents have been notified."

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Power Reactor Event Number: 49349
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: GERALD BAKER
HQ OPS Officer: PETE SNYDER
Notification Date: 09/16/2013
Notification Time: 16:57 [ET]
Event Date: 09/16/2013
Event Time: 15:00 [EDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DON 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

VENT STACK MONITOR MAINTENANCE

"System(s) Affected: RM-8169 Vent Stack Radiation Monitor
"Actuations & Their Initiation Signals: None
"Causes (If known): Pre-Planned Maintenance
"Effect of Event on Plant: Loss of assessment capability
"Actions Taken or Planned: Compensatory samples - restore RM-8169 to service ASAP.
"Additional Information: None"

The licensee notified the NRC Resident Inspector, the State of Connecticut and local Waterford Dispatch.

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Power Reactor Event Number: 49351
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DOUG LAMARCA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2013
Notification Time: 21:11 [ET]
Event Date: 09/16/2013
Event Time: 14:55 [EDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

DEGRADED CONDITION CAUSED BY RHR RELIEF VALVE LEAKAGE

"At 1455 EDT, [on 91/16/13], [Susquehanna] Engineering determined the leakage from the 2B RHR Pump Suction Relief valve caused the Engineered Safety Feature (ESF) Leakage to exceed the 2.5 gpm which was provided to the NRC during the implementation of the Alternate Source Term (AST) submittal. The calculated leakage rate was 7.5 gpm.

"This event is being reported as a degraded condition pursuant to 10CFR50.72(b)(3)(ii).

"Unit 2 is currently in Mode 4 (cold shutdown) for a maintenance outage."

This leaking RHR pump suction relief valve, previously identified in EN #49344, is being evaluated and repaired.

The licensee has notified the NRC Resident Inspector and the state.

Page Last Reviewed/Updated Tuesday, September 17, 2013
Tuesday, September 17, 2013