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Event Notification Report for September 26, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/25/2013 - 09/26/2013

** EVENT NUMBERS **


49352 49354 49357 49383 49384 49386

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Agreement State Event Number: 49352
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: CARLSON TESTING, INC.
Region: 4
City: TIGARD State: OR
County:
License #: 90410
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/17/2013
Notification Time: 11:42 [ET]
Event Date: 09/14/2013
Event Time: 01:30 [PDT]
Last Update Date: 09/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE WITH POTENTIAL EXPOSURE FROM AN UNSHIELDED SOURCE ROD

An operator did not maintain direct control of a Troxler Model 3440 Gauge and it was run over by a roller at a work site in Portland, Oregon. This resulted in severe damage to the gauge and the source rod being separated from the device.

The licensee's CRSO (Corporate Radiation Safety Officer) responded to the work site to check for elevated radiation levels and determined that the sources were still intact.

Personnel shielded the rod and transported the gauge and the rod back to the licensee's facility. The damaged gauge has been placed in a locked storage room at the licensee's corporate office with warnings attached to the door to prevent entry. The dose received by the CRSO was 4.36 mrem.

The licensee will provide refresher training and review and revise procedures as necessary. The licensee will ship the gauge back to Troxler Laboratories in the near future.

The gauge is a Troxler Model 3440, Serial # 37190, with 9.0 mCi Cs-137 and 44.0 mCi Am-241/Be sources.

State Event Report # OR 13-0037.

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Agreement State Event Number: 49354
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: PETE SNYDER
Notification Date: 09/18/2013
Notification Time: 16:28 [ET]
Event Date: 09/18/2013
Event Time: [EDT]
Last Update Date: 09/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT'S LIVER

The Commonwealth of Massachusetts submitted the following information via email:

"A dose that likely differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more.

"The licensee's radiation safety officer reported to the Agency [Massachusetts Radiation Control Program] on 9/18/2013 that on same date licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver for treatment of metastatic disease; that 16.8 millicuries of yttrium-90 was prescribed; and that 12.06 millicuries was administered resulting in an under dose of 28.1 percent.

"The licensee discovered the event upon measurement of waste material including dose vial as part of normal quality assurance.

"The licensee's radiation safety officer reported that the authorized user and the referring physician have been notified and it is unknown at time of the report whether the referring physician has elected to notify the patient.

"The licensee's radiation safety officer reported that medical staff does not believe that this error will adversely affect the patient treatment outcome.

"The licensee will submit a written report within 15 days in accordance with the [Massachusetts] requirements of 105 CMR 120.594(A)(4) to include why event occurred and actions to prevent recurrence.

"Root cause and corrective action are not known at this time and the Agency continues to investigate.

"System Name: Brachytherapy Product; Manufacturer: Sirtex Wilmington LLC"

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: 49357
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: NATHAN PIEPER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/19/2013
Notification Time: 09:58 [ET]
Event Date: 09/19/2013
Event Time: 04:50 [CDT]
Last Update Date: 09/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KENNETH RIEMER (R3DO)

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

TECHNICAL SUPPORT CENTER EMERGENCY DIESEL GENERATOR REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"A planned maintenance evolution at the Duane Arnold Energy Center (DAEC) will remove the emergency power supply to the TSC from service. The TSC would be rendered non-functional with the loss of emergency power. The repair to the power supply is expected to last 2 hours.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Maintenance will be expedited to restore the emergency power supply to service.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC emergency power supply has been restored to normal operation.

"NRC Resident Inspector has been notified."

* * * UPDATE FROM TIM ERGER TO HOWIE CROUCH AT 1325 EDT ON 9/22/13 * * *

The TSC EDG remains unavailable due to emergent work. The licensee has notified the NRC Resident Inspector.

Notified R3DO (Riemer).

* * * UPDATE FROM MIKE STROPE TO DANIEL MILLS AT 1237 EDT ON 9/25/13 * * *

The TSC EDG has returned to functional status. The licensee notified the NRC Resident Inspector.

Notified R3DO (Dickson).

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Power Reactor Event Number: 49383
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MIKE STROPE
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/25/2013
Notification Time: 11:08 [ET]
Event Date: 09/25/2013
Event Time: 03:04 [CDT]
Last Update Date: 09/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BILLY DICKSON (R3DO)

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

LOSS OF NORMAL TSC POWER DUE TO TRANSFORMER ISOLATION

"At 0304 (CDT), on Sept 25, 2013, the Duane Arnold Energy Center (DAEC) Technical Support Center (TSC) normal power supply was lost when the T4 '36KV-12.5KV DAEC SITE TRANSFORMER' was lost. Automatic power transfer occurred to maintain power to the TSC from the TSC Emergency Diesel Generator (EDG) which automatically started. Prior to the loss of normal power, the TSC Emergency Diesel Generator maintenance functional testing had been completed and was in standby readiness, awaiting post maintenance testing to be completed on the auto start circuit. The TSC Emergency Diesel Generator responded normally to the loss of power and energized TSC loads. The TSC remained functional throughout the incident.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(xiii) due to the loss of an emergency assessment capability. An update will be provided once the normal power supply has been restored."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 49384
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WALTER ORF
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/25/2013
Notification Time: 11:54 [ET]
Event Date: 09/25/2013
Event Time: 10:06 [EDT]
Last Update Date: 09/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAKE WELLING (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

STACK RADIATION MONITOR REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"The Millstone Power Station Unit 2 High Range Stack Radiation Monitor, RM-8168 is being removed from service for preplanned maintenance. The radiation monitor is estimated to be out of service for approximately 6 hours. This action is reportable as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii)."

The NRC Resident Inspector has been notified. State and local authorities were notified by the licensee.

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Power Reactor Event Number: 49386
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: MARK GREER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/25/2013
Notification Time: 21:20 [ET]
Event Date: 09/25/2013
Event Time: 15:30 [EDT]
Last Update Date: 09/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
BLAKE WELLING (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

ENVIRONMENTAL IMPACT DURING SERVICE WATER MOLLUSK BIOCIDE TREATMENT

"During Service Water mollusk biocide treatment, divers in Lake Ontario found approximately 20 Goby fish dead near the intake structure. Nine Mile Point Unit 2 Operating License Appendix B, Environmental Protection Plan, paragraph 4.1 requires a 24-hour notification of any occurrence of an unusual or important event that indicates or could result in significant environmental impact causally related [to] plant operations. This fish kill may have been caused by the chemical injection line being dislodged above the intake structure. Chemical injection was secured when the mispositioned line was discovered. The New York State DEC [Department of Environmental Conservation] was notified in a related report of the unexpected injection site of the chemical.

"The NRC Resident inspector has been notified."

Page Last Reviewed/Updated Thursday, September 26, 2013
Thursday, September 26, 2013