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Event Notification Report for November 14, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/13/2013 - 11/14/2013

** EVENT NUMBERS **


49501 49508 49531 49533 49534

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 49501
Rep Org: RESEARCH MEDICAL CENTER
Licensee: RESEARCH MEDICAL CENTER
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-18625-01
Agreement: N
Docket:
NRC Notified By: STEPHEN SLANICK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/04/2013
Notification Time: 17:45 [ET]
Event Date: 11/04/2013
Event Time: 10:00 [CST]
Last Update Date: 11/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING OVEREXPOSURE TO BLADDER DURING PROSTATE TREATMENT

During a prostate cancer treatment, at 1000 hours [CST] on 11/04/13, it was discovered that one I-125 strand with 6 seeds was improperly inserted into the bladder. The patient's prescribed dose was 144 gray to the prostate with a 12% exposure to the bladder. The procedure to the prostate was completed with extra I-125 seeds and the estimated dose to the bladder is 18%. It is believed that shadowing from the urethra, during treatment, was the cause. An attempt to withdraw the seeds from the bladder when the problem was identified was unsuccessful. The patient has been informed and the patient's physician will be informed and will consult with the urologist as soon as possible to determine a method for seed retrieval.

* * * UPDATE ON 11/8/13 AT 1150 EST FROM STEPHEN SLACK TO DONG PARK * * *

The following was received via email:

"The event took place during an implant of I-125 seeds into the prostate of a patient. One strand of six seeds was instead implanted into the bladder. Attempts to remove the strand of seeds at that time were unsuccessful.

"Renewed attempts were made to remove the strand this morning and they were successful. The implant was planned for 144 Gy to the prostate over the full decay time of the I-125. This would have resulted in a mean dose to the bladder of 22.34 Gy. If the extra seeds had remained in place, the mean dose to the bladder would have been 39.15 Gy; hence the report of a Medical Event.

"By removing the seeds this morning, the mean dose to the prostate has been reduced to 23.09 Gy. This is more than 50 rads to the organ but less than a 50% increase over what the organ would have gotten in the planned treatment."

Notified R3DO (Riemer) and FSME Events Resource via email.

* * * UPDATE ON 11/13/13 AT 1757 EST FROM STEPHEN SLACK TO NESTOR MAKRIS * * *

The following was received via email:

The first sentence of the last paragraph in the previous update should have read "By removing the seeds this morning, the mean dose to the bladder has been reduced [to 23.09 Gy]." rather than the mean dose to the prostate.

Notified R3DO (Cameron) and FSME Events Resource via email.

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: 49508
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: S&ME - GREENSBORO OFFICE
Region: 1
City: GREENSBORO State: NC
County:
License #: 0922-3
Agreement: Y
Docket:
NRC Notified By: CHRIS FIDALGO
HQ OPS Officer: PETE SNYDER
Notification Date: 11/06/2013
Notification Time: 11:08 [ET]
Event Date: 11/06/2013
Event Time: 08:30 [EST]
Last Update Date: 11/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following Agreement State Report was received via facsimile:

"The licensee contacted [the NC Radiation Protection] agency at approximately 0930 EST with the following info: A dump truck at a construction site ran over an lnstroTek Model 3500 Xplorer moisture density gauge. The area of the accident was cordoned off and the licensee RSO [was sent to] report back to agency with survey readings and leak test results. The gauge sources contain 11 mCi of Cs-137 and 44 mCi of Am-241/Be.

"A survey by the licensee [RSO] showed a maximum reading of 0.5 mrem/hr. The instrument make/model was of the survey meter was not specified. Sources appear to be intact. The gauge and debris were returned to the gauge case (doubles as shipping container- DOT 7A Yellow II). The gauge will be shipped to lnstroTek corporation for repair or disposition."

NC State Report Number: ICD 13-20

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Power Reactor Event Number: 49531
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/13/2013
Notification Time: 09:53 [ET]
Event Date: 11/13/2013
Event Time: 02:26 [EST]
Last Update Date: 11/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
J LILLIENDAHL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

SECONDARY CONTAINMENT ZONE II DIFFERENTIAL PRESSURE LOST DURING RECOVERY FROM VENTILATION DRAWDOWN TEST

"On November 13, 2013 at 0226 [EST], Secondary Containment Zone II (Unit 2 Reactor Building) differential pressure was lost during restoration of a ventilation drawdown test. During restoration Unit 2 'A' Train Reactor Building Ventilation fans tripped. The 'B' Train fans were placed in service and secondary containment was restored. Zone I (Unit 1 Reactor Building) and III (Common Refuel Floor Area) ventilation remained in service and stable.

"Zone II differential pressure recovered within a few minutes and was verified to be stable. LCO 3.6.4.1 was exited for both units at 0257 [EST]. Tech Spec Secondary Containment Operability requires a negative pressure of at least 0.25 inches water gauge.

"There have been no further perturbations in differential pressure and secondary containment remains operable.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

The cause of the Unit 2 "A" Train Reactor Building ventilation fans tripping is still under investigation.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 49533
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PIERCE C. MOORE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/13/2013
Notification Time: 11:42 [ET]
Event Date: 11/13/2013
Event Time: 09:24 [CST]
Last Update Date: 11/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

FUEL OIL LEAK TO THE ENVIRONMENT

"Approximately 10 gallons of fuel oil was spilled from excavation equipment onto the ground inside the owner controlled area. Notifications will be made to the National Response Center and the Kansas Dept. of Health and Environment. Cleanup by on-site personnel is in progress. No fuel oil made contact with any surface water.

"NRC resident inspector has been notified [by the licensee]."

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Part 21 Event Number: 49534
Rep Org: ENGINE SYSTEMS, INC.
Licensee: ENGINE SYSTEMS, INC.
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOM HORNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/13/2013
Notification Time: 11:18 [ET]
Event Date: 10/25/2013
Event Time: [EST]
Last Update Date: 11/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
HAROLD CHERNOFF (NRR)
WILLIAM GOTT (IRD)
PART 21 GROUP (EMAI)

Event Text

PART21 - DIODE CR7 WIRING REVERSED ON AUTOMATIC VOLTAGE REGULATOR PANELS

The following is a summary of information received via facsimile:

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 10/25/2013 after receiving notification from APS-Palo Verde Nuclear Generating Station that diode CR7 on their automatic voltage regulator (AVR) panels had the wiring connections reversed. During installation of the AVR panels, generator output voltage buildup was observed to be longer than expected during fast start testing. The slow voltage buildup was determined to be caused by a lack of generator field flashing. Troubleshooting revealed that the field flash diode CR7 wiring was reversed.

"The evaluation was concluded on 11/11/2013, and it was determined that this issue is a reportable defect as defined by 10CFR21. The incorrect wiring of diode CR7 prevents field flashing of the generator. Lack of generator field flashing can result in failure of generator voltage buildup, or excessive voltage buildup time, during starting of the emergency diesel generator (EDG). This condition could therefore have impacted operability of the EDG and prevented it from performing its safety related function.

"APS-Palo Verde is the only affected customer. This reversed CR7 wiring condition only applies to the five (5) AVR panels (P/N 072-12200-100-PVNGS) shipped to Palo Verde on ESI sales order 8001720 (4 panels shipped in May 2013 and 1 panel shipped in June 2013)."

Page Last Reviewed/Updated Thursday, November 14, 2013
Thursday, November 14, 2013