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Event Notification Report for January 8, 2014

U.S. Nuclear Regulatory Commission
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Event Reports For
01/07/2014 - 01/08/2014

** EVENT NUMBERS **


49680 49681 49683 49686 49699 49700

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Agreement State Event Number: 49680
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DEL-TIN FIBER, LLC
Region: 4
City: EL DORADO State: AR
County:
License #: ARK-0874-0312
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/30/2013
Notification Time: 12:04 [ET]
Event Date: 12/27/2013
Event Time: [CST]
Last Update Date: 12/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following information was received via email from Arkansas Department of Health:

"The licensee notified the [Arkansas] Department [of Health] on December 27, 2013 via email that a Ronan source holder model SA1-F37 shutter failed. The source holder serial number is M4785, and the source contains 100 mCi of Cesium-137. The problem was discovered during shutter checks. [According to the licensee], it appears the shutter handle is spinning on the shaft that rotates [to] open [and] close the shutter. [This] may be a result of a sheared pin that connects the handle to the shaft. Per the RSO, the gauge is still in use, and there have been no exposures to employees or members of the public. The RSO has notified applicable facility personnel.

"The licensee indicated the manufacturer was contacted on December 27, 2013 and repairs should be performed the week of January 6th-13th.

"The State of Arkansas is awaiting a written report after repairs. The State's event number is ARK-2013-013."

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Non-Agreement State Event Number: 49681
Rep Org: UNIVERSAL WELL SERVICES
Licensee: UNIVERSAL WELL SERVICES
Region: 1
City: BUCKHANNON State: WV
County:
License #: 37-35092-01
Agreement: N
Docket:
NRC Notified By: MEGAN YINGLING
HQ OPS Officer: VINCE KLCO
Notification Date: 12/31/2013
Notification Time: 10:35 [ET]
Event Date: 12/30/2013
Event Time: 13:30 [EST]
Last Update Date: 12/31/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

DAMAGED GAUGE SHUTTER HANDLE

The licensee reported a shutter handle was bent during fracking field operations that are located in Marion County, West Virginia. The shutter is stuck closed in a safe operations position in a fixed location and presents no danger to personnel. The malfunctioning device is a Berthold Model LB8010; Shield serial number (#10102); Source serial number (0561/10); Source of 10 milliCuries of Cesium-137.

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Agreement State Event Number: 49683
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: STERIS ISOMEDIX SERVICES, INC.
Region: 1
City: CHESTER State: NY
County:
License #: C2583
Agreement: Y
Docket:
NRC Notified By: ROBERT. DANSEREAU
HQ OPS Officer: VINCE KLCO
Notification Date: 12/31/2013
Notification Time: 10:37 [ET]
Event Date: 12/27/2013
Event Time: [EST]
Last Update Date: 12/31/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT- IRRADIATOR MALFUNCTION

The following information was received by facsimile:

"The Radiation Safety Officer reported a source rack travel event that occurred the evening of December 27, 2013. After an irradiation run, the 3 source racks in a panoramic irradiator were lowered into the pool; source rack 3 was completely lowered but source racks 2 and 1 only lowered 8 and 6 feet, respectively, below the water line causing a travel fault. MDS Nordion was immediately notified and provided guidance to Steris Isomedix staff. The highest exposure rate at the surface of the pool was 18 mR/hr. After investigation, it was determined that the pool water skimmer basket dislodged and became stuck behind source rack 1; source rack 1 pushed into source rack 2 which pushed into source rack 3. The basket was freed from the source rack using remote manipulation tools around [0100] on December 28. The highest worker exposure (from a pocket dosimeter) was less than 1 mrem. A full written report of this event including corrective actions will be submitted to the Department [New York State Department of Health]."

New York Event: NY-13-07

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Agreement State Event Number: 49686
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/31/2013
Notification Time: 16:35 [ET]
Event Date: 12/27/2013
Event Time: [EST]
Last Update Date: 12/31/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR MEDICINE ADMINISTERED TO WRONG PATIENT

The following Agreement State Report was received via facsimile:

"Notifications: York Hospital [a PA DEP licensee] left a voice message on Friday, December 27, 2013 after business hours; the voice message was reviewed by the South Central Regional Office on Monday, December 30, 2013. This is an immediate reporting event under 35.3045(a)(2)(iii).

"Event Description: On Friday, December 27, 2013 a nuclear medicine technologist at York Hospital injected the wrong patient with 500 microcuries (microCi) of indium-111 (ln-111) Oxine leukocyte (ln-111 Oxine WBC or ln-111 WBC). This was to be part of a radiolabeling leukocyte component procedure for another patient that was in an adjacent room. The nuclear medicine technologist noticed swelling at the injection site and notified a nurse. Physicians and patient were informed of the incident on December 27th. Additional information regarding the dimensions of the tissue volume affected by the extravasation has become available from non-nuclear imaging performed subsequent to the ln-111 WBC injection. The shallow dose to the skin was estimated to be approximately 210 rad (2.1 Gy).

"In addition, a request has been made for approval to conduct follow-up whole body imaging of the residual ln-111 in the patient's body, towards providing additional information utilizable in refining further the shallow and whole body dose estimate.

"CAUSE OF THE EVENT: Human error. The nuclear medicine technologist did not check the patient's wrist-band, nor did they correlate the name and birth date provided verbally from the wrong patient, as to being not the appropriate patient for the ln-111 WBC injection.

"ACTIONS: A reactive inspection by the PA DEP South Central Region took place on Monday, December 30th. The nuclear medicine technologist was immediately placed on administration leave by the licensee. Further investigations by PA DEP and the licensee are underway."

PA Event Report ID No: PA130030

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: 49699
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JACK OSBORNE
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/07/2014
Notification Time: 13:12 [ET]
Event Date: 01/07/2014
Event Time: 07:45 [EST]
Last Update Date: 01/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
WAYNE SCHMIDT (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

UNANALYZED CONDITION CAUSED BY HIGH ENERGY LINE BREAK BARRIER DOOR OPEN DURING MAINTENANCE

"At approximately 0745 on January 7, 2014, a review of maintenance activities performed on October 3, 2013 on Salem Unit 2, identified an instance in which a High Energy Line Break (HELB) barrier access door was not properly controlled during a Turbine Driven Auxiliary Feedwater Pump room maintenance activity. A HELB event occurring in a room with its barrier door open could adversely affect equipment in an adjacent room. The steam supply to the Turbine Driven Auxiliary Feedwater Pump was not isolated in support of the maintenance activities and the room HELB barrier door was not properly controlled during maintenance in the room. Consequently, a HELB event occurring in the Unit 2 Turbine Driven Auxiliary Feedwater Pump room with the impaired barrier door, could have rendered the Turbine Driven Auxiliary Feed water Pump and both of the Motor Driven Auxiliary Feedwater Pumps in the adjacent room inoperable.

"This event is being reported under the requirements of 10 CFR 50.72(b)(3)(ii)(B) as "the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety." An ENS notification is required if an unanalyzed condition occurred within 3 years of the date of discovery even if the event is not on-going at the time of discovery.

"The Licensee has notified the NRC Resident."

The licensee also will notify the Lower Alloways Creek Township.

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Power Reactor Event Number: 49700
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: QUOC VO
HQ OPS Officer: DAN LIVERMORE
Notification Date: 01/07/2014
Notification Time: 16:07 [ET]
Event Date: 01/07/2014
Event Time: 12:10 [PST]
Last Update Date: 01/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BOB HAGAR (R4DO)

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

REACTOR BUILDING STACK MONITOR TEMPORARILY OUT OF SERVICE FOR MAINTENANCE

"At 1210 PST on January 7, 2014 the Reactor Building Stack Radiation Monitor- Intermediate Range detector was declared non-functional due to scheduled maintenance on supporting equipment. The monitor is expected to be out of service for approximately 1 hour. Preplanned compensatory actions have been implemented.

"This event is being reported as a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

"At 1238 PST on January 7, 2014 the Reactor Building Stack Radiation Monitor -Intermediate Range detector was declared functional following scheduled maintenance on supporting equipment. Emergency Assessment Capability has been restored. Preplanned compensatory actions have been secured.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014