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Event Notification Report for January 9, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/08/2014 - 01/09/2014

** EVENT NUMBERS **


49681 49683 49686 49701 49702

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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: 49701
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT MELTON
HQ OPS Officer: GEROND GEORGE
Notification Date: 01/08/2014
Notification Time: 17:35 [ET]
Event Date: 01/07/2014
Event Time: 14:39 [CST]
Last Update Date: 01/08/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BOB HAGAR (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

OFFSITE NOTIFICATION FOR SPILL IN THE RIVER BEND OWNER CONTROL AREA

"On January 8, 2014, at 1439 CST, River Bend Station management determined that a spill discovered on the morning of January 7 was reportable in accordance with NEI 07-07 (Nuclear Energy Institute), Ground Water Protection Initiative. The spill was the result of freeze damage that occurred on a valve connected to the cooling tower blow-down line. Dams were installed to prevent the water from reaching any storm drains, and the spill was confined to the owner-controlled area. Since this system has the potential to contain diluted radioactive plant effluent, samples were collected for analysis. The leak was immediately reduced to a small drip and actions are in progress to completely isolate and repair the valve. The effluent was determined today to contain 4584 pico-curies per liter of tritium, but no detectable gamma activity. The calculated volume of the leak was between 100 and 1200 gallons. This exceeds the NEI reporting criterion of 100 gallons from a source containing licensed material. The Louisiana Department of Environmental Quality was notified at 1549 CST today.

"This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi) as an event requiring notification of the state government.

"The NRC resident inspector has been notified."

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Power Reactor Event Number: 49702
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: RUSSELL LONG
HQ OPS Officer: GEROND GEORGE
Notification Date: 01/08/2014
Notification Time: 19:49 [ET]
Event Date: 01/08/2014
Event Time: 10:10 [PST]
Last Update Date: 01/08/2014
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

LOSS OF ASSESSMENT CAPABILITY - NON-FUNCTIONAL AREA RADIATION MONITORS

"At [1010 PST] on 1/08/14, during performance of a surveillance the power supply for ten area radiation monitors in the Reactor Building was found with voltage out of specification. As a result, the affected area radiation monitors were declared non-functional. This condition represents a major loss of assessment capability and is being reported as such under 10 CFR 50.72 (b)(3)(xiii). As directed by station procedures, compensatory measures have been enacted until the power supply is restored.

"The Resident Inspector has been notified."

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