Event Notification Report for January 22, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/21/2014 - 01/22/2014
EVENT NUMBERS
49762497564975849759
Agreement State
Event Number: 49762
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: NESTOR MAKRIS
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: NESTOR MAKRIS
Notification Date: 01/24/2014
Notification Time: 10:56 [ET]
Event Date: 01/22/2014
Event Time: 00:00 [EST]
Last Update Date: 01/24/2014
Notification Time: 10:56 [ET]
Event Date: 01/22/2014
Event Time: 00:00 [EST]
Last Update Date: 01/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
PENNSYLVANIA AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following was received via fax from the Commonwealth of Pennsylvania:
"Notifications: Licensee reported this event to the Department's [Pennsylvania Department of Environmental Protection] Southeast Regional Office on January 23, 2014. This is an immediate reporting event under 35.3045(a)(1)(i).
"Event Description: On January 22, 2014, the licensee experienced a medical event in which 76% of a yttrium-90 (Y -90) TheraSphere liver cancer therapy dose was delivered to the patient. Both the patient and referring physician were notified of the under dose.
"Cause of the Event: Occlusion. The remaining activity appeared to have precipitated out and remained in the catheter.
"Actions: Awaiting the required 15 day written report from the licensee. The Department will provide updated information as received.
"Media attention: None at this time."
Event number: PA140005
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.
The following was received via fax from the Commonwealth of Pennsylvania:
"Notifications: Licensee reported this event to the Department's [Pennsylvania Department of Environmental Protection] Southeast Regional Office on January 23, 2014. This is an immediate reporting event under 35.3045(a)(1)(i).
"Event Description: On January 22, 2014, the licensee experienced a medical event in which 76% of a yttrium-90 (Y -90) TheraSphere liver cancer therapy dose was delivered to the patient. Both the patient and referring physician were notified of the under dose.
"Cause of the Event: Occlusion. The remaining activity appeared to have precipitated out and remained in the catheter.
"Actions: Awaiting the required 15 day written report from the licensee. The Department will provide updated information as received.
"Media attention: None at this time."
Event number: PA140005
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.
Agreement State
Event Number: 49756
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ELEMENT MATERIALS TECHNOLOGY HOUSTON, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: 06451
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Licensee: ELEMENT MATERIALS TECHNOLOGY HOUSTON, INC.
Region: 4
City: HOUSTON State: TX
County:
License #: 06451
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2014
Notification Time: 17:13 [ET]
Event Date: 01/22/2014
Event Time: 00:00 [CST]
Last Update Date: 01/22/2014
Notification Time: 17:13 [ET]
Event Date: 01/22/2014
Event Time: 00:00 [CST]
Last Update Date: 01/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4DO)
FSME EVENTS RESOURCE (EMAI)
BLAIR SPITZBERG (R4DO)
FSME EVENTS RESOURCE (EMAI)
TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO RADIOLOGICAL WORKER
The following information was obtained from the State of Texas via email:
"On January 22, 2014, the Agency [Texas Department of Health] was notified by the licensee's Radiation Safety Officer that they had received a report from their dosimetry processor indicating one of their employees had received 11.27 rem DDE [Deep-Dose Equivalent] on their OSL [optically stimulated luminescence] dosimeter for the exposure period of December 1, 2013 to December 31, 2013. This brought the individuals exposure for the year 2013 to 14.250 rem DDE. The RSO stated they had interviewed the employee, who is a radiography trainee, and was not able to discredit the exposure. The radiographer trainer the trainee worked with was also interviewed and did not have an explanation for the exposure. The trainee has been removed from all duties requiring exposure to radiation. The RSO stated they will contact the Radiation Emergency Assistance Center/Training Site, (REAC/TS) the morning of January 23, 2014, to have a cytogenetic blood testing performed of the individual.
"The RSO stated the trainee's exposure total for the same exposure period, as measured by their self-reading dosimeter, was 165 millirem. The RSO stated the trainee had not been involved in any reported source recoveries or misconnects. The RSO stated they had not observed any medical conditions that would support the reported exposure. The RSO does not believe the exposure is real, but since he has not identified another explanation for the reading he will treat it as real until proven otherwise. Additional information will be provided as it is receive in accordance with SA-300."
Texas Incident #: I-9149
The following information was obtained from the State of Texas via email:
"On January 22, 2014, the Agency [Texas Department of Health] was notified by the licensee's Radiation Safety Officer that they had received a report from their dosimetry processor indicating one of their employees had received 11.27 rem DDE [Deep-Dose Equivalent] on their OSL [optically stimulated luminescence] dosimeter for the exposure period of December 1, 2013 to December 31, 2013. This brought the individuals exposure for the year 2013 to 14.250 rem DDE. The RSO stated they had interviewed the employee, who is a radiography trainee, and was not able to discredit the exposure. The radiographer trainer the trainee worked with was also interviewed and did not have an explanation for the exposure. The trainee has been removed from all duties requiring exposure to radiation. The RSO stated they will contact the Radiation Emergency Assistance Center/Training Site, (REAC/TS) the morning of January 23, 2014, to have a cytogenetic blood testing performed of the individual.
"The RSO stated the trainee's exposure total for the same exposure period, as measured by their self-reading dosimeter, was 165 millirem. The RSO stated the trainee had not been involved in any reported source recoveries or misconnects. The RSO stated they had not observed any medical conditions that would support the reported exposure. The RSO does not believe the exposure is real, but since he has not identified another explanation for the reading he will treat it as real until proven otherwise. Additional information will be provided as it is receive in accordance with SA-300."
Texas Incident #: I-9149
Power Reactor
Event Number: 49758
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JOE LIZEWSKI
HQ OPS Officer: JEFF ROTTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JOE LIZEWSKI
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/22/2014
Notification Time: 23:36 [ET]
Event Date: 01/22/2014
Event Time: 19:56 [CST]
Last Update Date: 01/22/2014
Notification Time: 23:36 [ET]
Event Date: 01/22/2014
Event Time: 19:56 [CST]
Last Update Date: 01/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
NICK VALOS (R3DO)
NICK VALOS (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
LOSS OF SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE
"A spurious closure of a Secondary Containment isolation damper caused a trip of the Fuel Building ventilation system and a loss of Secondary Containment differential pressure. Secondary Containment differential pressure exceeded -0.25 inches of water vacuum rendering Secondary Containment inoperable between the time of 1956 and 2003 [CST]. The damper re-opened, fuel building ventilation was restarted and Secondary Containment differential pressure was restored to normal. This event is reportable under 10CFR50.72(b)(3)(v)c.
"The Licensee will be notifying the NRC Resident Inspector".
Investigation for the spurious closure of a Secondary Containment isolation damper is in progress.
"A spurious closure of a Secondary Containment isolation damper caused a trip of the Fuel Building ventilation system and a loss of Secondary Containment differential pressure. Secondary Containment differential pressure exceeded -0.25 inches of water vacuum rendering Secondary Containment inoperable between the time of 1956 and 2003 [CST]. The damper re-opened, fuel building ventilation was restarted and Secondary Containment differential pressure was restored to normal. This event is reportable under 10CFR50.72(b)(3)(v)c.
"The Licensee will be notifying the NRC Resident Inspector".
Investigation for the spurious closure of a Secondary Containment isolation damper is in progress.
Fuel Cycle Facility
Event Number: 49759
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
Region: 2 State: NC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: JEFF ROTTON
Region: 2 State: NC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/23/2014
Notification Time: 11:30 [ET]
Event Date: 01/22/2014
Event Time: 13:15 [EST]
Last Update Date: 01/23/2014
Notification Time: 11:30 [ET]
Event Date: 01/22/2014
Event Time: 13:15 [EST]
Last Update Date: 01/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RANDY MUSSER (R2DO)
ALADAR CSONTOS (NMSS)
RANDY MUSSER (R2DO)
ALADAR CSONTOS (NMSS)
INOPERABLE CRITICALITY WARNING SYSTEM LOCAL ALARM IN WILMINGTON FIELD SERVICES CENTER BUILDING NUMBER 1
"On 1/22/14 at 1:15 PM [EST], it was discovered during routine testing on an outdoor Criticality Warning System (CWS) Data Acquisition Module (DAM #21), that the module had inadequate voltage to properly sound a portion of the local alarm horns in the Wilmington Field Services Center (WFSC) building #1. While another module provides overlapping detector coverage, it does not provide overlapping horn audibility in the affected areas. The cause of the event is believed to be related to a battery component failure.
"Personnel were immediately removed from the affected areas and repairs initiated to restore normal operation of the system.
"The module was repaired and the system returned to normal on 1/22/14 at approximately 3:00 PM. The affected outdoor CWS horns were retested to ensure proper system operability. There are no active fissile material operations at the WFSC, thus no unsafe condition existed.
"Longer term preventive actions are being evaluated.
"This event is being reported pursuant to the requirements of 10CFR70.50 (b)(2)."
The licensee will be notifying NRC NMSS Licensing Project Manager, NRC Region II Inspection Coordinator, State of North Carolina Radiation Protection Branch, and the New Hanover Emergency Response Branch.
"On 1/22/14 at 1:15 PM [EST], it was discovered during routine testing on an outdoor Criticality Warning System (CWS) Data Acquisition Module (DAM #21), that the module had inadequate voltage to properly sound a portion of the local alarm horns in the Wilmington Field Services Center (WFSC) building #1. While another module provides overlapping detector coverage, it does not provide overlapping horn audibility in the affected areas. The cause of the event is believed to be related to a battery component failure.
"Personnel were immediately removed from the affected areas and repairs initiated to restore normal operation of the system.
"The module was repaired and the system returned to normal on 1/22/14 at approximately 3:00 PM. The affected outdoor CWS horns were retested to ensure proper system operability. There are no active fissile material operations at the WFSC, thus no unsafe condition existed.
"Longer term preventive actions are being evaluated.
"This event is being reported pursuant to the requirements of 10CFR70.50 (b)(2)."
The licensee will be notifying NRC NMSS Licensing Project Manager, NRC Region II Inspection Coordinator, State of North Carolina Radiation Protection Branch, and the New Hanover Emergency Response Branch.