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Event Notification Report for February 4, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/03/2014 - 02/04/2014

** EVENT NUMBERS **


49762 49764 49766 49769 49770 49787 49788 49789

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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
Notification Date: 01/24/2014
Notification Time: 10:56 [ET]
Event Date: 01/22/2014
Event Time: [EST]
Last Update Date: 01/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

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.

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Agreement State Event Number: 49764
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BOSTON UNIVERSITY MEDICAL CENTER
Region: 1
City: BOSTON State: MA
County:
License #: 44-0062
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/24/2014
Notification Time: 17:24 [ET]
Event Date: 01/24/2014
Event Time: 15:00 [EST]
Last Update Date: 01/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT - MISADMINISTRATION OF I-131

The following information was obtained from the Commonwealth of Massachusetts via facsimile:

"30 mCi of I-131 (NaI) was administered to the wrong patient. Blocking agent has been prescribed by doctor. Patient is described as in their 70s. Doctor and patient have been informed. 15 day report will follow."

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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Non-Agreement State Event Number: 49766
Rep Org: US AIR FORCE
Licensee: US AIR FORCE
Region: 1
City: ARLINGTON State: VA
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: DANIEL SHAW
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2014
Notification Time: 08:39 [ET]
Event Date: 10/01/2013
Event Time: [EST]
Last Update Date: 01/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BLAIR SPITZBERG (R4DO)
FSME EVENT RESOURCE (EMAI)
MATTHEW HAHN (ILTA)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LOSS OF RADIOACTIVE MATERIAL

The following report was received via email;

"1. IAW 10 CFR 20.2201(a)(1)(ii), we are providing a written report for the loss of radioactive material. The loss of material was reported on 27 Jan 14; 1) telephonically to NRC Operations Center, Event No. 49766 and 2) via E-mail to NRC, Region IV (Ms. Cook). The following information addresses the reporting requirements:

"a. Description of the licensed material: The subject device contained nickel 63 (Ni-63), one source, at 15 millicuries. The source is encapsulated in a hollow brass cylinder which in turn is sealed in a ceramic shield as referenced in Sealed Source & Device Registry (SS&DR) NR-0163-D-102-E (19 Oct 2010). The subject device was generally licensed (GLD) and used by USAF Security Forces Personnel (75th SFS) of Hill AFB, Ogden, UT.

"b. Description of circumstances for loss: The missing Ionscan 500DT was added to the Installation Radiation Safety Officers inventory of all GLDs on Hill AFB in October 2007. The serial number of the missing source is 50083. It was surveyed semi-annually through May 2013. During the November 2013 leak test/inventory of GLDs, the device was not at the security gate where it has always been. The 75 SFS storage warehouse was checked and it was not there either.

"c. Statement of disposition: 75 SFS personnel were asked multiple times about the disposition of the item. On 11 December 2013, they reported the Ionscan was no longer in their possession. They reported that the item was dropped and damaged during transport. An Airman was assigned to locate a disposal location that would be able to take the item and was directed to dispose of it there. Later the Airman reported that he had done this. The Airman was in the process of being dismissed from the Air Force at that time and is no longer in the Air Force for questioning on how he disposed of the item. Therefore, the final disposition of the item is unknown at this time.

"d. Exposures to individuals: Because the device contains Ni-63, which is sealed and incorporated into the Ion Mobility Spectrometer assembly, the radiation level surrounding the device would be indistinguishable from background.

"e. Actions taken: Requests have been made of multiple levels of 75 SFS command to obtain more specifics on the event. No additional information has been received to-date.

"f. Procedures/measures to rectify future loss: The installation radiation safety officer will reinforce the policies outlined in Air Force Instruction (AFI) 40-201, Managing Radioactive Materials in the United States Air Force for proper disposal of generally licensed devices."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49769
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: ARC ENVIRONMENTAL
Region: 1
City: BALTIMORE State: MD
County:
License #: MD-07-199-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/27/2014
Notification Time: 16:35 [ET]
Event Date: 01/27/2014
Event Time: 14:40 [EST]
Last Update Date: 01/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

MARYLAND AGREEMENT STATE REPORT - STOLEN LEAD PAINT ANALYZER

The following information was received from the State of Maryland via email:

"The Maryland Radiation Program received a telephone call around 3:55 p.m. [EST] from [the RSO] of Arc Environmental (MD-07-199-01) informing the Department [Maryland Department of the Environment] that an XRF (RMD LPA1) was stolen from 2611 East Monument Street, Baltimore, Maryland where they were performing an inspection. The theft occurred at about 2:40 p.m. when the two inspectors, [names deleted], were leaving the site. They thought the other had put the XRF in the vehicle, and when they realized they did not have it, returned to the site, but the XRF was gone. They will provide the Department a copy of the police report when it is available. MDE may put out a press release on 1/28/14 if the device is not recovered."

Per the vendor documentation, the LPA1 nominally contains 12 mCi of Co-57.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49770
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: FLOWER HOSPITAL
Region: 3
City: SYLVANIA State: OH
County:
License #: 02120 49 0004
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/27/2014
Notification Time: 17:05 [ET]
Event Date: 01/24/2014
Event Time: [EST]
Last Update Date: 01/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STUART SHELDON (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following was received from the State of Ohio via email:

"On Jan. 27, 2014, the RSO of Flower Hospital provided a telephone report of medical event that occurred on Jan. 24 and 27, 2014.

"A patient was being treated with a Varian GammaMed Plus HDR with 4.7 Ci of lr-192 in a vaginal cylinder. The written directive was for three fractions of 500 cGy for a total of 1,500 cGy. Then during the delivery of the second fraction the licensee realized that they were only delivering a planned dose of 166 cGy. The licensee completed the second fraction as planned. The treatment planning was entered as one third of the 500 cGy for three fractions instead of three fractions of 500 cGy. The license will modify the treatment plan to give the full prescribed 1500 cGy to the patient.

"The patient was notified on Jan. 27, 2014.

"This is a reportable medical event under OAC 3701:1-58-101 (A)(1)(c.) for a fractionated dose that differs by more than 50%."

Ohio Report #: OH140001

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: 49787
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: STEVEN MELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/03/2014
Notification Time: 02:41 [ET]
Event Date: 02/03/2014
Event Time: 00:43 [CST]
Last Update Date: 02/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STUART SHELDON (R3DO)

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

Event Text

TECHNICAL SUPPORT CENTER EMERGENCY VENTILATION SYSTEM OUT OF SERVICE FOR PLANNED MAINTENANCE

"At 0043 [CST] on Monday, February 3, 2014, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system was removed from service for planned preventative maintenance activities on the TSC ventilation system condensing unit. The TSC air handing and filtration units will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 88 hours. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Preparedness (EP) procedures and checklists. If radiological conditions require TSC facility evacuation during ventilation system maintenance; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with established procedures.

"The licensee notified the NRC Resident Inspector."

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Power Reactor Event Number: 49788
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN HAMM
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/03/2014
Notification Time: 10:26 [ET]
Event Date: 02/03/2014
Event Time: 10:03 [EST]
Last Update Date: 02/03/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GERALD MCCOY (R2DO)
DAN DORMAN (NRR)
VICTOR MCREE (RA)
SCOTT MORRIS (IRD)

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

UNUSUAL EVENT DECLARED DUE TO TOXIC GAS RELEASE THAT COULD AFFECT NORMAL OPERATION

At 1003 EST, Unit 1 declared an Unusual Event - EAL HU 3.1 (Toxic/corrosive/asphyxiate/flammable gas release that could affect normal operations) due to smoke in the Unit 1 "B" Battery room. The Unit 1 standby UPS inverter cabinet was smoking and leaking fluid. The fire brigade responded and declared the room uninhabitable due to smoke. The standby inverter was de-eneergized and the smoke subsided. The standby inverter was not in service and no plant equipment was lost. Unit 2 was not affected. Request for offsite assistance was sent to the local fire department but was not needed.

The licensee notified the NRC Resident Inspector, the State of North Carolina, and local emergency response organizations.

Notified Federal Agencies [DHS SWO, FEMA Operations Center, NICC Watch Officer, and NuclearSSA] via email.

* * *UPDATE PROVIDED TO JEFF ROTTON FROM MARTIN HAMM AT 1045 EST ON 02/03/2014* * *

Licensee terminated from the Unusual Event at 10:25 EST.

Licensee notified the NRC Resident Inspector, the State of North Carolina and local emergency response organizations.

Notified Federal Agencies [DHS SWO, FEMA Operations Center, NICC Watch Officer and Nuclear SSA] via email.

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Power Reactor Event Number: 49789
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHARLES BAREFIELD
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/03/2014
Notification Time: 18:39 [ET]
Event Date: 02/03/2014
Event Time: 12:00 [CST]
Last Update Date: 02/04/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GERALD MCCOY (R2DO)

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

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO A REFRIGERANT LEAK IN THE HVAC SYSTEM

"The facility Technical Support Center (TSC) was rendered non-functional due to a malfunction in the TSC HVAC system. A leak in the refrigerant tubing has resulted in a loss of refrigerant and affected the system's ability to provide proper climate control. Repairs are being planned and will commence today. The out of service time is greater than one hour which by the station's Technical Requirements Manual is an 8 hour non-emergency report.

"Compensatory measures per site procedure FNP-0-EIP-6.0 (TSC Setup and Activation) for maintaining emergency assessment, off-site response, and off-site communication capabilities are available. These measures include the conditional relocation of the TSC staff in the event of a declared emergency if the Emergency Director deems the TSC to be uninhabitable.

"A follow up notification will be made when the TSC is declared functional."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE AT 0100 EST ON 02/04/14 FROM RICK LULLING TO S. SANDIN * * *

The following was received as a courtesy notification follow-up:

"At 2320 CST on 2/3/2014 the TSC HVAC was declared functional following post maintenance testing. Satisfactory pressure testing, system evacuation, and system re-charging were performed following the repair to two tubing leaks. Emergency assessment, off-site response, and off-site communication capabilities have been fully restored to the Technical Support Center. The Emergency Director, and NRC Senior Resident Inspector have been informed."

Notified R2DO (McCoy).

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