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Event Notification Report for February 20, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/19/2014 - 02/20/2014

** EVENT NUMBERS **


49815 49816 49817 49822 49841 49842 49844

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Agreement State Event Number: 49815
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/11/2014
Notification Time: 17:37 [ET]
Event Date: 01/24/2014
Event Time: [EST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING UNINTENDED DOSE

"During a liver radio embolization procedure with Y-90 SIRTEX Sir-Spheres on January 24, 2014 an unanticipated shunting occurred and was identified during the procedure. The procedure for the right liver lobe was stopped when the shunting was identified. The licensee runs contrast between vial doses to verify proper delivery of the microspheres. After imaging of the patient, the licensee determined on January 27, 2014 that the unintended dose to the gastric fundus was 11 Gray. The licensee reported the medical event to ODH BRP [Ohio Department of Health - Bureau of Radiation Protection] by telephone on February 11, 2014 at 3:30pm [EST].

"The referring physician and patient were notified on January 24, 2014. The patient is asymptomatic (no adverse effects) and is currently receiving medical monitoring."

Ohio Report #: OH140002


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: 49816
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS GROUP, INC.
Region: 4
City: BENICIA State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/11/2014
Notification Time: 18:03 [ET]
Event Date: 02/09/2014
Event Time: 10:35 [PST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LEFT UNATTENDED

The following Agreement State report was received via email:

"On February 10, 2014, [the California Department of Health, Radiologic Health Branch] RHB Richmond received a call from the MISTRAS Group RSO, indicating that a radiographer had inadvertently left behind a radiography camera when he drove off the parking lot at the Chevron Richmond Refinery. On February 9, 2014, at 1035 [PST] after the radiographer finished radiography using IR100 Camera containing 31 Curies Ir-192, s/n 6614, he left the radiography camera on the bumper of the truck; later, assuming that he left the camera inside the truck, he drove off and the camera fell onto the pavement. According to the radiographer, the camera was left unattended for a short period of time. Later, a Chevron Richmond employee noticed the camera in the parking lot and contacted the Chevron facility Manager. Chevron management contacted Mistras RSO and he drove to the refinery and took possession of the camera."

California Report #: 021014

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49817
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS GROUP, INC.
Region: 4
City: BENICIA State: CA
County:
License #: 4886-48
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/11/2014
Notification Time: 18:40 [ET]
Event Date: 02/09/2014
Event Time: 06:00 [PST]
Last Update Date: 02/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following Agreement State report was received via email:

"On February 10, 2014, [the California Department of Health, Radiologic Health Branch] RHB Richmond received a call from MISTRAS Group, Inc. RSO, regarding a source disconnect. On February 9, 2014, at 0600 [PST], during radiography at Chevron Refinery, using IR-100 camera, containing 31 Curies, Ir-192, s/n 6614, the source pigtail connector became disconnected from the drive cable. Following good health physics practices, the RSO retrieved and secured the source into the shielded position. Exposures to personnel [were] less than 50 millirem for this event."

California Report #: 021114

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Agreement State Event Number: 49822
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EISENHOWER MEDICAL CENTER NUCLEAR MEDICINE DEPARTMENT
Region: 4
City: RANCHO MIRAGE State: CA
County:
License #: LN2425-33
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/12/2014
Notification Time: 15:07 [ET]
Event Date: 02/11/2014
Event Time: 06:00 [PST]
Last Update Date: 02/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST MEDICAL PACKAGE

The following information was received via email:

"On February 11, 2014, the RSO of Eisenhower Medical Center, LN2425-33, contacted [the California Department of Health, Radiologic Health Branch] RHB about a Bracco CardioGen Rb-82/Sr-82 generator that was packaged for shipment to the manufacturer for disposal. The package was left unattended/unsecured in an unrestricted area on February 10, 2013 between 1600 PST and 1800 PST awaiting [common carrier] pickup . The package was sealed with radioactive material labels. When the first technician arrived at the facility at approximately 0600 [PST], the box was missing and no paperwork from [the common carrier] had been left. [The common carrier] was contacted and they had no records of a pick-up. [The common carrier] has initiated an investigation.

"The licensee reported the following information for the package:
"Surface dose rate 19.4 mR/hr and 1 meter dose rate 323 microR/hr;
"Surface wipe 713 dpm/100cm2; and
"Total mCi 99.9 (3.60 GBq).

"On February 12, 2014, the RSO contacted RHB and stated that someone from housekeeping placed the package in the dumpster which was picked up on February 11 and sent to the Riverside County Landfill. The landfill and Riverside County HAZMAT were informed. The licensee personnel then proceeded to the landfill to attempt to recover the package. The package has not been recovered as of this time."

California Report #: 021114

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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Power Reactor Event Number: 49841
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: NICHOLAS E. RULLMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2014
Notification Time: 14:29 [ET]
Event Date: 02/19/2014
Event Time: 08:29 [PST]
Last Update Date: 02/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DON ALLEN (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 PRIMARY CONTAINMENT OXYGEN AND HYDROGEN MONITORING

"This notification is being made due to a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). At 0829 (PST), on 2/19/2014 the Division 1 sample rack for monitoring primary containment oxygen and hydrogen atmospheric concentrations was removed from service for planned maintenance activities. The Division 1 sample rack is expected to be out of service for 14 hours. The redundant Division 2 sample rack was previously removed from service for maintenance and remains out of service for repairs. Compensatory measures to monitor primary containment for hydrogen and oxygen are available via grab samples using chemistry procedures.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49842
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAN WILLIAMSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2014
Notification Time: 15:32 [ET]
Event Date: 02/19/2014
Event Time: 10:19 [EST]
Last Update Date: 02/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (R1DO)

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 EMERGENCY VENTILATION FAILURE

"On 2/19/2014 at 1019 EST, the Technical Support Center emergency ventilation system failed to operate during TSC Ventilation Operability Check per EP-MA-124-1001-F-02 performed by Limerick Emergency Preparedness staff. Troubleshooting of this equipment deficiency found a blown control power fuse. The fuse failure is attributed to its age. The system has been restored to operational status as of 1430 EST on 2/19/2014.

"If an emergency had been declared and TSC activation was required, the TSC would have been staffed and activated unless the TSC became uninhabitable due to ambient temperatures, radiological or other conditions. The Station Emergency Director would assess habitability in accordance with station procedures. TSC relocation of personnel would be directed as required until such time that the TSC emergency ventilation system was returned to service."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 49844
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DREW RADOSEVIC
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/19/2014
Notification Time: 20:31 [ET]
Event Date: 02/19/2014
Event Time: 14:03 [CST]
Last Update Date: 02/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
HIRONORI PETERSON (R3DO)

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

FITNESS FOR DUTY - LICENSED EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL

A licensed employee supervisor had a confirmed positive test for alcohol during a for cause fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

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