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Event Notification Report for May 29, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/28/2014 - 05/29/2014

** EVENT NUMBERS **


50126 50127 50145 50147

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Agreement State Event Number: 50126
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: WATSON CLINIC
Region: 1
City: LAKELAND State: FL
County:
License #: 2619-1
Agreement: Y
Docket:
NRC Notified By: RICHARD DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/20/2014
Notification Time: 15:00 [ET]
Event Date: 05/19/2014
Event Time: [EDT]
Last Update Date: 05/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED UNINTENDED SHALLOW SKIN DOSE

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

"[On] Monday May 19, 2014, on follow-up visit, the patient presented with burns on the thighs and the labia. [The] Radiation Oncologist ordered an immediate investigation: High Dose Remote After Loader (HDR) Prescription event. No further action will be taken on this incident."

The patient received 21Gy in three (3) fractions. Following completion of treatment, a review of the Treatment Planning on Oncentra TPS revealed a reference length of 1223 mm instead of 1323 (expected value +/- 1 mm). The reference length used in the TPS was measured prior to CT with the SPS (Source Position Simulator) by two physicists. Therefore, the radiation was 10 cm short from reaching the target which explains the occurrence of burns on the patient's thighs.

"The three prescribed fractions were delivered on: 3/31/14, 04/07/14 and 04/14/14."

Florida Incident Number: FL14-043

The device used is an HDR containing Ir-192 with a Capri Applicator.

A corrective action plan has been developed by the licensee to prevent recurrence. The licensee informed both the prescribing physician and the patient. No long-term adverse health effects are expected.

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: 50127
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KAPSTONE KRAFT PAPER CORPORATION
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/20/2014
Notification Time: 19:03 [ET]
Event Date: 04/08/2014
Event Time: [PDT]
Last Update Date: 05/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - OHMART FIXED GAUGE WITH A BROKEN SHUTTER HANDLE

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

"This incident is a report of a broken fixed gauge shutter handle which originally was reported to [Washington Division of Radiation Protection] as a GL [General Licensed] device. This incident is a failure of the on/off (shutter) mechanism with the shutter stuck in the closed (safe) position when the handle broke off. [Washington Division of Radiation Protection] learned later that this was not a GL device as reported . . . but a specific license gauge. [Washington Division of Radiation Protection] acted upon the reporting criteria as this meets 10 CFR 31.5 (c)(5) criteria that applies to general license radioactive material and a report within 30 days with a description and remedial action of actual or indicated failure to the on-off mechanism. This report falls into that 30 day time frame but the device is a specifically licensed device.

"Licensee informed Washington Department of Health (WA DOH) on 14 May 2014 that a shutter handle broke off a fixed gauge during shutdown for routine operations on 8 April 2014. Surveys by radiation safety officer and by health physics service provider consultant confirmed dose rates were within acceptable ranges and consistent with gauge SS&D sealed source and device data. The gauge manufacturer is scheduled to be onsite 23 May 2014 to assess and repair. An investigation continues and corrective actions are pending.

"WA DOH incident number WA-14-019.

"One Ohmart fixed gauge, model SH-F1, serial 2860GK. 100 millicuries original activity [Cs-137] in November 1996; now 67 millicuries today 20 May 2014. Source model pending, source serial believed same as device serial. Source and shutter and device conditions unknown, but believed to be undamaged and intact (dose rates similar to SS&D data). Problem with source and device to be determined by gauge manufacturer scheduled to be onsite 23 May 2014 to assess and repair."

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Power Reactor Event Number: 50145
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: ROBERT SALES
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/28/2014
Notification Time: 11:26 [ET]
Event Date: 05/28/2014
Event Time: 10:37 [EDT]
Last Update Date: 05/28/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
BILL DEAN (RA)
JENNIFER UHLE (NRR)
JOHN ROGGE (R1DO)
WILLIAM GOTT (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 DUE TO RELEASE OF CHLORINATED WATER

"At 1037 EDT on May 28, 2014 an Unusual Event [EAL HU5] was declared due to a release of toxic gas that could have adversely affected plant operations. The leak was due to a leak in pipe containing water and chlorine. The pipe has been isolated and the leak has stopped."

The chlorine smell was initially noticed at approximately 1008 EDT. The leak was coming from a buried underground pipe. There were no personnel injuries or medical response needed.

The licensee notified the NRC Resident Inspector, State, and local authorities. The licensee plans on issuing a press release.

Notified DHS SWO, FEMA Ops Center, NICC Watch Officer, and Nuclear SSA via email.

* * * UPDATE FROM ROBERT SALES TO CHARLES TEAL AT 1202 EDT ON 5/28/14 * * *

At 1140 EDT on 5/28/14 Oyster Creek has exited the Unusual Event. The leak has been isolated and is not affecting normal plant operations.

The licensee notified the NRC Resident Inspector, State, and local authorities. The licensee plans on issuing a press release.

Notified R1DO (Rogge), NRR EO (Chernoff), IRD MOC (Gott), DHS ASWO, FEMA Ops Center, NICC Watch Officer, and Nuclear SSA via email.

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Power Reactor Event Number: 50147
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TRAVIS ROLLINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/28/2014
Notification Time: 23:57 [ET]
Event Date: 05/28/2014
Event Time: 20:00 [EDT]
Last Update Date: 05/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
EUGENE GUTHRIE (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

OFFSITE NOTIFICATION REGARDING POTENTIAL MALFUNCTIONING EMERGENCY NOTIFICATION SIREN

"One emergency siren was making noise [siren 27]. Huntersville Fire Department was contacted by someone in the area of the siren. No siren was activated. Initial investigation shows power loss to this one siren around the time of occurrence. Local news media contacted Duke Energy representative to question if sirens were set off. Continue to investigate to determine the issue with this one siren. Emergency Planning notified Mecklenburg County of failure of siren #27."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, June 05, 2014
Thursday, June 05, 2014