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Event Notification Report for June 2, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/30/2014 - 06/02/2014

** EVENT NUMBERS **


48298 50135 50137 50139 50153 50154 50158 50160 50161 50162

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Agreement State Event Number: 48298
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: ROGER WILLIAMS MEDICAL CENTER
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7D-026-01
Agreement: Y
Docket:
NRC Notified By: CHARMA WARING
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/11/2012
Notification Time: 13:07 [ET]
Event Date: 08/28/2012
Event Time: [EDT]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED TWO UNDERDOSES OF Y-90 TO DIFFERENT TREATMENT SITES

The following information was received from the State of Rhode Island via fax:

"Event Type: Medical event involving the administration of Yttrium-90 microspheres.

"Notification(s): On August 30, 2012, the RI Department of Health Office of Facilities Regulation, Radiation Control Program received a phone call from the facility's Radiation Safety Officer, with a follow-up e-mail the same day.

"Event Description: On 08/28/2012, two incorrect doses were prepared for a Y-90 microsphere treatment. Both doses were for the same patient (i.e., two different treatment sites). One dose was drawn at 28.7% less than prescribed and the other dose was drawn at 22.9% less than prescribed. The final administered doses were less than 40.3% and 27.2% prescribed, respectively.

"Cause of the event: Under investigation and unknown at this time.

"Actions: Adverse effects to the patient are not expected; a follow-up reactive inspection is planned.

"[Rhode Island] Event Report ID: 2012-001"

* * * UPDATE FROM CHARMA WARING TO PETE SNYDER AT 1503 EDT ON 10/24/12 * * *

The State of Rhode Island provided the following information via fax:

"Cause of the event: For both doses, after withdrawing the microspheres from the shipping container, the licensee nuclear medicine technologist added sterile water to the syringe prior to transferring them into the v-vial. The policy is that the Y-90 is transferred into the v-vial prior to adding sterile water. The technologist then added additional sterile water to the v-vials in accordance with procedure.

"For both doses, after placing the v-vial into the dose calibrator, the technologist noticed that the dose was less than the 10% prescribed by the physician. The technologist was confused about the correction factor of 0.82 required for the v-vial when placed into the dose calibrator. The technologist did not understand why the original dose drawn from the shipping vial was within +/- 10%, but the v-vial dose was not. The technologist ultimately concluded that the shipping v-vial should have also been corrected by 0.82 and sent the dose to Interventional Radiology (IR) where it was administered.

"Although the dose withdrawn from the shipping container was originally within +/- 10%, some of the microspheres were most likely lost during transfer to the v-vial. The most likely cause was due to adding sterile water, prior to transfer. The doses drawn by the Nuclear Medicine Technologist were 9.84 mCi for the right lobe (Vial 1) and 10.41 mCi for segment VII, neither of which are within the +/- 10% established by policy.

"After administration of both doses, the v-vials were sent back to Nuclear Medicine per procedure and assayed in the dose calibrator for residual activity. The dose to the right lobe (Vial 1) and the dose to segment VII (Vial 2) had 1.6 mCi and 0.57 mCi remaining, respectively. Therefore, not all of the microspheres were administered. As a result, the final administered dose to the right lobe was 8.24 mCi and the dose to Segment VII was 9.84 mCi. This resulted in an under administered dose of 40.3% to the right lobe and an under administered dose of 27.2% to segment VII.

"Licensee Actions: As a result of this event, the RSO performed an in-service training [that] was held on 9/21/12. The licensee also does an additional 'timeout' when the dose is brought to the IR suite to verify prescribed versus drawn dose. The Nuclear Medicine staff alternate drawing the Y-90 doses to maintain familiarity with the procedure.

"RI RCP [Rhode Island Radiation Control Program] Actions: The corrective actions outlined by the licensee have been complete therefore, no further action is required at this time."

Notified R1DO (Caruso) and FSME Events Resource (email).

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.

* * * UPDATE AT 1144 EDT ON 5/30/14 FROM CHARMA WARING TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"Per the physician, this misadministration, which was lower than the planned dose based on body surface area, will not result in any harm to the patient. Repeat administration was already anticipated, if there was evidence for a response. The Bremsstrahlung scan shows increased activity in the tumor bed as well, consistent with an adequate delivery to the target. As a result of this event, the RSO will perform an in-service training on the Y-90 SirSphere Worksheet which will include practice runs so staff are comfortable with the math involved (specifically the correction factor of 0.82). The RSO has requested and the Director of Diagnostic Imaging has agreed that the Nuclear Medicine technologists shall rotate frequently on performing Y-90 microsphere dose preparations. Additionally, once the dose is brought to IR there will be an additional timeout to verify that the prepared dose by Nuclear Medicine matches that of the WD [written directive].

"[The physician] notified that patient via telephone on August 30, 2012."

Notified the R1DO (Rogge) and FSME Event Resources (via e-mail)..

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Agreement State Event Number: 50135
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: NEBRASKA METHODIST HOSPITAL
Region: 4
City: LINCOLN State: NE
County:
License #: 01-07-02
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/23/2014
Notification Time: 16:05 [ET]
Event Date: 05/22/2014
Event Time: [CDT]
Last Update Date: 05/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE DUE TO MISCALCULATION

The following was received from the State of Nebraska via fax:

"At 1430 CDT, the RSO from Nebraska Methodist Hospital called to report a possible overexposure to a patient who had received a prostate treatment of implanted lodine-125 seeds. The RSO, who was also the Medical Physicist on the case, stated that he had mistakenly used the millicurie value for the air kerma value. The treatment dose was intended to be 145 Gray (14,500 rad) but the implant dose was calculated to be 178 Gray (17,800 rad) so the dose differentiated by 27 percent. It is unknown if the target organ (rectum) will exceed 50 rem."

Nebraska Item Number: NE140004

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: 50137
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ST JOSEPHS HOSPITAL AND MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-024
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 05/23/2014
Notification Time: 17:19 [ET]
Event Date: 04/04/2014
Event Time: [MST]
Last Update Date: 05/23/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

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

"On May 22, 2014, the Agency was notified of a medical event that occurred on April 4, 2014 involving Y-90 labeled SIR Spheres.

"On April 4, 2014, an adult liver tumor patient was treated with an injection of SIR Spheres. The patient was prescribed 59.4 Gy to the liver, but instead, the actual dose to the liver was approximately 39 Gy. It was determined that the error occurred in the step of transferring the dose from the delivery vial to the dosing vial. The step of drawing up the sterile fluid was inadvertently omitted by the nuclear medicine technologist working alone which led to much less than the expected activity/sphere being transferred to the dosing vial. Only after the completion of the procedure was the large amount of residual activity detected and noted. The physicians noted that physiologic factors can affect the amount of spheres reaching the tumor so the discrepancy of the dose delivered apparently was not alarming or significant to them. The RSO discovered the medical event during a records review and recognized that the patient only received 63% of the prescribed dose."

Arizona First Notice Number: 14-013

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Agreement State Event Number: 50139
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CORRADINO GROUP
Region: 1
City: MIAMI State: FL
County:
License #: 2770-1
Agreement: Y
Docket:
NRC Notified By: DAVID PIESKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 05/24/2014
Notification Time: 18:28 [ET]
Event Date: 05/24/2014
Event Time: [EDT]
Last Update Date: 05/24/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (E-MA)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following was received from the State of Florida:

A Troxler moisture density gauge, Model 3430 (Serial #39376), was stolen from a locked trailer located at the 36th Street Bridge Project.

Additional information will be provided when it is available.

Florida Event Number: FL14-045

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: 50153
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TERRY BRANDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/30/2014
Notification Time: 14:43 [ET]
Event Date: 05/30/2014
Event Time: 07:59 [CDT]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ANN MARIE STONE (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

Event Text

SECONDARY CONTAINMENT AIRLOCK INOPERABLE FOR 10 SECONDS

"At 0759, on May 30, 2014, both doors in one of the Secondary Containment Airlocks were open concurrently. The doors being open at the same time caused a failure to meet SR 3.6.4.1.2 to verify that either the outer door(s) or the inner door(s) in each Secondary Containment access opening are closed. The identified condition caused Secondary Containment to be considered INOPERABLE per TS LCO 3.6.1.4. Upon discovery, immediate action was taken to close the doors. This action allowed SR 3.6.4.1.2 to be met, and restored Secondary Containment to OPERABLE status.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(v)(C).

"The NRC Resident Inspector has been notified."

The cause of this event was a misaligned door magnet.

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Power Reactor Event Number: 50154
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TERRY BRANDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/30/2014
Notification Time: 14:43 [ET]
Event Date: 05/30/2014
Event Time: 10:43 [CDT]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANN MARIE STONE (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

Event Text

HIGH PRESSURE COOLANT INJECTION PUMP RECEIVED AN INVALID ISOLATION SIGNAL

"At 1043 CDT, during an instrument test, the High Pressure Coolant Injection (HPCI) system isolated due to an invalid signal. The isolation was on the 'A' (inboard) logic, which rendered the HPCI system INOPERABLE. The isolation was received while instrument technicians were installing a relay block during the performance of Surveillance Test Procedure 3.3.6.1-43 'HPCI Steam Line High DP Instrument Channel Functional Test.'

"Operations Personnel have repressurized HPCI piping, installed the relay cover, and declared HPCI System OPERABLE at 1209 [CDT].

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) due to the failure of a single train system preventing accident mitigation.

"The NRC Resident Inspector has been informed."

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Power Reactor Event Number: 50158
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: FARA J. ORESHACK
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/30/2014
Notification Time: 17:06 [ET]
Event Date: 05/30/2014
Event Time: 09:30 [MST]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MICHAEL VASQUEZ (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
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - LICENSED OPERATOR IN VIOLATION OF FITNESS FOR DUTY POLICY

A licensed operator violated the station's fitness for duty policy due to alcohol during a random fitness-for-duty test. The employee's access to the plant has been withdrawn.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 50160
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONNIE WILKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/30/2014
Notification Time: 20:16 [ET]
Event Date: 05/30/2014
Event Time: 16:10 [EDT]
Last Update Date: 05/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
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

GROUTING IN FIRE PENETRATIONS DOES NOT MEET REQUIREMENTS

"Conditions were identified in which grouting in some fire penetrations through hollow block walls on Units 1 and 2 do not comply with design drawings. While some grouting is present in the penetration, the determination has been made that the qualification of the amount and configuration of the grouting present does not meet Appendix R requirements. Further evaluation by Engineering concluded that this condition could compromise both safe shutdown paths on each unit in the event of a postulated fire. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were established in accordance with the plant's Fire Hazard Analysis (FHA) to compensate for this condition to ensure that safe shutdown paths are preserved until the conditions can be corrected."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 50161
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN KAHANCA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/31/2014
Notification Time: 14:28 [ET]
Event Date: 05/31/2014
Event Time: 11:36 [CDT]
Last Update Date: 06/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL VASQUEZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

EMERGENCY TONE ALERT RADIO TRANSMITTER NOT FUNCTIONAL

"At time 1136 CDT, 5/31/14 Cooper Nuclear Station was informed by the National Weather Service that the Shubert radio transmission tower was not functioning. This affects the tone alert radios used to notify the public in the event of an emergency condition. This is considered to be a major loss of the Public Prompt Notification System capability and is reportable under 10CFR50.72(b)(3)(xiii).

"Nemaha, Richardson and Atchison county authorities within the 10 mile EPZ have been notified of the condition and the affect on the tone alert radios and will utilize Local Route Notification (backup notification method).

"Estimated return to service time is unknown. The cause of the failure is a severed communication line."

The licensee also found FTS 2001 lines to be non-functional. The communications line was severed during road construction.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1530 EDT ON 6/1/2014 FROM KYLE SAYLOR TO MARK ABRAMOVITZ * * *

At 2232 CDT on 5/31/2014, the licensee was notified that the tone alert system had been returned to service. At 1230 CDT on 6/1/2014, the FTS 2001 phone system testing was completed verifying the normal status of these phones.

The licensee will notify the NRC Resident Inspector.

Notified the R4DO (Vasquez).

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Power Reactor Event Number: 50162
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN LOGAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/01/2014
Notification Time: 17:51 [ET]
Event Date: 06/01/2014
Event Time: 13:14 [CDT]
Last Update Date: 06/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (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

LOSS OF TECHNICAL SUPPORT CENTER COOLING CAPABILITY

"At 1314 [CDT] on 6/01/2014, Technical Support Center ventilation alarm was received in the main control room. The Equipment Operator reported that the trouble alarm for the roof mounted condensing units was in alarm and the condensing units were tripped. Upon resetting the alarms the condensing units ran for three to five minutes and tripped again. This caused a loss of Technical Support Center cooling capability. Technical Support Center Air Handling system and filtration remain in operation. The room temperature is being monitored locally. Wet bulb temperature at 1500 [CDT] was reported to be 78.5 deg F. Corrective action process has been initiated.

"This event is reportable under 10CFR50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 3 since this condition affects an emergency response facility."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, June 02, 2014
Monday, June 02, 2014