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Event Notification Report for August 26, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2014 - 08/26/2014

** EVENT NUMBERS **


50372 50374 50377 50397 50398

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Agreement State Event Number: 50372
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: OHIO STATE UNIVERSITY MEDICAL CENTER
Region: 3
City: COLUMBUS State: OH
County: FRANKLIN
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/15/2014
Notification Time: 14:53 [ET]
Event Date: 08/14/2014
Event Time: [EDT]
Last Update Date: 08/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE TO LIVER

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

"The licensee prepared and delivered a therapeutic dose of TheraSpheres to a patient's liver on August 14, 2014. The written directive was for 120 Gy to the liver with 27 mCi of Y-90 TheraSpheres. On August 15, 2014, the licensee discovered that 20% of the dose that was supposed to be administered to the patient was still in the bottom of the vial. Although the licensee prepared the vial in accordance with the manufacturer's instructions, 20% of the TheraSpheres remained in the bottom of the vial and did not go into suspension.

"The patient and referring physician have been notified.

"The Bureau [Ohio Bureau of Radiation Protection] will be conducting a follow-up investigation regarding this event."

The patient received 96 Gy to the liver instead of the prescribed 120 Gy.

Ohio incident # OH140010

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: 50374
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: PHILLIPS 66 CO
Region: 4
City: PONCA CITY State: OK
County:
License #: OK-07402-12
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/15/2014
Notification Time: 17:04 [ET]
Event Date: 08/15/2014
Event Time: [CDT]
Last Update Date: 08/15/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED INDUSTRIAL GAUGE

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

"Phillips 66 Co. (OK-07402-12) has reported the failure of the shutter mechanism on one of their fixed gauges. Earlier today the shutter was closed while the licensee collected a leak test sample. The RSO noted that the shutter was difficult to operate. When they returned the shutter handle to the 'open' position, the control room which monitors the gauge readings reported that the readout briefly returned to its normal level, then dropped back to zero when the shutter was supposed to be fully open. Repeated attempts showed that the gauge only operated when the shutter was approximately 75% of the fully 'open' position. The licensee has contacted the gauge manufacturer but they won't be able to supply a replacement for approximately 6 weeks. The licensee has requested permission to leave the gauge in service until a replacement is available. The gauge is installed on a stand pipe 18 feet above ground level in an oil refinery in Ponca City, OK. It is only accessible by catwalk which the RSO is going to cordon off. Material in the gauge is Cs-137, 25 mCi when new in 1993. We[State of OK] have told the RSO they may leave the gauge in operation pending the results of the leak test. If these show the source to be leaking they must immediately remove the gauge from service."

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Non-Agreement State Event Number: 50377
Rep Org: PATRIOT ENGINEERING AND ENVIRONMENT
Licensee: PATRIOT ENGINEERING AND ENVIRONMENT
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 092-1073-1
Agreement: N
Docket:
NRC Notified By: BRIAN KING
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/18/2014
Notification Time: 15:28 [ET]
Event Date: 08/15/2014
Event Time: 16:30 [EDT]
Last Update Date: 08/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DAVE PASSEHL (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

DAMAGED MOISTURE/DENSITY GAUGE

A moisture/density gauge was run over by a bulldozer at a construction site in Indianapolis, Indiana. The RSO performed surveys of the gauge and no abnormal dose rates were observed. The gauge was leak tested and the data has been sent to Seaman Nuclear Products for analysis. The gauge has been removed from service and is secured at the licensee's facility.

The gauge is a Seaman Model C-75 moisture/density gauge and typically contains 8 mCi of Cs-137 and 40 mCi of Am-241/Be.

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Power Reactor Event Number: 50397
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM MULLINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/25/2014
Notification Time: 04:10 [ET]
Event Date: 08/25/2014
Event Time: 05:00 [CDT]
Last Update Date: 08/25/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVE PASSEHL (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

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"On 8/25/2014, planned preventive maintenance activities are being performed on the Braidwood Generating Station Technical Support Center (TSC) Ventilation System. The work will be completed within approximately 42 hours. This activity includes preventive maintenance on the TSC condensing unit which affects the TSC ventilation. During the planned maintenance, the TSC condensing unit will be rendered non-functional.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff as necessary. This planned maintenance will not impact the emergency filtration capability of the TSC.

"This event is reportable per 10CFR50.72(b)(3)(xiii) for 'any event that results in a major loss of emergency assessment capability.' The planned maintenance will not be able to restore the TSC condensing unit to service within the facility activation time specified in the emergency plan (1 hour) in the event of an accident. The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 50398
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: ALLAN MCLAUGHLIN
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/25/2014
Notification Time: 09:51 [ET]
Event Date: 08/25/2014
Event Time: 08:12 [CDT]
Last Update Date: 08/25/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVE PASSEHL (R3DO)
PATRICK HILAND (NRR)
WILLIAM GOTT (IRD)
JENNIFER UHLE (NRR)
DARYL ROBERTS (R3DR)

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

UNUSUAL EVENT DECLARED DUE FIRE ALARM IN REACTOR BUILDING

"At 0757 CDT on 8/25/14, LaSalle Main Control Room received a fire alarm from the Unit 2 Reactor Building 807 foot elevation. Operators dispatched and confirmed no fire at 0817 CDT (20 min). At 0812 CDT (15 min) an unusual event (HU3) was declared due to not having verified no fire within 15 minutes of the alarm. No fire was confirmed and plans are in progress to terminate event."

The NRC Resident Inspector has been notified. The licensee notified the Illinois Emergency Management Agency.

Notified DHS SWO, FEMA Operation Center, FEMA National Watch Center, NICC, Nuclear SSA via email.

* * * UPDATE PROVIDED BY ALAN MCLAUGHLIN TO JEFF ROTTON AT 1046 EDT * * *

"At 0915 CDT on 8/25/2014, the LaSalle Shift Emergency Director terminated the Unusual Event (HU3) which had been declared at 0812 CDT. No fire present was verified at 0817 CDT and required hourly firewatch is in place. Maintenance Department has begun efforts to locate and replace faulted detector or other degraded component."

The licensee notified the NRC Resident Inspector and the Illinois Emergency Management Agency.

Notified R3DO(Passehl), NRREO (Hiland), IRD (Gott). Notified DHS SWO, FEMA Operation Center, FEMA National Watch Center, NICC, Nuclear SSA via email.

Page Last Reviewed/Updated Tuesday, August 26, 2014
Tuesday, August 26, 2014