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Event Notification Report for July 14, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/13/2015 - 07/14/2015

** EVENT NUMBERS **


50877 51199 51200 51223 51224 51225

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Agreement State Event Number: 50877
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: PHOENIX BAPTIST HOSPITAL AND MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-146
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/10/2015
Notification Time: 16:50 [ET]
Event Date: 02/27/2015
Event Time: [MST]
Last Update Date: 07/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
PATRICIA MILLIGAN (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR MEDICINE TECHNOLOGIST RECEIVED OVEREXPOSURE

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

"On February 27, 2015, the licensee received notification from Landauer that one of their nuclear medicine technologists received a dynamic whole body dose of 11 Rem for the wear period of September 1, 2014 to October 31, 2014. The technologist only works at the hospital 1 day a week.

"The Agency [State of Arizona] continues to investigate the event."

Arizona First Notice: 15-006

* * * UPDATE ON 7/13/15 AT 1650 EDT FROM BRIAN GORETZKI TO JEFF HERRERA * * *

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

"The Agency [Arizona Radiation Regulatory Agency] has made a determination that the 11 Rem exposure to the individual at Phoenix Baptist Hospital is valid and has assigned the technologist 10 Rem in year 2014 and 1.01 Rem in year 2015."

Notified R4DO (Gaddy), INES National Officer (Milligan) and NMSS Events (via email).

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Agreement State Event Number: 51199
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: APPLUS RTD USA INC
Region: 1
City: WELLSVILLE State: NY
County:
License #: C5609
Agreement: Y
Docket:
NRC Notified By: DANIEL J. SAMSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/03/2015
Notification Time: 14:04 [ET]
Event Date: 07/02/2015
Event Time: 13:30 [EDT]
Last Update Date: 07/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following report was received from the New York State Department of Health via facsimile:

"On 7/2/15, at 1330 EDT, the Radiation Safety Officer (RSO) of Applus RTD USA Inc., called the New York State Department of Health to report that they had a source disconnect of an industrial radiography camera at a temporary jobsite in Wellsville, New York. They were taking images of a pipeline using an QSA Global Model: 880 Delta with an 80 curie Iridium source. The radiography team secured the area by extending the barricades and keeping 100% visual surveillance of the area. Applus RTD is not approved per the license to perform source retrieval. Applus contracted with another NYS licensee authorized to perform the source retrieval. Applus's RSO and the retrieval personnel arrived on site at 1715 EDT and the source was secured at 1815 EDT.

"According to the RSO, no person of the general public was ever in danger of receiving a dose above the legal limits."

New York State Event Report ID No.: NYDOH-15-06

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Agreement State Event Number: 51200
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE BROAD SCOPE MEDICAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/06/2015
Notification Time: 15:52 [ET]
Event Date: 06/14/2013
Event Time: [CDT]
Last Update Date: 07/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY TONGUE LOW DOSE RATE IMPLANT RESULTED IN OVERDOSE TO SKIN

The following report was received from the Kentucky Department of Health via facsimile:

"Brachytherapy LDR [low dose rate] tongue implant was loaded with thirty 1.12 mCi lr-192 sources on 6/13/13 by attending radiation oncologist. On 6/14/13 at [0730] [CDT] another physician rounded on the patient and all catheters and sources were in the proper position. At [1000] nursing on 6 East changed bedding of patient. At [1230] attending radiation oncologist rounded on patient and discovered one of the strands of sources (5 sources total) was no longer in the catheter. Physician removed nursing personnel and himself from the room and notified Physics. A Geiger counter was used to survey the room and a hot area was found in the linen basket. The linens were surveyed individually and the source was found. At [1245] the sources were reinserted into the proper catheter. Dosimetry was done to compare the plans and the deviation was well below the 20% reportable levels and almost indiscernible on the DVH [Dose Volume Histogram].

"During an inspection of the medical broad scope license, RHB [Kentucky Radiation Health Branch] reviewed the above procedure and inquired as to the dose potentially received by healthy tissues, namely the skin, assuming worst the case scenario. Specifically, the lr-192 strand displaced from the catheter actually lay against the patient's skin in one location for the whole 2 hours and 15 minutes between the time the physician last saw the strand in place and the time the patient's bed linen were changed. Based on this unrecognized worst case scenario, the RSO performed a dose calculation to the patient's skin and determined the patient may have potentially received a dose of 51.75 rem to the skin at a location which was not anticipated to receive any appreciable dose had the strands remained in place. A dose of 51.75 rem exceeds the limit requiring the report and notification of the Medical Event. A dose to the skin or an organ or tissue other than the treatment site that exceeds by five-tenths (0.5) Sv (fifty (50) rem) to an organ or tissue and fifty (50) percent or more of the dose expected from the administration defined in the written directive. The RSO at U of L [University of Louisville] e-mailed RHB a copy of the Medical Event report on July 6, 2015 at [1446]. Upon receipt of an email to the Radiation office the required 24 hour notification is made to the NRC Headquarters Operations Officer.

"The physician was notified of this potential medical event at the time of the inspection. The patient had follow up visits during and after the course of 6/14/13 treatment and was not found to be necessary to notify them of this potential event since no effects to the patient were noted."

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: 51223
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL GRIFFIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/13/2015
Notification Time: 07:50 [ET]
Event Date: 07/13/2015
Event Time: 08:30 [EDT]
Last Update Date: 07/13/2015
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

PRIMARY AND BACKUP METEOROLOGICAL TOWERS TO BE REMOVED FROM SERVICE FOR UPGRADE

"On July 13, 2015, planned activities will be performed to upgrade the Vogtle Electric Generating Plant Meteorological Towers and its communication equipment. The emergency response data system will be affected. The work will be completed within approximately 5 days. This activity requires the meteorological tower to be out of service greater than 72 hours rendering equipment used for emergency assessment non-functional.

"The TSC and EOF remain functional during the outage. Compensatory measures exist within emergency plan implementing procedures to obtain meteorological tower data via Savannah River Site and with the National Weather Service. Meteorological information will be relayed via the emergency notification system to the NRC Operations Center.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) for 'any event that results in a major loss of emergency assessment capability.' The Emergency Response Organization has been notified of the upgrade and necessary compensatory actions.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51224
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: DEREK DEBUSSCHER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/13/2015
Notification Time: 13:33 [ET]
Event Date: 07/13/2015
Event Time: 08:38 [EDT]
Last Update Date: 07/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
STEVE ORTH (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

OFFSITE NOTIFICATION DUE TO SPILL OF PORTABLE CHEMICAL TOILET TO THE ENVIRONMENT

"On 7/13/15 at 1000 EDT, a spill to the environment was determined to be reportable to the state environmental and local health agencies.

"The spill occurred when a portable chemical toilet tipped over and was identified at approximately 0838 EDT. The contents and exact quantity of the spill are unknown, but the toilet has a capacity of 60 gallons. The discharge flowed to a storm drain which ultimately discharges to the beach of Lake Michigan. Rainfall was present when the spill was identified. Cleanup efforts are in progress.

"The State of Michigan, via the Pollution Emergency Alert System (PEAS), was notified as required by the Site Spill Plan by the Site Environmental Coordinator at 1024 [EDT]. The Local government (Van Buren County) was notified at 1045 [EDT] via 911.

"The NRC Senior Resident Inspector has been notified."

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Power Reactor Event Number: 51225
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: MICHAEL SLABY
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/13/2015
Notification Time: 15:45 [ET]
Event Date: 07/13/2015
Event Time: 12:10 [EDT]
Last Update Date: 07/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
FRANK ARNER (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

Event Text

INADVERTENT ACTIVATION OF EMERGENCY SIREN BY VENDOR

"At approximately 1210 [EDT] on July 13, 2015 during conduct of vendor maintenance, a contract maintenance worker inadvertently activated siren 71.

"The licensee was notified of the siren activation by the vendor at 1211 [EDT].

"Wayne County was notified of the siren activation by the vendor at 1212 [EDT].

"One of the 96 sirens in the 10-mile Emergency Planning Zone (EPZ) were activated for less than one minute.

"No press release is planned by Exelon.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, July 14, 2015
Tuesday, July 14, 2015