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Event Notification Report for July 24, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/23/2015 - 07/24/2015

** EVENT NUMBERS **


51233 51235 51237 51238 51239 51253 51256 51257

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Agreement State Event Number: 51233
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOSPITALS OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County: CUYAHOGA
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: KARL VAN AHN
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2015
Notification Time: 10:50 [ET]
Event Date: 07/14/2015
Event Time: 10:30 [EDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE

The following information was received by the State of Ohio via email:

"On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]."

Ohio Report: OH150007

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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Non-Agreement State Event Number: 51235
Rep Org: UNITED STATES AIR FORCE
Licensee: UNITED STATES AIR FORCE
Region: 3
City: WRIGHT-PATTERNSON AFB State: OH
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2015
Notification Time: 15:52 [ET]
Event Date: 07/15/2015
Event Time: 15:15 [EDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

LOST Am-241 SOURCES

The following was received via email:

"The Installation Radiation Safety Officer of the Wright- Patterson AFB telephoned at 1515 [EDT] stating that they lost two sources which have 10 microcuries of Am-241 each. IAW 10 CFR 20.2201, [the licensee has] reported the loss of sources to the NRC Operation Center."

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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Agreement State Event Number: 51237
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: READING HOSPITAL
Region: 1
City: WEST READING State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/16/2015
Notification Time: 14:09 [ET]
Event Date: 07/15/2015
Event Time: [EDT]
Last Update Date: 07/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - OVERDOSE TO PATIENT DURING PROSTATE SEED IMPLANT

The following information was received via facsimile:

"On July 16, 2015 the licensee informed the Department's [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Central Office of a medical event. The event is reportable within 24-hours per 10 CFR 35.3045(a)(1)(i). Both the patient and referring physician were notified.

"On July 15, 2015, a patient was scheduled to receive a partial iodine-125 (I-125) prostate seed implant of 107 Gy, to be followed by a course of external beam radiation therapy of 45 Gy. During the procedure, the physician made an error and administered a full I-125 implant of 160 Gy. This resulted in a 49.5 percent overdose. No harm is expected to the patient.

"Cause of the event: Human error.

"The licensee plans to compensate for the overdose by eliminating the follow-up external beam therapy. A full report is expected within 15 days. The Southcentral Regional Office plans to perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID No.: PA150020

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: 51238
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: CORNEJO AND SONS
Region: 4
City: WICHITA State: KS
County:
License #: 22-B952
Agreement: Y
Docket:
NRC Notified By: JASON BARNEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/16/2015
Notification Time: 15:16 [ET]
Event Date: 07/16/2015
Event Time: 01:00 [CDT]
Last Update Date: 07/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following was received from the Kansas Department of Health and Environment via email:

"A nuclear density gauge was struck at approximately 0100 [CDT], Thursday, July 16, 2015. At 0132 [CDT], [Kansas Division of Emergency Management] KDEM on duty staff officer, received a call from the Kansas Highway Patrol that a nuclear density gauge had been struck in Wichita. [Kansas Department of Transportation] KDOT was on scene. [KDOT] said the gauge was in use at the time by Cornejo and Sons. The supervisor from Cornejo was on the scene. He said the gauge was completely destroyed. He could see the source plate containing the neutron source and said the source rod was stuck in the car that hit the gauge. [KDEM] had similar incidents in the past and could put the source in 5 gallon bucket of dirt for shielding and transport both sources back to their shop, place in a secure area, and contact Troxler for further instructions. KDOT had a radiation survey instrument on scene and did not detect any unusual readings.

"At that time emergency response personnel at the scene were not letting anyone approach the debris and the source rod. [Personnel at the scene] confirmed that the Cs-137 source was still intact and that Cornejo could transport both sources back to their shop. [The licensee] recovered the sources and were transporting them back to their shop. On the afternoon of July 16, 2015, [Kansas Department of Health and Environment] confirmed that Cornejo had the source rods secured. [The licensee RSO] stated that they contacted Troxler to begin the source return process i.e. pictures of the source rods as well as leak tests."

Kansas Item Number: KS150008

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Agreement State Event Number: 51239
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SUTTER-SOLANO
Region: 4
City: VALLEJO State: CA
County:
License #: 1943
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/16/2015
Notification Time: 17:40 [ET]
Event Date: 06/22/2015
Event Time: [PDT]
Last Update Date: 07/16/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SEED IMPLANT RESULTS IN UNDERDOSE

The following was received by the State of California via email:

"During the investigation of the licensee's brachytherapy program, the RHB [Radiation Health Branch] personnel discovered a possible medical event. After further review, the RHB personnel determined on 7/14/15 that a medical event had occurred on 6/22/15 which resulted in an underdose of 27 percent to a patient than the dose called for in the written directive. The licensee is in agreement with the RHB that this is a medical event. The investigation is ongoing and there may be additional medical events discovered as documentation is reviewed."

State 5010 Number: 070115

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: 51253
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: WALTER GRUER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/23/2015
Notification Time: 04:21 [ET]
Event Date: 07/23/2015
Event Time: 01:15 [CDT]
Last Update Date: 07/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
HEATHER GEPFORD (R4DO)
SCOTT MORRIS (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Cold Shutdown

Event Text

INITIATION OF PLANT SHUTDOWN DUE TO RCS LEAKAGE

"On July 23, 2015 at 0115 [CDT], Callaway Plant initiated a shutdown required by Technical Specifications (TS). At 2139 [CDT] on July 22, 2015, TS 3.4.13 Condition A was entered due to unidentified RCS leakage being in excess of the 1 gpm TS limit. The leak was indicated by an increase in containment radiation readings, increasing sump levels, and decreasing levels in the Volume Control tank (VCT).

"A containment entry identified a steam plume; due to personnel safety the exact location of the leak inside the containment building could not be determined.

"At this time radiation levels inside [the] containment are stable and slightly above normal. There have been no releases from the plant above normal levels.

"The [NRC] Senior Resident Inspector was notified."

* * * UPDATE PROVIDED BY ROB STOUGH TO JEFF ROTTON AT 1757 EDT ON 07/23/2015 * * *

"Callaway entered TS 3.4.13 Condition B at 0053 [CDT on July 23, 2015] for the subject leakage since reactor coolant pressure boundary leakage could not be ruled out by visual inspection. The estimated leak rate when the decision was made to shut down the plant was approximately 1.8 gpm. The plant entered Mode 3 at 0600 CDT.

"Additionally, at approximately 1315, it was determined that the duration of the required outage would be greater than three days, thus requiring notification to the Missouri Public Service Commission. This offsite notification is reportable to the NRC [per 10CFR50.72(b)(2)(xi)], and the above table has been updated to reflect this reporting requirement."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Gepford).

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Power Reactor Event Number: 51256
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: WESLEY LYON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/23/2015
Notification Time: 15:52 [ET]
Event Date: 07/23/2015
Event Time: 13:05 [EDT]
Last Update Date: 07/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RANDY MUSSER (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 DUE TO SODIUM HYPOCHLORITE SPILL

"At 1120 EDT on 07/23/2015, while performing Chemistry rounds, a Chemistry Technician discovered an underground leak near the Plant Service Water bleach moat. The Plant Service Water bleach injection pumps were secured at 1130 EDT on 07/23/2015. The leak was later confirmed to be bleach. Approximately 200-300 gallons of 12.5% sodium hypochlorite are estimated to have leaked out of a broken underground pipe. This amount exceeded the reportable limit [100 lbs. or 80 gallons] as specified by the National Response Center. The bleach leaked into the surrounding soil and into a Plant Hatch storm drain where it pooled before reaching the Altamaha river. No bleach discharged into the river.

"Cleanup began immediately by neutralizing the bleach with sodium bisulfite and is still on-going.

"Plant Management authorized Southern Nuclear Company Environmental Affairs to report to the US Coast Guard National Response Center at 1305 EDT on 07/23/2015 in accordance with corporate procedures. The event was reported to the National Response Center at 1316 EDT. The Georgia Environmental Protection Division was also contacted.

"This event is reportable under 10 CFR 50.72(b)(2)(xi) as an event or situation related to the protection of the environment for which a notification to other government agencies have been made.

"NRC Resident Inspector was notified at 1530 at 07/23/2015.

"CR [Condition Report] 10099779"

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Power Reactor Event Number: 51257
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: ROB STOUGH
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/23/2015
Notification Time: 19:39 [ET]
Event Date: 07/23/2015
Event Time: 13:57 [CDT]
Last Update Date: 07/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HEATHER GEPFORD (R4DO)

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

Event Text

AUXILIARY FEEDWATER MANUAL START DUE TO LOSS OF MAIN FEEDWATER PUMP DURING PLANT COOLDOWN

"During plant cooldown in response to conditions reported to the NRC in Event Notification 51253, Callaway was in Mode 3 (Hot Standby) and on the way to Mode 5 (Cold Shutdown). In accordance with cooldown procedures, Callaway was operating with one Main Feedwater Pump when the pump speed unexpectedly lowered to 0 RPM. The pump was manually tripped in response to the condition. This led to a decrease in water level in the steam generators. In response, operators manually activated the Auxiliary Feedwater System. All systems and components functioned normally in response to the event, and plant operators are currently continuing the controlled shutdown from Mode 3 to Mode 5. Safety related buses are receiving normal off-site power and the grid is currently stable."

"The NRC Resident Inspector was notified."

Page Last Reviewed/Updated Friday, July 24, 2015
Friday, July 24, 2015