United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 15, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/14/2012 - 02/15/2012

** EVENT NUMBERS **


47646 47648 47650 47659 47663

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Agreement State Event Number: 47646
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ROBERT WOOD JOHNSON UNIV HOSPITAL
Region: 1
City: NEW BRUNSWICK State: NJ
County:
License #: 450729
Agreement: Y
Docket:
NRC Notified By: WILLIAM CSASZAR
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 12:18 [ET]
Event Date: 02/07/2012
Event Time: 19:00 [EST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN INTENDED

The following was received from the state of New Jersey via email:

"A patient was treated with a Varian VariSourceTM HDR unit on February 7, 2012. The prescription dose was 200 cGy per fraction for 8 fractions. The first two fractions were delivered to the patient with a fractional dose of 25 cGy instead of the prescribed fractional dose of 200 cGy before the discovery of the event around 7 p.m. on February 7, 2012. The initial treatment plan was designed for a single fractional dose of 200 cGy and was approved on screen by the physician. The plan was later modified to 8 fractions with a fractional dose of 200 cGy before the delivery of the first fraction. This modification was however done incorrectly and the isodose line of 200 cGy, instead of 1600 cGy, was planned to cover the target volume. [Isodose means a radiation dose of equal intensity to more than one body area.] Two fractions of treatment (out of a planned 8) were delivered on 2/7/2012 before discovery of the event, resulting in a dose of 25 cGy per fraction (instead of 200 cGy) prescribed to the target volume."


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: 47648
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-211-27
Agreement: Y
Docket:
NRC Notified By: TERESA PURRINGTON
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 16:00 [ET]
Event Date: 02/02/2012
Event Time: [CST]
Last Update Date: 02/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN GIESSNER (R3DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - Y-90 THERASPHERE DOSAGE TO UNINTENDED AREAS

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

"On February 3, 2012, Minnesota Department of Health Radioactive Materials unit received notice that a licensee had a medical event during a Y-90 SIRS spheres procedure. After infusion of radioactive Y-90, in the form of SIRS spheres for treatment of the liver, it was discovered, by follow-up radionuclide scanning, that some of the material was not in the liver as intended. Material appeared in vessels involving the spleen and digestive track instead. The amount has not been determined at this time, but it is possible that this may cause unintended, permanent, functional damage. The interventional radiologist involved with the treatment has ensured us that the patient will be notified along with the referring physician today. It is likely that some form of medical intervention will be taken.

"On February 6, 2012, the Radioactive Material supervisor and inspector met with the licensee to discuss the medical event. The Y-90 SIRS spheres procedure went accordingly to plan; it was discovered on the follow-up SPECT imaging that an estimated 10%-15% of the material was in the spleen, gastric fundus, and duodenum. The patient and ordering physician had been notified. The intended area for the material was the liver with an activity of 50 GBq. The three unattended areas that were discovered with material were estimated to receive a dose of 0. The Medical Physicist gave us the best preliminary dose estimates based on CT images obtained the day after the procedure at which the stomach and duodenum were different in shape. Early dose estimates for each region (spleen, gastric fundus, and duodenum) estimates approximately 30 Gy for each area.

"The Minnesota Department of Health Radioactive Materials unit will continue communication and obtain the final estimation for dose estimates."

* * * UPDATE FROM TERESA PURRINGTON TO VINCE KLCO AT 1055 EST ON 2/14/2012 * * *

The following information was received by email:

"Abbott Northwestern has submitted final best estimates pertaining to the medical event of Y-90 SIRS Spheres that occurred on Thursday, February 2, 2012. The final administered activity after accounting for loss in the delivery system was 1.53 GBq, original activity was 1.55 GBq. Estimates of radioactivity, organ volumes and radiation dose were derived by evaluation of SPECT CT images. The final best estimates are determined as follows:

"Organ / tissue Fraction of activity Volume (cc) Average dose (Gy)
Liver 0.839 1209 53
Fundus of stomach 0.058 101 44
Spleen 0.093 200 35
Portion of duodenum 0.010 41 35

"These estimates have a relatively high uncertainty (at least 20%) and local concentrations and doses may be significantly higher. Maximum concentrations per pixel in the SPECT images were as much as 50% higher than the average concentration."

Notified the R3DO (Passehl) and FSME EO (McIntosh).

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: 47650
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MULTI-CINEMA INC
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JENNIFER MCALLISTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 15:51 [ET]
Event Date: 01/31/2012
Event Time: [CST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

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

"On January 31, 2012, Oklahoma Department of Environmental Quality (ODEQ) received email notification from America Multi-Cinema, Inc. (AMC) that they had lost one (1) tritium (H-3) radioluminescent exit sign. The amount of H-3 is unknown. AMC has filed a report for the Oklahoma City Police Department. The case number is 12-001181. According to AMC, the missing exit sign was discovered before a site survey had been performed, so AMC could not provide the manufacturer or serial number of the stolen unit. At this time, no further information is available."

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Agreement State Event Number: 47659
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BP PRODUCTS NORTH AMERICA INC.
Region: 4
City: TEXAS CITY State: TX
County:
License #: L00254
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 02/11/2012
Notification Time: 10:32 [ET]
Event Date: 02/09/2012
Event Time: 18:00 [CST]
Last Update Date: 02/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - INDUSTRIAL GAUGE STUCK SHUTTER

The following information was received by email:

"On February 10, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that the shutter on an Ohmart model SH-LG 2 nuclear gauge containing 8.5 curies of Cesium-137 was found to be stuck in the open position. Open is the normal position for the shutter and the failure does not pose any additional exposure risk. The licensee is trying to lubricate the operating arm in an effort to free the shutter. The licensee has contacted the manufacturer for assistance. Additional information will be provided in accordance with SA-300."

Texas Incident: I-8931

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Power Reactor Event Number: 47663
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: GEORGE CURTIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/14/2012
Notification Time: 12:55 [ET]
Event Date: 02/14/2012
Event Time: 12:40 [EST]
Last Update Date: 02/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BINOY DESAI (R2DO)

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

Event Text

LOSS OF EMERGENCY RESPONSE FACILITY INFORMATION SYSTEM DUE TO PLANNED MODIFICATION

"At 1240 EST, on February 14, 2012, power was removed to a major portion of the Emergency Response Facility Information System (ERFIS) to perform a planned modification on Power Panel - 8. This work will install a new breaker in PP-8 requiring that the panel be de-energized for the maintenance. The expected duration of ERFIS inoperability is approximately 6 hours. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, and the Inadequate Core Cooling Monitor (ICCM). The loss of ERFIS requires alternate methods, as described in plant procedures, to be used for the above-described functions. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still be made, if required, during the time that the ERFIS computer system is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. An additional message will be provided when the ERFIS is restored. It should also be noted that during the period of ERFIS inoperability, it is likely that the system could be restored within one hour to support Emergency Response Facility activation. This report is provided to conservatively cover the possibility that restoration within one hour may not be able to be accomplished if facility activation were to occur. The NRC Resident Inspector has been notified."


* * * UPDATE FROM KEN BOYD TO DONALD NORWOOD AT 1516 EST ON 12/14/2012 * * *

"At 1240 EST, on February 14, 2012, the Emergency Response Facility Information System (ERFIS) computer system became inoperable. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS), Safety Parameter Display System (SPDS), Meteorological Data link system, and the Inadequate Core Cooling Monitor (ICCM). Actions were completed to restore the ERFIS computer system to an operable status at 1458 EST on February 14, 2012. Alternate methods, as described in plant procedures, were available for the above-described functions during the time that the ERFIS computer system was inoperable. Therefore, it is expected that appropriate assessment of plant conditions, notifications, and communications could still have been made, if required, during the time that the ERFIS Computer system was inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii), which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability."

The licensee notified the NRC Resident Inspector. Notified R2DO(Desai).

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012