United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 28, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2012 - 03/28/2012

** EVENT NUMBERS **


47756 47759 47761 47762 47763 47768 47774 47775 47777

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47756
Rep Org: MIDDLESEX CARDIOLOGY ASSOCIATES
Licensee: MIDDLESEX CARDIOLOGY ASSOCIATES
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 062355901
Agreement: N
Docket:
NRC Notified By: JOSEPH CORNING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/20/2012
Notification Time: 13:25 [ET]
Event Date: 03/20/2012
Event Time: 12:30 [EDT]
Last Update Date: 03/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WAYNE SCHMIDT (R1DO)

Event Text

INCORRECT PATIENT ADMINISTERED NUCLEAR STRESS TEST

"This will serve as the incident report on a patient who inadvertently received an injection of technetium 99m in the Middletown office of Middlesex Cardiology Associates. [The gentleman] is a 68-year-old patient. He has underlying dementia and, at times, poor understanding of his medical care. He arrived at the office over 30 minutes late for his appointment. He identified himself to the front office staff [by his first name]. Because of HlPPA laws, the front office staff did not announce his full name. It turns out that a separate patient, [with the same first name] was scheduled for a 12:30 PM nuclear stress test. [The patient] was brought to the nuclear cardiology imaging department which is separate from the usual patient waiting room. He was told that he was going to have a pharmacologic stress test performed. Before the medical assistant could ask his date of birth, the patient indicated to the nuclear staff that he had had coffee earlier in the day which raised some confusion as to whether he could undergo pharmacologic stress testing. [The patient] never indicated that he was simply there for an office visit. He was subsequently told that he could only have resting imaging performed and would have to return on a separate day for the pharmacologic stress test. He agreed. He had undergone previous nuclear testing and therefore did not protest having an injection of technetium performed. He subsequently received 32.8 mCi of technetium 99 sestamibi. At that point, the correct nuclear stress test patient, checked in with the front office staff. Immediately, it became evident that there were 2 gentleman [with the same first name] scheduled for separate visits on 3/20/12. License photo identification was then performed. It was then discovered that [the first patient] had inadvertently received the technetium injection inappropriately. Given the fact that this dose of technetium would only produce a total body dose of 0.55 rads or approximately 5.3 mGy, there was not felt to be any concern for long-term medical sequelae.

"The patient's physician had a discussion with the patient and subsequently called his daughter to discuss the incident. A detailed letter was also sent to the patient's primary care physician.

"Based on NRC regulations, I contacted the [NRC] Operations Center at 1:25 PM on 3/20/12. I spoke to [the Headquarters Operations Officer] to explain the situation. This afternoon, we had a meeting with all front office staff and nuclear staff to review the importance of patient identification so that this type of incident will never occur again. Patients for nuclear testing will be identified by first and last names as well as birthdates to eliminate confusion."

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.


* * * RETRACTION FROM JOSEPH CORNING TO DONALD NORWOOD AT 1249 EDT ON 3/27/2012 * * *

The total body dose received from the injection of techntium 99 was not high enough to warrant reporting this as a medical event. This event is therefore being retracted.

Notified R1DO (Newport) and FSME (McIntosh).

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Agreement State Event Number: 47759
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: WOOD RIVER REFINERY
Region: 3
City: ROXANA State: IL
County:
License #: IL-01282-01
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/22/2012
Notification Time: 11:03 [ET]
Event Date: 03/21/2012
Event Time: [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - PROCESS GAUGE SHUTTER STUCK IN OPEN POSITION

The State of Illinois reported the following information via email:

"The Wood River Refinery reported that a shutter mechanism on a fixed gauge (Ohmart Model SH-F1B, S.N. 2508CN) was found stuck in the open position during a routine survey and maintenance check. The gauge contained a 3.7 GBq (100 mCi) Cs-137 source. Staff were unable to return it to the shielded position. The gauge is in an unoccupied area.

"The device/area has been posted. Surveys indicate normal radiation levels in the vicinity of the device compared to the SSD registry. There is product in the vessel and 2 other gauges are in the vicinity.

"Personnel and shift managers have been informed of the situation. A service vendor has been on scene and so far has been unable to close the shutter after lubrication. Additional service measures are being pursed by the vendor."

IL Item No. IL12005

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Agreement State Event Number: 47761
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PROBE TECHNOLOGY SERVICES
Region: 4
City: FORT WORTH State: TX
County:
License #: 05112
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/22/2012
Notification Time: 17:29 [ET]
Event Date: 03/14/2012
Event Time: [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
CHRISTIAN EINBERG (FSME)
ILTAB (EMAI)
MEXICO (EMAI)

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

Event Text

AGREEMENT STATE REPORT - SOURCE LOST DURING TRANSPORT

The State of Texas provided the following information via email:

"On March 22, 2012, the Agency was notified by a licensee that a 350 millicurie (13 GBq) Americium 241-Beryllium source was lost during shipment. The source was picked up in Fort Worth, Texas by a common carrier for delivery to Houston, TX on March 14, 2012. When the source arrived in Houston, TX it was discovered that the source should have been delivered to the company's Corpus Christi, TX location. The common carrier contacted the licensee in Fort Worth and they agreed to have the source sent to the Corpus Christi location. On March 20, 2012, the licensee in Corpus Christi contacted the licensee in Fort Worth and stated that they had not received the source. The licensee in Fort Worth contacted the common carrier and was informed by them that they could not locate the source, but they were looking for it. On March 22, 2012, at 1420 hours the Fort Worth licensee contacted this Agency to report that they had decided to report the source as lost.

"The Agency contacted the carrier and they confirmed that the package was loaded on the truck going from Houston to Corpus Christi. They stated that the truck stopped in San Antonio, TX prior to going to Houston. The common carrier is still looking for the source. They stated that all of their transportation centers have been notified of the lost package. Additional information will be provided as it is received in accordance with SA-300.

Texas Incident #: I-8941.

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: 47762
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: SHARED MEDICAL TECHNOLOGY
Region: 3
City: NEW RICHMOND State: WI
County:
License #: 005-1271-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/22/2012
Notification Time: 17:35 [ET]
Event Date: 03/22/2012
Event Time: 11:45 [CDT]
Last Update Date: 03/22/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION DURING TREATMENT

The State of Wisconsin provided the following information via e-mail:

"On March 22, 2012 at 2:30pm the Wisconsin Radiation Protection Section received a telephone notification that a fire had occurred at the licensee's location while performing a lung perfusion study at 11:45am, utilizing a 60 mCi dose of Tc-99m DTPA. The lung perfusion kit being used was a Biodex Medical Systems model Aerotech 1, lot #: 07811324. Per a discussion with the RSO, a patient was receiving a lung perfusion study when the perfusion kit 'burst into flames.' The Nuclear Medicine Technician (NMT) removed the face mask from the patient and the patient's hair caught on fire and the NMT put the fire out with their hands. The patient was immediately taken to the Emergency Room and the first degree burns on their face and neck have been treated.

"The area has been secured and surveys are in progress. The licensee will not be conducting any nuclear medicine procedures until the Radiation Protection Section has completed our investigation."

WI Event Report ID: WI120002.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 47763
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: PETE SNYDER
Notification Date: 03/22/2012
Notification Time: 20:26 [ET]
Event Date: 03/20/2012
Event Time: [EDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING LIVER DISEASE TREATMENT

"Event type: A medical event (ME) involving the administration of Yittrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).

"Notifications: On March 21,2012, the Department's [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] Southeast Regional Office received notification via a phone call about this ME.

"Event Description: The patient was being treated for disease of the liver and received 77% of the intended dose.

"CAUSE OF THE EVENT: Currently under investigation and unknown at this time.

"ACTIONS: No harm to the patient is expected. The treating physician notified the patient.

"The Department [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] plans to do a reactive inspection."

PA Event Report ID: PA120009.

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.

* * * RETRACTION FROM JOSEPH MELNIC TO VINCE KLCO ON 3/26/12 AT 0937 EDT VIA FAX * * *

"Notifications: On March 21, 2012, the Department's Southeast Regional Office received notification via a phone call about this ME. After the HOO notification was made the Department was informed that the measurement for actual dose delivered was repeated two times, both indicating the administration was within acceptable limits.

"Event Description: The patient was being treated for disease of the liver and was initially thought to have received 77% of the intended dose, however after additional measurements were made the dosage delivered was determined to be 81.2% and 82.2%.

"ACTIONS: Medical Event is being retracted."

Notified the R1DO (Newport) and FSME EO (McIntosh).

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Agreement State Event Number: 47768
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NON-DESTRUCTIVE INSPECTION CORPORATION
Region: 4
City: LAKE JACKSON State: TX
County:
License #:
Agreement: Y
Docket: L02712
NRC Notified By: ROBERT FREE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/25/2012
Notification Time: 09:20 [ET]
Event Date: 03/24/2012
Event Time: 16:00 [CDT]
Last Update Date: 03/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE TO RADIOGRAPHER WHEN CAMERA SOURCE BECAME DISCONNECTED

The following information was received by facsimile:

"On March 24, 2012, the licensee notified the Agency that it one of its radiography teams had experienced a disconnect of a 65 curie iridium-192 on a QSA Delta 880 radiography camera at a temporary work site in Pasadena, Texas. The crank out drive cable had broken and the source had completely disconnected. After an authorized individual performed the source retrieval, the licensee's RSO learned that the radiographer trainer disconnected the source tube from the camera and had carried the source tube around his neck while he climbed down the ladder of the scaffold. The source was in the tube at this time, but it is uncertain at this time the source's location within the tube. When the radiographer trainer reached the platform he removed the source tube from his neck. The licensee's initial dose estimates for the radiographer trainer are a whole body dose of at least 56 rem and an extremity limit that may exceed 100 rem. The radiographer's film badge is being sent for immediate reading. The licensee is conducting an investigation.

"NOTE: During the licensee's initial phone call to the Agency, the Agency understood the whole body dose estimate to be 6 rem and considered the event to be a 24-hour report (the Agency did report to the NRC HOO within 24 hours). However, when the Agency received the written initial report this morning, March 26, 2012, it was discovered that the estimate is 56 rem, which requires immediate notification. This report is being submitted to update and upgrade the event. More information will be provided as it is obtained.

The State also corrected the source strength to 65 curie Ir-192 source. REAC/TS was notified on 03/26/12 and the licensee has made contact with them.

Texas Incident: I-8942

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Power Reactor Event Number: 47774
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: AMY BURKHART
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/27/2012
Notification Time: 14:06 [ET]
Event Date: 03/27/2012
Event Time: 09:50 [CDT]
Last Update Date: 03/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (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

OFFSITE NOTIFICATION DUE TO INADVERTENT SIREN ACTUATION

"At 1145 CDT on 3/27/12, OPPD [Omaha Public Power District] was notified by Harrison County Emergency Management that the sirens in Harrison County Iowa were inadvertently activated at 0950 CDT on 3/27/12. This activation occurred during an exercise at Fort Calhoun Station which included FEMA evaluation of local State and County participation. The sirens were activated by Iowa Emergency personnel for less than 5 seconds. An OPPD and State of Iowa joint media press release will be conducted following the termination of the Emergency Planning exercise."

The licensee notified the State of Iowa EMA and the Harrison County Sherriff's Dispatch. The licensee also notified the NRC Resident Inspector.

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Power Reactor Event Number: 47775
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: CURTIS BULLOCK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/27/2012
Notification Time: 17:54 [ET]
Event Date: 03/27/2012
Event Time: [EDT]
Last Update Date: 03/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK LESSER (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

Event Text

HISTORICAL UNAVAILABILITY OF EMERGENCY OPERATIONS FACILITY VENTILATION DUE TO MAINTENANCE

"During a review of past maintenance that was performed on the Emergency Operations Facility (EOF) ventilation system, it was identified that there were three periods of time when the maintenance would have impacted the functionality of the facility and the ventilation system would not be able to be restored promptly. Site reporting guidance has been revised to assure accurate reporting.

"The periods of time where maintenance impacted the functionality of the EOF are as follows:
1. April 30 to May 1, 2009 for approximately 36 hours due to condenser and air handler replacement.
2. January 14 to 18, 2010 for approximately 96 hours due to damper and ductwork replacement.
3. November 17 to 19, 2010 for approximately 72 hours due to a compressor failure.

"This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2 since the work activities affected an emergency response facility for the duration of the maintenance.

"The Senior Resident Inspector has been informed."

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Power Reactor Event Number: 47777
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: BRENT EFIRD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/27/2012
Notification Time: 23:11 [ET]
Event Date: 03/27/2012
Event Time: 20:20 [CDT]
Last Update Date: 03/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

SPENT FUEL HANDLING MACHINE NOT FULLY QUALIFIED FOR A SEISMIC EVENT

"The following condition is being reported by Arkansas Nuclear One, Unit 2 (ANO-2) in accordance with 10CFR 50.72(b)(3)(ii)(B), 'Unanalyzed Condition.' Conservative engineering analysis has determined that the Spent Fuel Handling Machine (2H-3) is not qualified in a design basis earthquake event. Current seismic analysis is indicating a lack of margin for several structural parts of the machine.

"The Spent Fuel Handling Machine (2H-3) is currently parked and de-energized in a safe position and administratively prohibited from being moved over any irradiated fuel assemblies in the spent fuel pool. Until further engineering evaluation or modifications can occur the Spent Fuel Handling Machine (2H-3) will remain in its current position and de-energized."

The licensee has notified the NRC Resident Inspector.

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