United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 13, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/12/2012 - 04/13/2012

** EVENT NUMBERS **


47599 47821 47827 47828 47829

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Non-Agreement State Event Number: 47599
Rep Org: AVERA MCKENNAN HOSPITAL
Licensee: AVERA MCKENNAN HOSPITAL
Region: 4
City: SIOUX FALLS State: SD
County: MINNEHAHA
License #: 4016571-01
Agreement: N
Docket:
NRC Notified By: RICHARD MASSOTH
HQ OPS Officer: VINCE KLCO
Notification Date: 01/17/2012
Notification Time: 13:04 [ET]
Event Date: 01/16/2012
Event Time: 16:00 [MST]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GREG PICK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT DUE TO POTENTIAL DIFFERENT FRACTIONAL DOSE DELIVERED THAN PRESCRIBED

The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.

* * UPDATE FROM RICHARD MASSOTH TO JOHN KNOKE AT 1826 EST ON 01/31/12 * *

"On January 17, 2012 the NRC Operations Center was verbally notified of two Therapeutic Underdose Occurrences discovered by the licensee on January 16 and 17, 2012. These occurrences involved a fractionated Breast High Dose Rate Afterloader (HDR) treatment with a SenoRx Contura multicatheter breast applicator. The first and third delivered treatment fractions were found to be less than 50% of the intended fractional dose. The entire course of the treatment in the written directive included ten equal-dose fractions of 3.4 Gray per fraction for a total dose of 34 Gray to the prescribed treatment site. To correct for the underdose occurrences, two additional treatment fractions were added and the treatment plan was modified to achieve the total dose specified in the written directive.

"The licensee now believes that this medical event has also caused an unintended dose to skin outside of the prescribed treatment site, requiring notification under 10CFR35.3045(a)(3). The licensee has performed computer simulation, calculations and physical measurements using TLDs simulating the treatment geometry to model the unintended skin dose. The event delivered an unintended skin dose exceeding at least the skin erythema threshold (2 Gy). The licensee is continuing to monitor the patient response to the skin dose and is working to refine the unintended skin dose estimates. An NRC reactive inspection team is on-site."

Notified R4DO (Jeff Clark) and FSME (Greg Suber)

* * * UPDATE FROM TRACI HOLLINGSHEAD TO HOWIE CROUCH AT 1044 EDT ON 4/12/12 * * *

The licensee confirmed that they agree with their medical consultants' findings that the patient received approximately 2720 rads of unintended skin dose.

Notified R4DO (Gaddy) and FSME (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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Non-Agreement State Event Number: 47821
Rep Org: SINAI-GRACE HOSPITAL
Licensee: SINAI-GRACE HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: SNM-1991
Agreement: N
Docket:
NRC Notified By: TIM APPLEGATE
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/11/2012
Notification Time: 11:15 [ET]
Event Date: 01/31/2012
Event Time: [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID HILLS (R3DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

PATIENT BURIED WITH PLUTONIUM-238 PACEMAKER

A former patient at St. John Macomb-Oakland Hospital expired on 1/31/12 and the body was released to the family for burial. The patient had a Medtronic pacemaker with a radionuclide of Plutonium-238. The RSO at Sinai-Grace Hospital notified the NRC of this event.

There is no planned action to recover the pacemaker from the buried patient.


THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 47827
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID BROOKINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/12/2012
Notification Time: 07:28 [ET]
Event Date: 04/11/2012
Event Time: 10:48 [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Refueling 0 Refueling

Event Text

FITNESS FOR DUTY - A CONTRACT SUPERVISOR TESTED POSITIVE ON A DRUG TEST

A non-licensed contract supervisor tested positive for illegal drugs on a random fitness-for-duty test. The individual's access has been terminated. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 47828
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: GEORGE CURTIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/12/2012
Notification Time: 09:42 [ET]
Event Date: 04/12/2012
Event Time: 09:30 [EDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

TSC AND EOF OUT OF SERVICE DUE TO MAINTENANCE

"At approximately 0930 hours EDT on Thursday, April 12, 2012, the H. B. Robinson Steam Electric Plant, Unit No. 2, Technical Support Center (TSC)/Emergency Response Facility (EOF) air conditioning and charcoal filtration systems will be removed from service to facilitate the replacement of the charcoal filtration media. The duration of work is expected to be approximately 11 hours. Since the unavailability will last greater than 8 hours, this is considered a Loss of Emergency Assessment Capability, and reportable under 10 CFR 50.72(b)(3)(xiii).

"Due to the inability of the TSC/EOF ventilation system to maintain a habitable atmosphere, as a compensatory measure, Emergency Responders assigned to these facilities have been informed to report to the alternate facilities until such time that the TSC/EOF ventilation system has been returned to service.

"TSC/EOF ventilation system maintenance and post maintenance testing is scheduled to be completed by 2030 hours EDT on Thursday April 12, 2012.

"The NRC Resident Inspector has been informed."

* * * UPDATE FROM WARREN WONKA TO HOWIE CROUCH AT 0435 EDT ON 4/13/12 * * *

At 1814 EDT on 4/12/12, maintenance on the TSC/EOF ventilation system was completed and the TSC/EOF was returned to service.

Notified R2DO (O'Donohue).

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Fuel Cycle Facility Event Number: 47829
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/12/2012
Notification Time: 18:30 [ET]
Event Date: 04/12/2012
Event Time: 08:00 [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
MICHELE SAMPSON (NMSS)

Event Text

INTERNAL REPORTING REQUIREMENT FOR CRITICALITY SAFETY CONTROLS

"At approximately 8:00 am on April 12, 2012, a criticality safety engineer was notified that waste in the Dry Conversion Process (DCP) area was improperly placed into a designated storage location. Upon investigation, it was determined that waste in the designated location contained materials with a total of less than 5 kg of uranium. As a result, no unsafe condition existed.

"An operator placed a bag of waste adjacent to a partially filled receptacle instead of placing the bag into the receptacle. This resulted in a portion of one of the documented administrative controls for criticality safety, requiring 24 inches separation between waste storage locations, to be degraded. This event is being conservatively reported per internal procedural requirements.

"As an immediate corrective action, the material was removed and transferred to the waste processing area. In addition, a shop wide communication to Fuel Manufacturing Operations is underway to inform operators of the issue.

"Additional corrective actions and extent of condition are being evaluated.

"At no time was an unsafe condition present."

Notifications were sent to state and local agencies and NRC Region II.

Page Last Reviewed/Updated Friday, April 13, 2012
Friday, April 13, 2012