United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for July 30, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/27/2012 - 07/30/2012

** EVENT NUMBERS **


48118 48141

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Agreement State Event Number: 48118
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS
Region: 3
City: RACINE State: WI
County:
License #: 101-1299-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/19/2012
Notification Time: 17:06 [ET]
Event Date: 07/19/2012
Event Time: [CDT]
Last Update Date: 07/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
FSME via E-mail ()

Event Text

AGREEMENT STATE REPORT - 15 PROSTATE BRACHYTHERAPY MEDICAL EVENTS

The following information was received via facsimile:

"On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS [Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001.

"--Overdose to the prostate (medical event criteria used -D90>130%):
08/20/2009: 137.3%

"--Underdose to the prostate (medical event criteria used -D90<80%):
07/15/2005: 79.27%
03/13/2006: 79.17%
03/15/2006: 67.10%
07/26/2006: 72.35%
07/26/2006: 57.06%
02/13/2006: 78.37%
05/14/2009: 78.67%

"--Overdose to the rectum (medical event criteria used -V100>2cc):
12/13/2006: 2.42cc
12/19/2007: 2.23cc
03/03/2009: 2.54cc
07/08/2009: 3.32cc
11/19/2009: 2.89cc
05/05/2010: 2.41cc
05/20/2010: 3.92cc

"DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review."

Wisconsin Event Report ID No.: WI120008

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: 48141
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: JAMES CRABILL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/27/2012
Notification Time: 00:29 [ET]
Event Date: 07/26/2012
Event Time: 21:20 [CDT]
Last Update Date: 07/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DRAKE (R4DO)

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

LOSS OF AC POWER TO THE EMERGENCY OPERATIONS FACILITY

"At 2120 [CDT] [on 07/26/12], a loss of AC power to the Emergency Operations Facility (EOF) occurred effecting emergency response capability. The Technical Support Center (TSC) remained available. In the event of on emergency declaration requiring an EOF, the emergency Response Organization (ERO) would have been directed to report to the Backup EOF.

"Assessment capability via SPDS was not lost during this time period and communications equipment also remained available.

"Coincident with no local offsite power being available, the backup diesel generator was unable to supply AC power to the facility due to an overvoltage condition present on the transfer switch. No power was available from the time period of 2120 [CDT] to 2133 [CDT] when local offsite power was restored to the building.

"This notification is being made in accordance with 10 CFR 50.12(b)(3)(xiii) due to the unavailability of an emergency response facility."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, July 30, 2012
Monday, July 30, 2012