United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 1, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/31/2012 - 08/01/2012

** EVENT NUMBERS **


48128 48129 48130 48144

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Agreement State Event Number: 48128
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WATERTOWN MEMORIAL HOSPITAL
Region: 3
City: WATERTOWN State: WI
County:
License #: 055-1335-01
Agreement: Y
Docket:
NRC Notified By: ROYSTON NGWAYAH
HQ OPS Officer: VINCE KLCO
Notification Date: 07/24/2012
Notification Time: 14:23 [ET]
Event Date: 07/24/2012
Event Time: [CDT]
Last Update Date: 07/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
FSME via email ()

Event Text

AGREEMENT STATE REPORT- UNDERDOSE DURING A BRACHYTHERAPY TREATMENT

The following information was received by email:

"Wisconsin Department of Health Services (DHS) received notification via voicemail from the licensee on July 23, 2012 regarding the discovery of a brachytherapy medical event that occurred on July 17, 2007. The medical event involved a procedure during which the administered dose differed from the prescribed dose by more than 20% (underdose) for permanent prostate implants using Cs-131 seeds. The prescribed dose was 115 Gy. The delivered dose was 60 Gy. The medical event was identified by DHS inspectors during a recent routine inspection, at which time the inspectors also determined that the licensee had not conducted adequate review of their prostate brachytherapy cases against their medical event criteria.

"Per the licensee's procedures, a post-implant CT is performed the same day as the procedure and analyzed within two working days after. If the post-implant analysis reveals an underdose, which occurred in this situation, additional seeds are implanted and another post-implant CT/analysis process follows. The licensee is currently reviewing additional cases dating back to 2003 for medical events against the revised medical event criteria submitted to DHS on June 22, 2012. DHS is investigating the event and is currently in the process of communicating with the licensee regarding decisions on patient notifications. A special inspection team will be sent following the licensee's review."

Wisconsin Event: WI 120009

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: 48129
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: EASTMAN CHEMICALS COMPANY
Region: 4
City: LONGVIEW State: TX
County:
License #: 00301
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/24/2012
Notification Time: 14:24 [ET]
Event Date: 07/23/2012
Event Time: [CDT]
Last Update Date: 07/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
FSME via E-mail ()

Event Text

AGREEMENT STATE REPORT - BROKEN PROCESS GAUGE SHUTTER MECHANISM

The following information was received via E-mail:

"On July 24, 2012, the licensee notified the Agency [Texas Department of State Health Services] that on July 23, 2012, it discovered a shutter mechanism on an Ohmart SH-F2-45 gauge mounted on the side of a tank at the licensee's facility was broken and the shutter could not be closed. The gauge contained 200 millicuries of cesium-137. The 3/8 inch cast iron shutter rod broke approximately 1/4 inch below the top surface of the gauge. The licensee has submitted the appropriate request to the Agency for the gauge to remain in operation until repairs can be made. The licensee contacted the manufacturer and scheduled the repair. Further information will be provided as it is obtained.

"Gauge information:
Ohmart SH-F2-45
Serial number: 5334GK

"Source information:
cesium-137
200 millicuries
Serial number: 9-1999"

Texas Incident #: I - 8971

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Agreement State Event Number: 48130
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: FLINT HILLS RESOURCES CHEMICAL INTERMEDIATES
Region: 3
City: JOLIET State: IL
County:
License #:
Agreement: Y
Docket: 01337-01
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 07/24/2012
Notification Time: 15:50 [ET]
Event Date: 07/18/2012
Event Time: [CDT]
Last Update Date: 07/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
FSME via email ()

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following information was received by email:

"On the evening of July 18, 2012 the licensee's radiation safety officer contacted the [Illinois Emergency Management] Agency's Radiation Duty Officer to advise that a fixed gauge had failed to perform as expected when an attempt was made to close the shutter in advance of work scheduled to be performed on the vessel it was mounted on. The RSO reports that although the spindle of the handle rotated, the shutter did not close. The shutter remained stuck in the 'open' position and would not close. As a result, the planned work was deferred and access to the confined space has been prohibited. The gauge is mounted such that there are no adjacent work stations and unrestricted access is not possible. Radiation monitoring performed by the radiation safety officer showed no abnormal readings.

"The gauge shutter had been successfully tested in March with no abnormalities at that time. The gauge is mounted in such a way that although it is exposed to ambient temperatures, it is not directly exposed to the elements by virtue of an overhead cover. The gauge has not been subjected to any corrosives or solvents or other conditions which exceed the gauge prototype's test conditions. Arrangements have been made to have the manufacturer's representative on-site to conduct an evaluation and effect repairs as necessary at the end of the week."

The fixed gauge is a model SA-1 manufactured by Ronan Engineering (serial number 69094). The gauge contains a Cs-137 sealed source (.082 Ci).

Illinois Incident: IL 12011

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Power Reactor Event Number: 48144
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DANIEL MCCARTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/30/2012
Notification Time: 14:29 [ET]
Event Date: 07/30/2012
Event Time: 13:50 [EDT]
Last Update Date: 07/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK FRANKE (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

NOTIFICATION OF NORTH CAROLINA WILDLIFE RESOURCES DUE TO STRIP BASS MORTALITY

"Duke Energy notified the NC Wildlife Resource Commission of dead striped bass in the vicinity of the McGuire low level intake. Notification was made 7/30/12 at 1350 EDT. In addition, the NC Dept. of Environment and Natural Resources will be notified.

"Dead fish are suspected to have been caused by increasing lake temperature and decreased oxygen levels, which is common during the late summer."

The NRC Resident Inspector will be notified.

Notified both R2DO (Franke).

Page Last Reviewed/Updated Wednesday, August 01, 2012
Wednesday, August 01, 2012