United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 5, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/02/2012 - 11/05/2012

** EVENT NUMBERS **


48425 48441 48444 48445 48447 48475 48476 48477 48478 48479

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Agreement State Event Number: 48425
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA HOSPITAL AND CLINIC
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: VINCE KLCO
Notification Date: 10/19/2012
Notification Time: 17:34 [ET]
Event Date: 10/18/2012
Event Time: [CDT]
Last Update Date: 11/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL DOSAGE NOT DELIVERED AS PLANNED

A patient was being treated for a liver tumor and the dosage was delivered to the wrong lobe. The physician prescribed 17 mCi of Y-90 to the left lobe of the liver. The prescribing physician was not present during the dose administration procedure. The intervention radiologist examined a fluoroscope of the patient's liver and noted a larger tumor on the right lobe. The prescribed dosage was then delivered to the right lobe of the liver, not in accordance with the prescribed dosage plan. Patient examination detected no observable impact, and the physician is developing another dosage plan for the patient. The Iowa Department of Public Health will perform an onsite investigation.

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.

* * * UPDATE FROM RANDAL DAHLIN TO CHARLES TEAL ON 11/2/12 AT 1408 EDT * * *

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

"The University of Iowa nuclear medicine staff notified the Environmental Health & Safety (EHS) office on October 19, 2012 that they had discovered a reportable medical event that occurred during an October 18, 2012, therapy administration of Yttrium-90 microspheres (SIRSpheres) to a patient with liver metastases from a carcinoid tumor.

"The Nuclear Medicine authorized user had prescribed for the delivery of 17 millicuries of the Y-90 microspheres to the left lobe of the patient's liver with plans to also administer 34 millicuries of the Y-90 microspheres to the right lobe of the patient's liver at a later time. Y-90 activity to be administered was calculated based on body surface area and tumor involvement. However, the interventional radiologist performing the Y-90 microsphere administration under fluoroscopic guidance noted that the angiogram of the patient's liver showed more tumor blood flow in the right lobe of the patient's liver and decided it would be medically more advantageous for the patient to treat the right lobe of the liver first. He proceeded to treat the right lobe without consulting the authorized user.

"The interventional radiologist was only able to deliver 96% of the 17 millicurie Y-90 dose to the right lobe of the patient's liver before the right artery occluded. The authorized user discovered the administration discrepancy the next day when the patient was scheduled for post therapy imaging on October 19th. Both the patient and referring physician were informed of the medical event on October 19th. The physicians involved concluded that the patient's health and outcome were not affected by treating the right lobe of the liver first with only 17 millicuries of Y-90 microspheres since only 96% of activity could be injected before full embolization of the right hepatic artery occurred.

"The physicians plan to treat the left lobe of the patient's liver in approximately 4 weeks. The Iowa Department of Public Health (IDPH) performed an onsite investigation of this medical event on October 23, 2012. The IDPH inspector interviewed the University Radiation Safety Officer, the Nuclear Medicine Authorized User, the Interventional Radiologist performing the Y-90 administration, the Chief Nuclear Pharmacist, the Chairman of the Medical Radiation Protection Committee, and Hospital Radiation Safety Review Group. The cause of the event was a lack of understanding of the requirements for administering radioactive material under the supervision of an authorized user. The interventional radiologist made a medical decision to alter the administration site without consulting the prescribing authorized user.

"To avoid recurrence the following actions are being taken by the University of Iowa. All nuclear medicine authorized users prescribing Y-90 microsphere therapy will review the supervision requirements specified in Iowa Administrative Code 641-41.2(11) with all interventional radiologists on staff to ensure that they understand that they are required to follow the instructions of the prescribing authorized user. A roster of the individuals receiving this training will be forwarded to the IDPH upon completion. Additionally, nuclear medicine and interventional radiology will develop a written policy regarding the proper steps to be taken in the event that any deviation from the authorized user's written directive for the medical administration of radioactive materials is required. A copy of the policy will be forwarded to IDPH upon completion.

"Reporting Requirement: 35.3045(a)(1(i) - Total dose delivered that differs from the prescribed dose by 20% or more; and differs from the prescribed dose by more than 0.05 Sv (50 rem) SDE."

IA Report: IA120006

Notified R3DO (Kozak) and the FSME Event Resource via email.

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Agreement State Event Number: 48441
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA-153-1
Agreement: Y
Docket:
NRC Notified By: JOEL MIMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/25/2012
Notification Time: 08:03 [ET]
Event Date: 05/24/2011
Event Time: [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - Y-90 THERASPHERE SPILL

The following information was obtained from the State of Georgia via facsimile:

"Description of Event: A spill involving Y-90 microspheres (SIR-Spheres) that occurred on May 24, 2011 at Emory University Hospital [and] was reported by the Deputy Radiation Safety Officer. During an embolization treatment using Y-90 microspheres, resistance was encountered when flushing the catheter following the initial successful microsphere administration. The authorized user examined the catheter which was found to be occluded. Preparations were made to continue the administration with a second measured dose, but this was halted when further examination showed evidence of a leak between the Y-90 vial and the catheter. The procedure was postponed until contamination controls were complete. The patient received the completion of the prescribed dose pursuant to the Authorized User's written directives when the Interventional Suite was available for use on the following day.

"Describe clean-up actions taken by RCP [Georgia Radiation Control Program]: No action performed by RCP but the licensee sealed the Y-90 shielding and cart and removed [them] for decay and evaluation. The floor and equipment were decontaminated by licensee radiation safety staff.

"List radiation measurements taken by RCP: No measurements performed by the RCP but the licensee initiated spill containment procedures [and surveyed] the staff before allowing anyone to exit the room. Some minor contamination was discovered on staff clothing and shoes, but no contamination was detected on the skin of staff after removal of affected items. The deputy RSO surveyed the patient and had a bremsstrahlung scan of patient. No contamination was found on the patient during the scan.

"List any other actions required of RCP: The licensee is storing all waste from this event for decay and subsequent investigation."

Georgia Incident Summary number GA-2011-61i.

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Non-Agreement State Event Number: 48444
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BABTIST MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-1128-02
Agreement: N
Docket:
NRC Notified By: THOMAS MOENSTER
HQ OPS Officer: PETE SNYDER
Notification Date: 10/25/2012
Notification Time: 15:54 [ET]
Event Date: 05/01/2012
Event Time: 13:00 [CDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

RADIOPHARMACEUTICAL THERAPY RECORD TRANSPOSITION ERROR

A doctor prescribed a patient 0.4 mCi/Kg Zevalin (a prescription medication containing Yttrium-90). The calculated dose based on the patient's weight was 44 mCi; however, the package insert for the drug says the maximum dose to be used is 32 mCi. So 32 mCi of Y-90 was to be given to the patient.

A radiopharmaceutical therapy record was prepared as required at the hospital but the dose on the radiopharmaceutical therapy record was improperly copied as 23 mCi.

The dose prepared at the radiopharmacy and delivered to the patient was 31.8 mCi. The dose differed from that specified on the radiopharmaceutical therapy record by more than 20%.

The prescribing physician is aware and there is no significant impact to the patient.

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: 48445
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: GERDAU CHARLOTTE
Region: 1
City: CHARLOTTE State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES D. ALBRIGHT
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/25/2012
Notification Time: 15:24 [ET]
Event Date: 10/25/2012
Event Time: [EDT]
Last Update Date: 10/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - HIGH PORTAL MONITOR READINGS AT SCRAP YARD

The State of North Carolina reported the following via email:

"NC Radiation Protection Section received a call from Gerdau Charlotte regarding a load of scrap tire-wire that tripped their portal monitor. [An individual] measured 10 mR/hr on contact at the rear of the truck trailer using a handheld meter (Ludlum 192, background reported at 3 mR/hr). The shipment originated from Liberty Tire in Atlanta, GA.

"[The shipment] will be returned to Liberty Tire, Atlanta, GA, via CRCPD exemption NC-GA-12-01."

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Agreement State Event Number: 48447
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: FULTON COUNTY HOUSING AND COMMUNITY DEVELOPMENT
Region: 1
City: FAIRBURN State: GA
County:
License #: 1440-1
Agreement: Y
Docket:
NRC Notified By: CYNTHIA LONG
HQ OPS Officer: PETE SNYDER
Notification Date: 10/26/2012
Notification Time: 13:23 [ET]
Event Date: 10/25/2012
Event Time: [EDT]
Last Update Date: 10/26/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN X-RAY FLUORESCENCE ANALYZER

The following was submitted by the State of Georgia via email:

"Around noon time on 10/26/12, [a licensee representative] called and notified the Department [Georgia Radioactive Material Program] that upon his arrival at work that morning around 8:30 am, he discovered that his office was vandalized, and the Niton Model # XP300A/Serial # 22283 Lead Paint Analyzer radioactive device was stolen. He indicated that his door was left unlocked that night. When he walked in the two drawer file where the gauge was stored, was opened. The intruder was able to locate the key to the cabinet and the key was still in the open drawer. The device was locked in the carrying case, and the case was also stolen. The licensee stated that the device was last used on 10/25/12, and returned to storage around 5:00 pm before leaving work on that day. The device contains a Cadmium 109, 40 mCi source, Serial # TR0380."

Georgia incident ID: GA-2012-30i

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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Power Reactor Event Number: 48475
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON CHERNY
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/02/2012
Notification Time: 03:30 [ET]
Event Date: 11/02/2012
Event Time: 01:42 [CDT]
Last Update Date: 11/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO HIGH REACTOR COOLANT PUMP MOTOR BEARING TEMPERATURE

"At 0142 CDT, Comanche Peak Nuclear Power Plant Unit 1 was manually tripped due to high temperature indications on the 1-04 reactor coolant pump motor radial bearing concurrent with a high / low oil reservoir level alarm. The trip was uncomplicated; all control rods and shutdown rods fully inserted; neither emergency diesel generator started; all safety systems functioned as designed. Both motor driven and the turbine driven auxiliary feed water pumps started as required to restore steam generator levels as a result of the trip. The turbine driven AFW pump was stopped per procedure and returned to auto-start status. Currently, Unit 1 is in Mode 3, no load Tave of 557 degrees F, with temperature being maintained with AFW and steam dumps to the main condenser. All electrical busses are powered from offsite and grid conditions are stable."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48476
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: WILLIAM KISNER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/02/2012
Notification Time: 11:33 [ET]
Event Date: 11/01/2012
Event Time: 16:00 [EDT]
Last Update Date: 11/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GEORGE HOPPER (R2DO)

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

Event Text

FITNESS FOR DUTY - CONTRACT SUPERVISOR FOUND IN POSSESSION OF PROHIBITED SUBSTANCE

A non-licensed contract supervisor was found to have in his possession a prohibited substance prior to entry into the plant protected area. The contractor's access to the plant has been terminated. This event has been re-posted after additional discussions with the licensee. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48477
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: MATTHEW BUSCH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/03/2012
Notification Time: 11:50 [ET]
Event Date: 11/03/2012
Event Time: 08:23 [EDT]
Last Update Date: 11/03/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES NOGGLE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 24 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC SCRAM ON LOW REACTOR WATER LEVEL

"On November 3, 2012 at 0823 EDT, Nine Mile Point Unit 1 experienced an automatic reactor scram on low reactor water level. All control rods fully inserted and all plant systems responded per design following the scram. Prior to the automatic scram, an unexpected high Reactor Pressure Vessel (RPV) water level was experienced, followed by a turbine trip and subsequent lowering of RPV water level to the RPV low level scram set point. The cause of the water level transient is unknown.

"Following the automatic scram, the High Pressure Coolant Injection (HPCI) System automatically initiated as expected. HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System. At 0824 EDT, RPV level was restored above the HPCI System low level actuation set point and the HPCI System initiation signal was reset. Pressure control was established on the Turbine Bypass Valves, the preferred system. No Electromatic Relief Valves actuated due to this scram.

"Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. Since the scram, there have been no anomalies observed with feedwater system operation. Decay heat is being removed via steam to the main condenser using the bypass valves. The offsite grid is stable with no grid restrictions or warnings in effect. The unit is currently implementing post scram recovery procedures.

"The licensee has notified the NRC Resident Inspector."

Unit 2 was not affected during this event.

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Power Reactor Event Number: 48478
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TODD MULFORD
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/04/2012
Notification Time: 14:52 [ET]
Event Date: 11/04/2012
Event Time: 12:30 [EDT]
Last Update Date: 11/04/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
LAURA KOZAK (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 47 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO SECONDARY SIDE STEAM LEAK

"At 1115 EST on November 4, 2012, primary coolant loop #2 was declared inoperable due to a small un-isolable steam leak on a drain valve of an atmospheric steam dump valve on the secondary side of the 'B' Steam Generator. The valve is ASME Class II high energy piping and the non-conforming condition could not be evaluated with the steam generator pressurized. Based on the condition of the valve and the inability to evaluate, Technical Specification 3.4.4, PCS loops - Modes 1 and 2, Required Action A.1 was entered which requires the plant to be placed in Mode 3 in 6 hours. Repair of the valve may require cooldown to Mode 5.

"At 1230 EST on November, 2012, Palisades initiated a shutdown in accordance with Technical Specification 3.4.4."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48479
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVE RICHARDSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/05/2012
Notification Time: 00:40 [ET]
Event Date: 11/04/2012
Event Time: 21:53 [EST]
Last Update Date: 11/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JAMES NOGGLE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM FROM FULL POWER FOLLOWING TURBINE TRIP

"The reactor was scrammed on a valid reactor protection system activation caused by a main turbine trip. The cause of the main turbine trip is under investigation. All control rods fully inserted. All isolations and initiations occurred as designed. High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) initiated as expected. RCIC injected into the reactor coolant system, HPCI did not, as expected."

This scram was characterized as uncomplicated and the reactor is stable in Mode 3. The plant is in a normal post shutdown electrical lineup. All systems functioned as required.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Monday, November 05, 2012
Monday, November 05, 2012