United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 28, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/27/2012 - 11/28/2012

** EVENT NUMBERS **


48519 48520 48521 48523 48537 48538 48540 48541

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Agreement State Event Number: 48519
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: LAKE CUMBERLAND REGIONAL HOSPITAL
Region: 1
City: SOMERSET State: KY
County:
License #: 202-123-26
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/19/2012
Notification Time: 11:03 [ET]
Event Date: 06/03/2011
Event Time: [CST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENTS INVOLVING PROSTATE SEED IMPLANTS

The following information was obtained from the Commonwealth of Kentucky via fax:

"KY RHB [Radiation Health Branch] was notified via e-mail by the Medical Physicist of the facility of two past medical events. The medical events involved two patients treated for prostate cancer with I-125 and Pd-103 seeds for which the Medical Physicist had developed the treatment plans. The Radiation Oncologist and the Urologist, who performed the procedures determined the dose delivered to the target organ based on D90 was less than 80% using the Variseed Treatment Planning software. The Radiation Oncologist who contoured the prostate and determined the post implant D90 doses, was not aware that a D90 less than 80% of the prescribed dose was a medical event that required reporting to the Radiation Health Branch. The patient treated on 6/3/11 was treated with 101 Bard STM1251, I-125 seeds (0.37 mCi/seed) monotherapy and received a D90 of 76.7%. The intended dose to the prostate was 145Gy and the administered dose was 111.2Gy. The second patient was treated on 4/12/12 with 73 seeds of Theraseed Model 200, Pd-103 (1.1 mCi/seed) as a part of a boost therapy to IMRT [Intensity Modulated Radiation Therapy]. This patient received a post implant D90 of 68.3%. The intended dose to the prostate was 90Gy and the administered dose was 61Gy. The Medical Physicist discovered these two medical events after performing an audit of the facility's permanent implant prostate brachytherapy program since its inception for a total of 71 patients. The State will continue to keep NRC informed of the status of our investigation.

"KY Event Report ID No: KY120013"

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: 48520
Rep Org: OAKWOOD MEDICAL CENTER
Licensee: OAKWOOD MEDICAL CENTER
Region: 3
City: DEARBORN State: MI
County:
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: ZUBIN BHARUCHA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/19/2012
Notification Time: 13:00 [ET]
Event Date: 09/18/2012
Event Time: [EST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BILLY DICKSON (R3DO)
FSME EVENTS RESOUCE ()

Event Text

PATIENT RECEIVED LESS THAN PRESCRIBED DOSE FOLLOWING BRACHYTHERAPY TREATMENT

On 9/18/12, a patient at the Oakwood Medical Center was administered a brachytherapy treatment of the prostate. 72 Iodine-125 seeds were implanted at the time. On a post-implant study on 11/18/12, it was determined that D90 dose for the treatment was 68.3%. The study indicated that the anterior prostate was somewhat "cold". There was some evidence of seed migration. The physician has been notified. The underdose is not expected to have any significant impact on 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: 48521
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PHYSICIAN RELIANCE LP
Region: 4
City: FORT WORTH State: TX
County:
License #: 05545
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/19/2012
Notification Time: 12:53 [ET]
Event Date: 01/05/2012
Event Time: [CST]
Last Update Date: 11/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME RESOURCES (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL PROSTATE THERAPY UNDERDOSE

"On November 16, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that a potential medical event occurred. On January 5, 2012, a patient received an Iodine-125 prostate seed implant of 63 seeds (0.475 mCi/seed). The implant was completed as planned and verification films were taken and confirmed that the implant appeared normal and no concerns were expressed during or immediately after the implant procedure. In late August or early September, a post plan was created for evaluation. 63 seeds were localized by a staff physicist and sometime after or during the post plan analysis, the staff physicist noticed the seed placement appeared inconsistent with the pre-plan. The staff physicist informally notified the Chief Physicist and a Senior Radiation Oncologist who each viewed the plan and concluded that further evaluation was needed. The implant appeared shifted inferior to the prostate. The final determination is that all of the parameters of the implant (activity per seed, total activity, seed distribution, etc.) were all consistent with the pre-plan except that the center of the seed distribution and the center of the prostate were separated by a couple of centimeters and the most inferior seed was approximately 3.5 cm inferior to the apex of the prostate. The licensee has been contacted to report prescribed dose, actual dose, and percent of dose received. Additional information will be provided IAW SA-300."

Texas Incident# I-9014

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: 48523
Rep Org: U. S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-328-38-01
Agreement: N
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/20/2012
Notification Time: 11:41 [ET]
Event Date: 10/29/2012
Event Time: [EST]
Last Update Date: 11/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
BILLY DICKSON (R3DO)
FSME EVENTS (EMAI)
RAY KELLAR (R4DO)

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

Event Text

MISSING IMPROVED CHEMICAL AGENT MONITOR

An ICAM (Improved Chemical Agent Monitor) is missing at Fort Riley, KS. The ICAM contains a 10 mCi Nickel-63 source. The licensee has initiated a formal investigation and notified NRC Region 3 Inspector (McGraw).

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: 48537
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE JOHNSTON
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/27/2012
Notification Time: 00:02 [ET]
Event Date: 11/26/2012
Event Time: 19:30 [EST]
Last Update Date: 11/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAMES DWYER (R1DO)

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

DEGRADED CONDITION DUE TO PINHOLE LEAK IN REACTOR HEAD SPRAY LINE

"Pinhole leak discovered on a Reactor Head Spray line weld during Nuclear Steam Supply System Leak Test.

"Oyster Creek Nuclear Generating Station is currently in the Shutdown Condition executing Refueling Outage 1R24, which includes Nuclear Steam Supply System (NSSS) Leak Testing, prior to startup.

"At 1930 on 11/26/2012, a pinhole leak was discovered on a Reactor Head Spray Class 1 piping weld. The leak was discovered during the NSSS Leak Test, while the Reactor was in the Shutdown Condition. The leak is on a flange to piping weld on the Reactor Head Spray system upstream of the N-7B nozzle. Water was found to be weeping from the pinhole leak (approximately 2 to 3 drops per minute).

"The cause is under investigation and corrective action plans are being developed.

"The leak has been evaluated by Exelon and determined to meet the criteria for reporting identified in NUREG-1022: Welding or material defects in the primary coolant system that cannot be found acceptable under ASME Section XI, IWB-3600, 'Analytical Evaluation of Flaws,' or ASME Section XI, Table IWB-3410-1, 'Acceptable Standards.'"

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 48538
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: RICHARD HONEYCUTT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/27/2012
Notification Time: 16:29 [ET]
Event Date: 11/27/2012
Event Time: 09:00 [EST]
Last Update Date: 11/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MIKE ERNSTES (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

LOSS OF ASSESSMENT CAPABILITY- RADIATION MONITOR INOPERABLE DUE TO DATABASE ERROR

"This is a non-emergency notification. At 0900 EST on November 27, 2012, it was discovered that radiation monitor RM-1WV-3546-1, Waste Processing Building Wide Range Gas Monitor was inoperable due to a database error. The database error appears to have occurred at approximately 1724 EST on November 26, 2012. The database error was corrected and the monitor returned to service at 0958 EST on November 27, 2012. This monitor is the only monitor credited in the EALs for monitoring a gaseous release from the Waste Processing Building.

"This radiation monitor is necessary for accident assessment and is credited for Emergency Action Level (EAL) classification in the Harris Nuclear Plant Emergency Plan. Inability to classify an EAL due to an out of service monitor is considered a loss of accident assessment capability and is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2. This condition does not affect the health and safety of the public or the operation of the facility because no events occurred during the time the radiation monitor was out of service.

"The NRC Resident Inspector has been notified."

See EN #48536 for similar report.

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Power Reactor Event Number: 48540
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DARVIN DUTTRY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/27/2012
Notification Time: 18:40 [ET]
Event Date: 11/27/2012
Event Time: 17:20 [EST]
Last Update Date: 11/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES DWYER (R1DO)
JOHN LUBINSKI (NRR)
JANE MARSHALL (IRD)

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 N 0 Cold Shutdown 0 Cold Shutdown

Event Text

OFFSITE NOTIFICATION DUE TO A FATALITY

"At 1720 hours on November 27, 2012 PPL SSES [Susquehanna Steam Electric Station] notified the Occupational Safety and Health Administration that an employee had suffered a fatality.

"On November 27, 2012 at 1313 hours, a PPL employee suffered an apparent heart attack while at the Luzerne County Community College (LCCC) Public Safety Training Institute while performing SCBA [Self Contained Breathing Apparatus] training. The employee was transported to the Geisinger Wyoming Valley hospital and pronounced dead. PPL was notified at 1432 of the fatality.

The LCCC training facility is not located on PPL owned property.

"This ENS report is being made in accordance with 50.72(b)(2)(xi).

"The NRC Resident Inspector was notified."

The licensee has also notified the Commonwealth.

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Power Reactor Event Number: 48541
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL KENNEDY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/28/2012
Notification Time: 02:38 [ET]
Event Date: 11/27/2012
Event Time: 20:38 [PST]
Last Update Date: 11/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JACK WHITTEN (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

CONTROL ROOM VENTILATION SYSTEM WILL NOT AUTOMATICALLY START IN PRESSURIZATION MODE

"The control room ventilation system (CRVS) pressurization mode is required to be actuated by a safety injection signal, control room radiation atmosphere air intake, and operator manual actuation in accordance with Technical Specification (TS) 3.3.7.

"On November 27, 2012 at 2038 hrs. PST, Pacific Gas and Electric Company (PG&E) identified that none of the CRVS four pressurization fans would operate continuously if they started in response to a safety injection or control room radiation atmosphere intake actuation signal. All of the pressurization fans remain capable of continuous operation via manual actuation. At 2050 PST the Unit 2 CRVS was manually placed in pressurization mode in accordance with TS 3.3.7, ACTION B.1.1.

"This was determined to be caused by a recent flow balancing of the CRVS that raised the static air pressure. The increased system static pressure actuates the fan-run pressure switches for each of the four associated pressurization fans, when only a single pressurization fan is operated. This results in the system logic securing all pressurization fans started by the CRVS automatic actuation signals. If all pressure switches actuate, automatically started pressurization fans will be secured until air pressure decays below the fan-run switch setpoint, at which time the pressurization fan would restart. This would result in cyclic operation of the pressurization fan.

"The fan-run pressure switches are not part of the manual actuation circuitry for the pressurization fans.

"Diablo Canyon (DCPP) is making this 8-hour, non-emergency notification under 10 CFR 50.72(b)(3)(v)(D).

"Plant personnel notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, November 28, 2012
Wednesday, November 28, 2012