Event Notification Report for February 18, 2008

AGREEMENT STATE REPORT INVOLVING A VEHICLE ACCIDENT WHILE TRANSPORTING A RADIOGRAPHY CAMERA

The following report was received via email from the State of Texas:

"At 8:04 p.m., Radiation Control (RC) was contacted through the 24-hour Radiological Emergency Assistance telephone number by San Jacinto Emergency Management, reporting a car accident in San Jacinto County, on Highway 59, north of Houston, where a company was transporting a radioactive camera which was thrown from the truck onto the roadside. The Emergency Management representative reported that there was no leakage from the camera and that the driver sustained minor injuries. They did not have the company's name or any additional information on the radioactive source and was following instructions to make the initial notification to the State. The Emergency Management representative said they would call back with additional information.

"The Emergency Management representative called back and relayed the following information:

"Company/Licensee: National Inspection Services - out of Crowley, TX

"The Emergency Management representative reported that the Cleveland Haz-Mat team was handling the incident, but did not have any contact information for them.

"RC placed a call to the company contact, who informed RC that he was enroute from Sulphur, LA and would be on-site in 2 hours. He gave me the name and the telephone number of the Haz-Mat chief on-site. He also said another company supervisor was enroute from Lafayette, LA and would be there ~1 hour.

"RC then called the Haz-Mat chief on-site, who reported that they surveyed with a Victoreen 6A series survey meter on the x100, x10 and x1 scales and got no readings of any radiation leakage. He said the camera was intact but out of its transport container. He informed RC that they were going to transport it back to the station. RC asked him for the manufacturer's information on the camera. The chief said he had it an ice cooler, with styrofoam overpack in the back of his truck and to call him back ~ 3 minutes for the information.

"Meanwhile RC called the company representative from Lafayette, had the camera information:

"Mfg.: SPEC 150 Ir-192 camera with ~ 30 Ci source.

"He said that a Level II Radiographer was also in the company vehicle and was on the accident scene with the chief and could answer any questions. He also said the Texas Radiation Safety Officer (RSO) was contacted and would get with RC. He said the truck was a complete loss, the darkroom broke apart off of the truck and the camera was thrown out of the darkroom. He said the Level II Radiographer followed their O&E procedures for handling the recovery and securing of the camera. He said the camera would be picked up tonight by the company representative from Sulphur and would be sent off to SPEC in the morning for leak testing. I reminded him of the written notification as a follow-up to the telephone notification. He did not know off-hand their Texas Radioactive Materials License (RAML) number.

"RC called the chief back right away, whose information concurred with the company representative's. RC then asked to speak with the Radiographer, who confirmed that he oversaw the camera recovery, examination and radiation surveying and concurred that the camera was neither damaged nor leaking. RC told him and the chief that in keeping with Increased Controls (IC), to have the Radiographer travel with the camera when it is transported back to the fire station, so that visual control of the camera is maintained by the licensee. RC also asked that the company representative from Sulphur, LA contact RC when they picked up the camera and the employee.

"RC placed a call back to the other company representative from Lafayette and relayed the same information to him. He agreed to call me back as soon as he had secured them both.

"RC followed up with a resolution summation call to San Jacinto Emergency Management.

"I will await the camera secured-confirmation call from Joe. At 11:04 p.m. (CST) RC received the telephone call from the Haz-Mat employee that the camera and company employee were both picked up.

"02/19/08, camera verification information from licensee @ 9:49 a.m.:

"Mfg: SPEC Model: 150 Serial No.: 875 or 820
"Source: Ir-192 25 Ci Mfg.: SPEC Serial No.: OH2913
"Last leak test: 01/31/08"

Texas Incident #: I-8484

AGREEMENT STATE REPORT - DENSITY GAUGE CONTAINING CS-137 INADVERTENTLY THROWN AWAY AS SCRAP WAS LATER RECOVERED

"Brief Description of Incident

"Railroad [RR] car arrived at Nucor Steel [in South Carolina] at 10AM on February 18, 2008. The RR car set off the exploranium detection equipment, so to ensure accuracy the RR car was passed through 4 times. Radiation measurement of RR car #JOSX 1771 was 25 microR/hr [which is] five times background (5 microR/hr). Notified SC-DHEC -Radiation Waste [DELETED] who further contacted NC DENR. [DELETED] from SC Nucor Steel was given CRCPD approval (see SC-NC 08-01) for return trip of rail car to point of origin, Iron & Metal Goldsboro, N.C.

"The Rail Car numbered JOSX 1771 returned from Nucor Steel Darlington, SC on February 28, 2008. [NC-DENR] arrived at their location in Goldsboro on February 29, 2008 in the AM, as requested and took reading from the rail car and found only one hot spot (35 microR/hr - Ludlum 19) that was located on the left side of the railcar toward the upper middle portion of container. The item in question was located.

"I annotated what was legible and it is the following: Model number 7062 BP; Serial Number 18317; Manufacturing Date 1984; Type and Amount of Isotope Cs-137, 100 mCi. Highest Readings 10.5 mR/hr on contact with Ludlum 19 and Identifinder.

"Gauge SN 18317 was retrieved from Iron & Metal Goldsboro with chain of custody letter signed by all parties, then taken to storage room at the GAF Materials Corp. where three other gauges are now kept.

GAF Materials has custody of the damaged gauge and will package it and ship it to a suitable vendor for repair.

N.C. Incident Number 08-09.

The State of North Carolina informed Region 1(Jim Cotton).

UNANALYZED CONDITION DUE TO #2 TURBINE BYPASS VALVE FAILURE

"Unit two reduced power to 90% to perform monthly turbine testing surveillance on 2/18/08. All tests were completed satisfactorily with the exception of the main turbine #2 Bypass Valve (BPV). At 0120 hours, the #2 BPV stroked fully open per procedure, but the last 10% of travel to full open did not yield the expected response of BPV fast open from 90% to 100%. The fast acting solenoid did indicate expected state change to 'energized' at 90% valve open, but the BPV did not indicate fast open. Therefore the Main Turbine Bypass System has been declared inoperable and associated actions of Tech Spec 3.7.7 have been invoked. This spec requires compliance with LCO 3 .2.2 MINIMUM CRITICAL POWER RATIO (MCPR) limits for an inoperable main turbine bypass system as specified in the COLR (Core Operating Limit Report), are made applicable (within 2 hours) or reduce THERMAL POWER to <24% RTP within the following 4 hours. The MCPR limits were calculated by reactor engineering and installed in the process computer at 0347 hours. A decrease in reactor power was not required once the MCPR limit was installed.

"The COLR (ref.: TRM Appendix A) states Unit Two can be operated with EITHER the End- of- Cycle Recirc Pump Trips (EOC-RPTs) out of service OR the Turbine Bypass Valves inoperable, but not both. The EOC-RPTs were already out of service as allowed for current conditions of the operating cycle. Upon discovery of the inoperable Bypass Valve, it was recognized that this placed Unit Two in an unanalyzed condition for fuel thermal limit. The shift crew took immediate actions to confirm the surveillance was current for EOC-RPTs and placed them in service per approved plant procedures. This was accomplished at 0315 hours, which returned the unit to an analyzed condition."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM J. ANDERSON TO P. SNYDER ON 3/20/08 AT 0943 * * *

"During the surveillance testing of the main turbine bypass valves, one of the three main turbine bypass valves did not function as expected. The function of the main turbine bypass system was degraded but not lost. Upon discovery the required action statement (RAS) in Technical Specifications 3.7.7 and 3.2.2 were properly entered, and the required actions were taken within the allowed out of service time of two hours. Based on the initial review of the condition and the fact that the core operating limits report (COLR) described operation in the condition with the EOC-RPT out of service concurrent with loss of the main turbine bypass capability as an unanalyzed condition, a notification was made in accordance with the following reporting requirement:

"'10 CFR 50.72 (b)(3)(ii)(B) The nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'

"The initial notification was a conservative action taken shortly after the condition was discovered. The condition was immediately identified during surveillance testing of the main turbine bypass valves, the required Technical Specifications RAS was entered and the actions completed within the allowed two hour time frame of 0120 - 0315 EST on 2/28/08. This prompt action prevented continued operation with EOC-RPT out of service and main turbine bypass inoperable and eliminated this potential to be in a condition where the design basis may not have been met.

"A more detailed review was subsequently performed which determined that the minimum critical power ratio thermal limit for having EOC-RPT out of service and main turbine bypass inoperable as calculated during the reload analysis was 1.42. At the time of the event the actual MCPR at that point in core life was 1.57. Even though prompt actions were taken as required, there was actual margin to the calculated MCPR limit of 1.42. Had a design basis transient occurred, the MCPR Safety Limit would not have been exceeded.

"Based on this information the determination has been made that the unit was not in an unanalyzed condition that significantly degraded plant safety. This notification serves to retract the previous event notification # 43992 made on 2/18/2008 at 0508 EST."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT INVOLVING A DOSE THAT IS DIFFERENT THAN PRESCRIBED

"On February 18, 2008, an administrative error medical event occurred at our Leksell Gamma Knife facility which resulted in the total dose delivered differing from the written directive by more than 20%, but which agreed with the therapy that was intended and planned by the radiation oncologist authorized user (AU) and the neurosurgeon. This was discovered during the 2008 annual quality management review that was completed on June 24, 2009.

"On February 18, 2008, a stereotactic radiosurgery treatment plan was developed by the neurosurgeon, AU and authorized medical physicist (AMP) that satisfied the therapy intentions of the AU and neurosurgeon. Two of the three metastatic lesions that were discussed in advance at the neurosurgery tumor board meeting on February 13, 2008 by the neurosurgeon and AU were treated, the third being geometrically out of range of the gamma knife system. Specifically, the lesion locations selected at the tumor board meeting were right cerebellum, right occipital lobe and left temporal/parietal. The left temporal/parietal was out of range. The correct intended dose of 20 Gy to 50% isodose was planned and delivered on February 18. The AU and AMP specified both lesions on the Gamma Knife planning QA form which was signed by the AU, Neurosurgeon and AMP. The AU signed the plan and initialed every page including screenshots of the isodoses superimposed on the MRI images for both lesions. The plan included all of the information required in 10 CFR 35.40 (b)(3). Finally, the time out form was completed by the AU, neurosurgeon and AMP.

"The administrative error medical event is the result of the AU not writing a directive for treatment of the right occipital lesion.

"[The event occurred due to] lack of attention to administrative tasks.

"[The individual who received the administration had] no detrimental effect. Treatment was delivered as planned according to doctor's orders.

"The gamma knife quality management review will be done on the day of treatment prior to delivery by a second physicist using the form/checklist attached. This process is already in effect."

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.

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DURING PROSTATE THERAPY

The state found three cases of prostate seed (Pd-103) medical misadministration during an inspection on 1/14/2011. These cases are related to one doctor.

2/18/2008: 100 Gy prescribed, 70.24 Gy administered
4/8/2008: 125 Gy prescribed, 71.6 Gy administered
3/17/2009: 100 Gy prescribed, 160.8 Gy administered

The physician was notified of the misadministration however the patients were not notified.

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.