Event Notification Report for December 23, 2008

DEGRADED SAFETY EQUIPMENT

"Area 600 uses a flammable gas as part of its operation. IROFS [Items Relied On For Safety] FIRE6-6 is a control that prevents the flammable gas from exiting the main process equipment and being released into an attached glovebox. FIRE6-6 makes use of a dual door system in which only one (1) door is allowed to be open at a time and the chamber between the doors is purged when both doors are closed. The accident scenario of concern is release of the flammable gas into the glovebox where it could mix with oxygen, creating a potential for an explosion inside Building 302. Additionally, IROFS FIRE6-8, 6-1 and 6-9 ensure an inert gas purge occurs prior to opening the main process equipment to the glovebox and are also credited as IROFS.

"The equipment associated with FIRE6-6 is designated as Safety Related Equipment (SRE) and is functionally tested annually. The regularly scheduled SRE Test was performed on December 23, 2008, and the purpose of the test is to demonstrate that each door remains closed while the other door is opened. The test failed because when the first door was opened, the second door also opened slightly (approximately one (1) inch). Though there are mitigating factors such as potential dilution of the flammable gas through the glovebox ventilation system, it was determined that IROFS FIRE6-6 was degraded and that the performance criteria of 10CFR70.61 were not met.

"A similar event was reported to the NRC (#44584) on October 21, 2008 for similar equipment in Bldg 302. However, the cause of the previous IROFS failure was due to a blocked speed controller which failed to bleed off air. The blocked speed controlled is unrelated to the current IROFS failure.

"POTENTIAL CONSEQUENCES: Potential explosion in a glovebox and release of radiological material and exposure to the worker. No actual explosion or radiological exposure occurred.

"SEQUENCE OF OCCURRENCES: The event occurred due a degraded IROFS that was discovered during a periodic functional test. Initial investigation indicates an airline solenoid valve is leaking by.

"ACTIONS TAKEN: Operations has closed the flammable gas supply for Area 600 Bldg 303 until the equipment associated with FIRE6-6 is fixed and the SRE test passes."

The licensee has notified the NRC Resident Inspector.

AGREEMENT STATE - MEDICAL MISADMINISTRATION

The following was provided by the state via facsimile:

Description and Analysis of event:

"A medical event was discovered at 11:00 AM on January 2, 2009 involving a patient who was undergoing high dose rate brachytherapy (HDR) for papillary serous adenocarcinoma of the uterus. The patient completed 4600cGy of external beam radiation therapy on 9/11/08 and was currently undergoing 3 high dose rate brachytherapy fractions, approximately 3 cm in length, at 500 cGy per fraction. During the patient's second HDR treatment, a review of the first HDR plan showed that the tandem was not fully inserted into the cylinder. The visualization on the CT scan of the placement of the tandem being partially inserted was not recognized by the planner or reviewer of the plan. The dwell positions were therefore placed in the airspace where the tandem should have been inserted versus at the retracted location. The first fraction (12/23/08) was therefore treated approximately 6 cm distal to what was represented by the isodoses on the plan printout. The x-ray (port film) at the time of treatment also showed the tandem not fully inserted into the cylinder.

"A plan was run with the isodoses placed 6 cm distal to the tip of the tandem channel. The isodoses show that the patient received dose (3 cm of active dwell positions as planned) to the distal vagina versus the proximal vagina as prescribed.

"The radiation oncologist was immediately notified of the tandem placement after discovery. The prescribing physician (radiation oncologist) notified the patient and the referring physician about the variance that had occurred in the patient's treatment as well as the possible complications.

"Patient Management:

"The radiation oncologist explained to the patient that there was no clinically significant increase in possible complications as a result of the HDR treatment to the distal vagina for 1 fraction (12/23/08). After careful review, the radiation oncologist decided he will continue as planned with the third HDR fraction at 500 cGy. He does not expect any increase in bladder or rectal toxicity and expects to see a decrease in normal tissue toxicity.

"Prevention of Future Occurrence:

"1. When the nurse assembles the cylinder applicator, the nurse will measure the tandem length outside the cylinder to ensure the tandem has been inserted to the maximum extent.

"2. The dosimetry and physics staff will receive an in-service on the difference in CT image based plans with an emphasis on how the tandem channel looks in the cylinder with the tandem fully inserted versus a partial insertion.

"3. The physicists will begin looking at the pre-treatment port film along with the radiation oncologist prior to initiating treatment."

Louisiana event number - LA090007

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.