Event Notification Report for April 14, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/13/2009 - 04/14/2009
General Information or Other
Event Number: 45007
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CANCER CARE NORTHWEST PET CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: M0227
Agreement: Y
Docket:
NRC Notified By: BRANDON KETTER
HQ OPS Officer: HOWIE CROUCH
Licensee: CANCER CARE NORTHWEST PET CENTER
Region: 4
City: SPOKANE State: WA
County:
License #: M0227
Agreement: Y
Docket:
NRC Notified By: BRANDON KETTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/21/2009
Notification Time: 14:39 [ET]
Event Date: 04/14/2009
Event Time: 00:00 [PDT]
Last Update Date: 07/01/2009
Notification Time: 14:39 [ET]
Event Date: 04/14/2009
Event Time: 00:00 [PDT]
Last Update Date: 07/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION
The following information was obtained from the State of Washington via email:
"On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.
"The aluminum connector to needle 13 detached from the plastic guide tube. It is possible that the source wire or the dummy wire, during retraction, snagged on the seam between the aluminum connector and the plastic guide tube. The HDR is connected to the plastic guide tube, the plastic guide tube is attached (glued) to the aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.
"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.
Isotope and Activity involved: Iridium-192, 185.2 GBq (5.0 curies). Source serial number: 02-01-0080-001-0121.
Overexposures: The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient.
Washington Incident Number: WA-09-015
* * * UPDATE PROVIDED VIA EMAIL FROM KETTER TO PARK AT 0823 EDT ON 7/1/09 * * *
"Updated, corrected event narrative: On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.
"The aluminum connector to needle 13 detached from the extension adaptor. The HDR is connected to the plastic guide tube, the plastic guide tube is attached to the extension adaptor (which includes the attached (glued) aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.
"The root causes of the failure of the adhesive that attached the aluminum connector to the plastic extension adaptor are: sterilization of the extension adaptor (manufacturer's written product information cautions that sterilization may cause adhesive failure), and reuse of extension adaptors (manufacturer's written product information recommends for single use only).
"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.
"The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient."
Notified the R4DO (Pick) and FSME EO (Burgess).
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.
The following information was obtained from the State of Washington via email:
"On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.
"The aluminum connector to needle 13 detached from the plastic guide tube. It is possible that the source wire or the dummy wire, during retraction, snagged on the seam between the aluminum connector and the plastic guide tube. The HDR is connected to the plastic guide tube, the plastic guide tube is attached (glued) to the aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.
"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.
Isotope and Activity involved: Iridium-192, 185.2 GBq (5.0 curies). Source serial number: 02-01-0080-001-0121.
Overexposures: The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient.
Washington Incident Number: WA-09-015
* * * UPDATE PROVIDED VIA EMAIL FROM KETTER TO PARK AT 0823 EDT ON 7/1/09 * * *
"Updated, corrected event narrative: On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment.
"The aluminum connector to needle 13 detached from the extension adaptor. The HDR is connected to the plastic guide tube, the plastic guide tube is attached to the extension adaptor (which includes the attached (glued) aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient.
"The root causes of the failure of the adhesive that attached the aluminum connector to the plastic extension adaptor are: sterilization of the extension adaptor (manufacturer's written product information cautions that sterilization may cause adhesive failure), and reuse of extension adaptors (manufacturer's written product information recommends for single use only).
"It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles.
"The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient."
Notified the R4DO (Pick) and FSME EO (Burgess).
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.
Fuel Cycle Facility
Event Number: 44988
Facility: PORTSMOUTH AMERICAN CENTRIFUGE
Region: 2 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817
NRC Notified By: ERIC SPAETH
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817
NRC Notified By: ERIC SPAETH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/14/2009
Notification Time: 13:40 [ET]
Event Date: 04/14/2009
Event Time: 00:00 [EDT]
Last Update Date: 04/15/2009
Notification Time: 13:40 [ET]
Event Date: 04/14/2009
Event Time: 00:00 [EDT]
Last Update Date: 04/15/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
MALCOLM WIDMANN (R2)
LAWRENCE KOKAJKO (NMSS)
MALCOLM WIDMANN (R2)
LAWRENCE KOKAJKO (NMSS)
DIESEL FUEL OIL SPILL REQUIRING OFFSITE NOTIFICATIONS
"On 04/14/09 at approximately 0918 hours, the Plant Shift Superintendent was notified of an oil spill that occurred on the plant site. A diesel generator sitting near a construction area was leaking fuel. Primary and secondary containment was initiated to contain the spill. At 1130 hours environmental response personnel determined that the quantity of oil spilled exceeded the Reportable Quantity (RQ).
"At 1144 hours, 04/14/2009, the Plant Shift Superintendent notified the National Response Center and the Ohio EPA that a Reportable Quantity (RQ) of oil (diesel fuel) was released to the environment.
"Ohio EPA assigned incident #: 0904-66-1084.
"National Response Center assigned incident #: 902636
"ACD2-RG-044, Appendix N, section 1 requires an NRC event notification when other government agencies are notified."
The amount of fuel oil spilled was 25 to 40 gallons. Licensee will be issuing a press release about this spill.
* * * UPDATE AT 2241 ON 4/14/2009 FROM SPAETH TO ABRAMOVITZ * * *
The licensee is issuing a press release and has revised the estimated spill to 300 gallons.
Notified the R2DO (Widman), NMSS (Kokajko), and PAO (Hayden) via e-mail.
* * * UPDATE ON 4/15/2009 AT 1400 FROM SPAETH TO ABRAMOVITZ * * *
This event occurred at the American Centrifuge Plant (Docket 70-7004, license SNM-2011) and not the gaseous diffusion plant.
Notified the R2DO (Widman) and NMSS (Kokajko) via e-mail.
"On 04/14/09 at approximately 0918 hours, the Plant Shift Superintendent was notified of an oil spill that occurred on the plant site. A diesel generator sitting near a construction area was leaking fuel. Primary and secondary containment was initiated to contain the spill. At 1130 hours environmental response personnel determined that the quantity of oil spilled exceeded the Reportable Quantity (RQ).
"At 1144 hours, 04/14/2009, the Plant Shift Superintendent notified the National Response Center and the Ohio EPA that a Reportable Quantity (RQ) of oil (diesel fuel) was released to the environment.
"Ohio EPA assigned incident #: 0904-66-1084.
"National Response Center assigned incident #: 902636
"ACD2-RG-044, Appendix N, section 1 requires an NRC event notification when other government agencies are notified."
The amount of fuel oil spilled was 25 to 40 gallons. Licensee will be issuing a press release about this spill.
* * * UPDATE AT 2241 ON 4/14/2009 FROM SPAETH TO ABRAMOVITZ * * *
The licensee is issuing a press release and has revised the estimated spill to 300 gallons.
Notified the R2DO (Widman), NMSS (Kokajko), and PAO (Hayden) via e-mail.
* * * UPDATE ON 4/15/2009 AT 1400 FROM SPAETH TO ABRAMOVITZ * * *
This event occurred at the American Centrifuge Plant (Docket 70-7004, license SNM-2011) and not the gaseous diffusion plant.
Notified the R2DO (Widman) and NMSS (Kokajko) via e-mail.
Power Reactor
Event Number: 44989
Facility: PERRY
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ANTHONY JARDINE
HQ OPS Officer: JOHN KNOKE
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ANTHONY JARDINE
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/14/2009
Notification Time: 14:18 [ET]
Event Date: 04/14/2009
Event Time: 07:43 [EDT]
Last Update Date: 04/14/2009
Notification Time: 14:18 [ET]
Event Date: 04/14/2009
Event Time: 07:43 [EDT]
Last Update Date: 04/14/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (R3)
LAURA KOZAK (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
SAFETY PARAMETER DISPLAY SYSTEM AND ERDS OUT OF SERVICE
"On April 14, 2009, at approximately 0743 hours, electrical power was lost to 480 volt busses V-1-F and V-2-F. These busses supply electrical power to the Emergency Response Data System (ERDS). The electrical power loss caused the ERDS, the Safety Parameter Display System (SPDS), and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) to be disabled. Preliminary investigation indicates that a failed inverter caused the power loss.
"Contingency plans have been established to transmit plant parameter data and perform the dose assessment function in the event of an emergency while ERDS is unavailable. The ERDS, SPDS and CADAP were restored at 1110 hours.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii), as a condition that results in a major loss of offsite communications capability."
The NRC Resident Inspector has been notified.
"On April 14, 2009, at approximately 0743 hours, electrical power was lost to 480 volt busses V-1-F and V-2-F. These busses supply electrical power to the Emergency Response Data System (ERDS). The electrical power loss caused the ERDS, the Safety Parameter Display System (SPDS), and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) to be disabled. Preliminary investigation indicates that a failed inverter caused the power loss.
"Contingency plans have been established to transmit plant parameter data and perform the dose assessment function in the event of an emergency while ERDS is unavailable. The ERDS, SPDS and CADAP were restored at 1110 hours.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii), as a condition that results in a major loss of offsite communications capability."
The NRC Resident Inspector has been notified.