Event Notification Report for April 29, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/28/2009 - 04/29/2009
EVENT NUMBERS
4503445030450314504145105
Hospital
Event Number: 45034
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARD
HQ OPS Officer: DONALD NORWOOD
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/30/2009
Notification Time: 14:51 [ET]
Event Date: 04/29/2009
Event Time: 13:30 [EDT]
Last Update Date: 04/30/2009
Notification Time: 14:51 [ET]
Event Date: 04/29/2009
Event Time: 13:30 [EDT]
Last Update Date: 04/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
CHRISTEPHER MCKENNEY (FSME)
DAVID HILLS (R3DO)
CHRISTEPHER MCKENNEY (FSME)
MEDICAL EVENT INVOLVING AN UNDERDOSAGE DURING TREATMENT FOR LIVER CANCER
"At approximately 1:30 pm, on April 29, 2009 a medical event occurred at Indiana University Medical Center, NRC License No. 13-02752-03. This medical event involved the treatment of a patient with Y-90 microspheres (Nordion TheraSpheres). A dosage of 61.3 mCi was prescribed by the Authorized User. TheraSpheres are provided as a unit dosage and said dosage was assayed at 12:15 pm (4/29/09) to contain 60.1 mCi. Based upon a radiation monitoring device affixed to the TheraSphere delivery system, the pre-treatment reading was 7 milliroentgens per hour (mR/hr). Following the administration of the microspheres and four subsequent flushings of the delivery system, the radiation monitor exhibited a reading of 2 mR/hr, indicating that approximately 28.6% (17.2 mCi) of the dosage remained in the delivery system. When the subsequent flushing failed to reduce the remaining activity in the system, an independent measurement of the residual activity was performed to confirm that the entire dosage had not been delivered as prescribed.
"The vendor (Nordion) was notified of this event earlier today (4/29/09). Based upon discussions with their technical representatives, it is their opinion that the residual microspheres may be attached to the septum of the dose vial. For future treatments, the vendor representative suggested that the dose vial be given a good shake during the check-in and assay procedure to help dislodge any microspheres that may have adhered to the vial septum during shipment. They also suggested that during the administration process if the residual dosage appears to be present in the dose vial, tilting and tapping the dose vial and/or the acrylic box containing the dose vial may dislodge any microspheres that may adhere to the vial septum. These suggestions are being incorporated into the written procedures for TheraSphere treatments.
"The Radiation Safety Office attempted to perform some radiation measurements of the delivery system to determine the location of the residual activity. Due to the relatively high exposure rates from the residual radioactivity in the delivery system, it was not possible to definitively determine the distribution of the residual activity in the system at this time, mainly due to the potential for contamination and elevated radiation levels to RSO staff. More thorough evaluations may be possible once the radioactivity in the system diminishes due to radioactive decay.
"Notification of the referring physician of the occurrence of this medical event was made at 10:25 am today (4/30/09). The patient's wife was notified of the occurrence of the medical event at 10:30 am today."
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.
"At approximately 1:30 pm, on April 29, 2009 a medical event occurred at Indiana University Medical Center, NRC License No. 13-02752-03. This medical event involved the treatment of a patient with Y-90 microspheres (Nordion TheraSpheres). A dosage of 61.3 mCi was prescribed by the Authorized User. TheraSpheres are provided as a unit dosage and said dosage was assayed at 12:15 pm (4/29/09) to contain 60.1 mCi. Based upon a radiation monitoring device affixed to the TheraSphere delivery system, the pre-treatment reading was 7 milliroentgens per hour (mR/hr). Following the administration of the microspheres and four subsequent flushings of the delivery system, the radiation monitor exhibited a reading of 2 mR/hr, indicating that approximately 28.6% (17.2 mCi) of the dosage remained in the delivery system. When the subsequent flushing failed to reduce the remaining activity in the system, an independent measurement of the residual activity was performed to confirm that the entire dosage had not been delivered as prescribed.
"The vendor (Nordion) was notified of this event earlier today (4/29/09). Based upon discussions with their technical representatives, it is their opinion that the residual microspheres may be attached to the septum of the dose vial. For future treatments, the vendor representative suggested that the dose vial be given a good shake during the check-in and assay procedure to help dislodge any microspheres that may have adhered to the vial septum during shipment. They also suggested that during the administration process if the residual dosage appears to be present in the dose vial, tilting and tapping the dose vial and/or the acrylic box containing the dose vial may dislodge any microspheres that may adhere to the vial septum. These suggestions are being incorporated into the written procedures for TheraSphere treatments.
"The Radiation Safety Office attempted to perform some radiation measurements of the delivery system to determine the location of the residual activity. Due to the relatively high exposure rates from the residual radioactivity in the delivery system, it was not possible to definitively determine the distribution of the residual activity in the system at this time, mainly due to the potential for contamination and elevated radiation levels to RSO staff. More thorough evaluations may be possible once the radioactivity in the system diminishes due to radioactive decay.
"Notification of the referring physician of the occurrence of this medical event was made at 10:25 am today (4/30/09). The patient's wife was notified of the occurrence of the medical event at 10:30 am today."
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.
Power Reactor
Event Number: 45030
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: JOE O'HARA
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 04/30/2009
Notification Time: 00:13 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
Notification Time: 00:13 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
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):
PAUL KROHN (R1DO)
PAUL KROHN (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
TONE ALERT RADIOS OUT OF SERVICE
"At 2230 on April 29, 2009, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09].
"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The National Weather Service is currently working to determine the cause of the failure and time frame for system restoration.
"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified.
"UPDATE: Notified by Oswego County that the Tone Alert Radios were restored 00:12 on 04/30/2009."
"At 2230 on April 29, 2009, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09].
"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The National Weather Service is currently working to determine the cause of the failure and time frame for system restoration.
"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified.
"UPDATE: Notified by Oswego County that the Tone Alert Radios were restored 00:12 on 04/30/2009."
Power Reactor
Event Number: 45031
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN DRISCOLL
HQ OPS Officer: JASON KOZAL
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JOHN DRISCOLL
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2009
Notification Time: 00:48 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
Notification Time: 00:48 [ET]
Event Date: 04/29/2009
Event Time: 19:38 [EDT]
Last Update Date: 04/30/2009
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):
PAUL KROHN (R1DO)
PAUL KROHN (R1DO)
| 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 |
TONE ALERT RADIOS OUT OF SERVICE
"At 2230 on April 29, 2009, with Nine Mile Point Unit 1 and Unit 2 operating at 100% reactor power, Oswego County Emergency Management notified the Unit 1 and Unit 2 Control Rooms that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09]. At 0015 on April 30, Oswego County Emergency Management notified the Control Rooms that the Tone Alert Radios had been restored to service as of 0012, April 30, 2009.
"This impacted the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF [James A. FitzPatrick see EN# 45030] Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The County Alert Sirens which also function as part of the Public Prompt Notification System remained operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency offsite communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified."
"At 2230 on April 29, 2009, with Nine Mile Point Unit 1 and Unit 2 operating at 100% reactor power, Oswego County Emergency Management notified the Unit 1 and Unit 2 Control Rooms that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 [on 4/29/09]. At 0015 on April 30, Oswego County Emergency Management notified the Control Rooms that the Tone Alert Radios had been restored to service as of 0012, April 30, 2009.
"This impacted the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF [James A. FitzPatrick see EN# 45030] Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The County Alert Sirens which also function as part of the Public Prompt Notification System remained operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency offsite communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program, and the [NRC] Resident Inspector has been briefed, and the state PSC will also be notified."
General Information or Other
Event Number: 45041
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: KELLOGG USA, INC
Region: 4
City: OMAHA State: NE
County:
License #: GL0552
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: BILL HUFFMAN
Licensee: KELLOGG USA, INC
Region: 4
City: OMAHA State: NE
County:
License #: GL0552
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/04/2009
Notification Time: 13:53 [ET]
Event Date: 04/29/2009
Event Time: 00:00 [CDT]
Last Update Date: 05/04/2009
Notification Time: 13:53 [ET]
Event Date: 04/29/2009
Event Time: 00:00 [CDT]
Last Update Date: 05/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WAYNE WALKER (R4DO)
CHRISTEPHER MCKENNEY (FSME)
ILTAB VIA E-MAIL
WAYNE WALKER (R4DO)
CHRISTEPHER MCKENNEY (FSME)
ILTAB VIA E-MAIL
AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS
The Nebraska Office of Radiological Health provided the following report via e-mail:
"The [Kellogg USA] facility was not able to locate four H-3 exit signs (SRB Model BXU20WS containing 17.51 Curies [each] of H-3, for serial #'s 217897, 217965, & SRB Model B100BX20 containing 17.51 Curies [each] of H-3 for serial #'s 220063 and 220071) while completing their annual inventory. They have made a number of searches and can not locate the four missing signs. The company is planning on the removal and proper disposal of all H-3 exit signs in the facility by 8/31/2009. The facility has 230 plus exit signs."
Nebraska Report NE090010
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.
The Nebraska Office of Radiological Health provided the following report via e-mail:
"The [Kellogg USA] facility was not able to locate four H-3 exit signs (SRB Model BXU20WS containing 17.51 Curies [each] of H-3, for serial #'s 217897, 217965, & SRB Model B100BX20 containing 17.51 Curies [each] of H-3 for serial #'s 220063 and 220071) while completing their annual inventory. They have made a number of searches and can not locate the four missing signs. The company is planning on the removal and proper disposal of all H-3 exit signs in the facility by 8/31/2009. The facility has 230 plus exit signs."
Nebraska Report NE090010
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.
General Information or Other
Event Number: 45105
Rep Org: ASCO VALVE INCORPORATED
Licensee: ASCO VALVE INCORPORATED
Region: 1
City: FLORHAM PARK State: NJ
County:
License #:
Agreement: N
Docket:
NRC Notified By: KAREN BOLIO
HQ OPS Officer: HOWIE CROUCH
Licensee: ASCO VALVE INCORPORATED
Region: 1
City: FLORHAM PARK State: NJ
County:
License #:
Agreement: N
Docket:
NRC Notified By: KAREN BOLIO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/29/2009
Notification Time: 11:54 [ET]
Event Date: 04/29/2009
Event Time: 00:00 [EDT]
Last Update Date: 05/29/2009
Notification Time: 11:54 [ET]
Event Date: 04/29/2009
Event Time: 00:00 [EDT]
Last Update Date: 05/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
GEORGE HOPPER (R2DO)
TOM HERRITY (email) (NRR)
OMID TABATAI (email) (NRO)
GEORGE HOPPER (R2DO)
TOM HERRITY (email) (NRR)
OMID TABATAI (email) (NRO)
PART 21 FOR MISSING PARTS ON ASCO SOLENOID VALVES
The following information was obtained from ASCO Valve QA Engineering via facsimile:
On 4/24/09 ASCO Engineering was made aware of a non-conformance in the valve assembly area. During the assembly of a solenoid valve, part number NPEFKX8300141EG 10688 125/DC, the valve assembler noticed that the valve was missing an insulating barrier and a wiring label used with screw terminal coils. Neither item was included on the valve Bill of Materials.
Purchase orders were reviewed and it was determined that North Anna Nuclear Power Station had purchased two of the subject valves. ASCO notified North Anna on April 27, 2009.
ASCO has taken measures to prevent future occurrences.
The following information was obtained from ASCO Valve QA Engineering via facsimile:
On 4/24/09 ASCO Engineering was made aware of a non-conformance in the valve assembly area. During the assembly of a solenoid valve, part number NPEFKX8300141EG 10688 125/DC, the valve assembler noticed that the valve was missing an insulating barrier and a wiring label used with screw terminal coils. Neither item was included on the valve Bill of Materials.
Purchase orders were reviewed and it was determined that North Anna Nuclear Power Station had purchased two of the subject valves. ASCO notified North Anna on April 27, 2009.
ASCO has taken measures to prevent future occurrences.