Event Notification Report for August 06, 2009

AGREEMENT STATE REPORT - NINE MISSING PO-210 AND PM-147 SEALED SOURCES

"On 19 June 2009, TTM Technologies in Redmond was contacted as part of a routine check of their inventory of generally licensed devices. It was discovered at this time that the facility was closing and that the gauges and static eliminators had been sent to TTM Technologies facilities in other states. TTM Technologies has since tracked down as many of the missing devices as possible. Those facilities that have received sources have been informed of the reporting requirements and regulations surrounding those generally licensed devices. NRD, Inc. was contacted to see if any of the remaining unaccounted for sources had been returned to them. They have not been. The remaining missing sources are being reported as lost.

"This report lists eight devices/sources. A ninth device/source (exactly the same as number 8 except for the serial number) is being included here instead. This device/source is serial number A2CK423. Seven of the nine devices/sources are Po-210 static eliminators and have gone through more than ten half-lives. The other two devices are sources of Pm-147 in beta backscatter gauges and have gone through approximately 8 half-lives. It is therefore concluded that the missing sources are of little threat to human health and safety.

"Source of Radiation:
Source Number: 1
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PM-147
Source Use: OTHER
Activity:0.9E-3 Ci 0.0333 GBq
Manufacturer: OXFORD INSTRUMENT
Model Number: GM-1
Serial Number: 75125P

"Source Number: 2
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PM-147
Source Use: OTHER
Activity:0.6E-3 Ci 0.0222 GBq
Manufacturer: OXFORD INSTRUMENT
Model Number: GM-1
Serial Number: 65986P

"Source Number: 3
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2001
Serial Number: A2EA910

"Source Number: 4
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2001
Serial Number: A2BM653

"Source Number: 5
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.05513 Ci 2.03981 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2DY847

"Source Number: 6
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2CE789

"Source Number: 7
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2BM653

"Source Number: 8
Form of Radioactive Material: SEALED SOURCE
Radionuclide: PO-210
Source Use: STATIC ELIMINATOR
Activity:0.010 Ci 0.37 GBq
Manufacturer: NRD, INC
Model Number: P-2021
Serial Number: A2CK423

"Corrective Actions: 1 Personnel received additional training."

Washington state reporting requirement WAC 246-221-240
Washington Report No: WA090061

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.

POTENTIAL DOSE TO WRONG SITE

A patient with radiation seed prostate implants came back to the facility to have a CAT Scan. Based on the CAT Scan results, the physician suspects the improper positioning of the radiation seed implants. Due to the patient's medical condition the hospital cannot conduct a verification CAT Scan with contrast material. The patient plans to return to the hospital at a later date. A hospital review of the patient's treatment is ongoing.


* * * UPDATE FROM TKI CHAK TO JOHN KNOKE AT 1530 ON 08/11/09 * * *

The licensee confirmed that the patient had improper positioning of the radiation seed implants. This was considered an under dose to the patient since the seeds went into the tissue and not the prostate. The patient was advised by the physician and will receive a follow-on treatment with a tomotheraphy procedure.

Notified FSME (Andrew Mauer) and R1DO (William Cook).

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 DOSE DIFFERENT THAN PRESCRIBED

The following was received from the state via e-mail:

"This incident was reported by a medical licensee (Centura Health Penrose - St. Francis Health Services License # 197-02) on 08/06/2009.

"On 22 July 2009, at patient at Penrose Hospital was implanted with 70 Palladium-103 seeds, 2.5 U each on that day. The application was via a Mick applicator, using intra-operative planning with a Variseed planning system. It was noted on the C arm film taken at the completion of the implant that there was some clumping of the seeds in groups. A post implant CT scan was done on 23 July 2009. The results of the computerized dosimetry plan was evaluated on the 5 August 2009 and it was determined that the prostate gland was under dosed, receiving a dose to 90% of the prostate volume (D90) of 36.6% of the prescribed 125 Gy. The AU [Authorized User] written directive listed an expected range of D90 to be 90% to 135%. The discrepancy between actual dose and prescribed falls outside of the 20% tolerance for delivered dose according to [Colorado State Regulation] RH 7.21.1.1 (1). A full report is expected from the licensee within 30 days."


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.

PLANNED MAINTENANCE TO AFFECT TECHNICAL SUPPORT CENTER

"On 8/6/09 at 0600 hours CDT the Monticello Nuclear Generating Plant's Technical Support Center uninterruptable power supply will be isolated to perform a planned maintenance activity. The maintenance activity requires implementation of compensatory measures to maintain TSC functions during the activity. The compensatory measures include having the Emergency Director report to the Control Room and co-locating the remaining TSC staff at the EOF should an event be declared requiring ERO activation. The ERO has previously successfully demonstrated the ability to implement these compensatory measures. The maintenance activity is scheduled to be completed with the TSC returned to full functionality by the end of the dayshift on 8/6/09. The Site Emergency Response Organization has been notified of the maintenance activity and instructed on the planned compensatory measures to be implemented during the activity. MNGP will notify the NRC upon completion of the activity restoring full TSC operability. This event is considered reportable per 10CFR50.72(b)(3)(iii). The licensee has notified the NRC Resident Inspector."

* * * UPDATE FROM D. BARNETT TO P. SNYDER AT 1943 ON 8/6/09 * * *

"On 8/6/09 at 1700 CDT the Monticello Nuclear Generating Plant's Technical Support Center was returned to service and declared functional. The Monticello Emergency Response Organization has been notified and the compensatory measures that were in effect have been terminated. The licensee has notified the NRC Resident Inspector."

Notified R3DO (Skokowski).

EMERGENCY OPERATIONS FACILITY PLANNED MAINTENANCE

"At approximately 1000, on Thursday, August 6, 2009, the heating, ventilation, air conditioning (HVAC), and filtration system of the Millstone Power Station (MPS) Emergency Operations Facility (EOF) will be removed from service to perform maintenance to improve the reliability and functionality of the system.

"The EOF is located inside the site's boundary approximately one mile from the protected area of the plant. As a result of this maintenance, the EOF will be unavailable for approximately 12 days. If an emergency requiring the use of the EOF is declared during this maintenance period, the designated alternate EOF, which is also located on site, will be utilized. The Station Emergency Response Organization (SERO) has been informed of this condition.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii). Millstone will notify the NRC upon completion of the planned maintenance activities and restoration of the EOF which is currently anticipated to occur on August 18, 2009.

"The licensee has notified the NRC Sr. Resident Inspector."

* * * UPDATE ON 8/14/2009 AT 1524 FROM MIKE MARTELL TO MARK ABRAMOVITZ * * *

The EOF was declared operable at 1324 EDT.

Notified the R1DO (Cook).