Event Notification Report for February 23, 2010

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following information was received from the State via facsimile:

"A Troxler Electronic Laboratories, Inc. Model 3430, portable gauging device [serial number 17906, containing approximately 8.0 millicuries of cesium-137 (source serial number 750-7391), and approximately 40 millicuries of americium-241/beryllium (source serial number 47-13347)] was hit by an excavator at a temporary jobsite. The Cs-137 source was in the safe shielded position when it was hit and the source remained shielded after it was struck by the excavator. A leak test was performed and no leakage was detected from either source."

Utah Event Number: UT-10-0001

POTENTIAL MEDICAL EVENT FROM DOSAGE DELIVERED TO DIFFERENT LOCATION THAN PRESCRIBED

"[The patient] completed her prescribed 5 day, 10fx [High Dose Rate] HDR Brachytherapy to the left breast on January 22, 2010, utilizing a multi-lumen mammosite catheter device. On Feb 22, 2010, in follow-up, the patient complained about skin reddening on the external breast, outside of the mammosite catheter insertion site. The medical physicist involved in the treatment planning process was notified about the unusual finding, who upon investigating the treatment and the plan used to deliver the radiation treatment, found that an incorrect measurement resulted in placement of the radioactive source 10 cm away from the intended position, thereby delivering the prescribed dose to a portion of the unintended area. Majority of the dose was delivered in air, but a significantly high dose was delivered to a small volume of the skin distal to the connector end of the catheter, which could have caused the skin reaction.

"Description of circumstances that led to the event: On Thursday, January 14 at 1130, [the patient] was brought to the HDR suit for CT simulation and the needed measurements. Following the CT scan of the left breast, the physicist went in the room with the source position simulator (a dummy source wire with the exact length of the actual live source cable) to measure the treatment distance for each catheter (distance to the tip of the catheter). A transfer tube was connected to the proximal end of each catheter and dummy cable was fed through the same till it could not go any further. This point is understood as the tip of the closed end catheter. While the dummy cable was being fed, the physicist felt resistance at 115.2 cm, which he recorded as the distance to the tip of the catheter. He then repeated the same measurement for the other three catheters and found that the distance of resistance was the same. All four lumens were measured and the distances were recorded. This multi-lumen mammosite catheter was the first one to be used on a patient and therefore the physicist assumed that this is the correct distance for this device, although other devices similar to this device have different treatment distances. The physicist did not exert extra pressure on the dummy cable fearing the rupture /malfunction of the catheters.

"There were two representatives from the manufacturer present, for proctoring, as this was the first case of the multi-lumen mammosite catheter. The physicist expressed his concern about the unusual treatment distance to one of the representatives, who said that the distance sounded right.

"The measured distances were entered in the plan as the position of the first dwell position of the radiation source for each catheter. The treatment plan was generated and sent to the treatment console for storage and treatment execution that next week. The planning system cannot detect any errors in the treatment distance, as long as the distance is within the length of the closed system.

"The patient returned for her first treatment on the morning of Monday, January 18, and started with treatments, twice a day for five days. There were no warnings or error messages from the treatment console and the treatments were delivered as planned.

"The radiation oncologist reported that the mammosite multi-lumen catheter had no unusual aspects or appearance at either insertion at surgery or at extraction after the last treatment fraction.

"Discovery of the error: Soon after the physician's follow-up meeting with the patient, Monday, February 22, 2010, the physicist was informed about the unusual skin reaction on the patient, on February 22, 2010. The physicist immediately began investigating the treatment records and the treatment plan. He then tried to measure the treatment distance on a sample mammosite multi-lumen device which the manufacturer had provided, as a test device, with the same source position simulator and encountered a similar resistance at the exact same distance. But when exerted more pressure on the source cable, it advanced further and the distance turned out to be 125.2, which was 10 cm longer than the measurement done on the patient. This observation led him to conclude that the patient did not receive the treatment at the intended area, but at 10 cm proximal to the catheter tip, which included some skin and tissue of the external breast medial to the entry point of the device where the skin reaction is. The physicist recalled similar resistance on the dummy source cable on other occasions, which leads to a possible fault with source position simulator assembly. It was also possible that the lumens were kinked at some point inside, where the housing of the lumens was bent (to facilitate wound dressing), thereby causing resistance for the advancing of the dummy source cable.

"A treatment plan was generated that night representing what happened and the following conclusions were made upon review by physics staff that next morning, February 23, 2010, regarding the treatment of the unintended tissue and skin:

"a. An average dose of 1700 cGy was delivered to approximately 100 cc of the unintended breast tissue.

"b. About 7.5 cc of the skin and underlying tissue received a high maximum dose of 6800 cGy (possibly the area of skin reaction)

"c. 35 cc of the intended breast tissue received an average dose of 340 cGy (10% of the total prescribed dose)

"Recommendations:

"1. The physicist should make a list of treatment distances for all standard applicators including partial breast treatment devices and catheters.

"2. Include a therapist or a nurse in the process of all patient measurements and have them double-check the patient measurements.

"3. Acquire a new source position simulator assembly and a set of transfer tubes.

"4. Make a second measurement of the treatment distance on all patient catheters prior to the first treatment."

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 - GAMMA KNIFE TREATMENT TO WRONG LOCATION

A gamma knife treatment prescribed to be administered to the left side of a patient was instead administered to the patient's right side. The scheduled 30 minute, 90 Gray procedure was terminated after 1.4 minutes when the administering physician detected the error. It is estimated that 4% of the prescribed dose was administered to the wrong area.

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.

UNANALYZED CONDITION - INCOMPLETE LIST OF SAFETY CONTROLS IN INTEGRATED SAFETY ANALYSIS SUMMARY

"During a [Global Nuclear Fuel, Americas] GNF-A ongoing review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), it was discovered at 3pm yesterday (2/22/2010) that the list of safety controls associated with the handling of hydrofluoric material may be incomplete in the ISA Summary.

"After further review, it was determined this morning that the list of Items Relied on for Safety (IROFS) was incomplete, and as a result, the UF6 conversion area has been shut down pending revision of the ISA to document IROFS for these processes. UF6 conversion will remain shutdown until IROFS have been identified and implemented.

"While this discovery did not result in an unsafe condition, it is being reported on 2/23/2010 pursuant to the reporting requirements of 10CFR70 Appendix A (b)(1) within 24 hours."

The licensee notified NRC Region 2 (Rich) and will notify the state and local authorities.

* * * UPDATE FROM PHILLIP OLLIS TO DONG PARK AT 0905 EST ON 3/11/10 * * *

"During the GNF-A ongoing review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), it was determined at 10:30am yesterday (3/10/2010) that the list of IROFS associated with the storage of uranium hexafluoride cylinders may be incomplete in the ISA Summary. As a result, conservative compensatory management measures for UF6 cylinder storage have been implemented pending revision of the ISA to document IROFS for these areas.

"While this discovery did not result in an unsafe condition, it is being reported as an addendum to event report 45717 pursuant to the requirements of 10CFR70 Appendix A(b)(1) within 24 hours."

Notified R2DO (Nease) and NMSS EO (Benner).

ERDS NOT AVAILBLE DUE TO PLANT COMPUTER MALFUNCTION

"The Emergency Response Data System (ERDS) link from the Critical Function Monitoring System (CFMS) was lost at approximately 0100 hours on February 23, 2010 due to a malfunction of the plant computer. Other systems such as Safety Parameter Display System (SPDS), RECS, and ENS remain available. In accordance with the site reporting procedure, a loss of ERDS for greater than 16 hours is reportable as a major loss of emergency assessment capability. Troubleshooting is in progress."

The licensee has notified the NRC Resident Inspector and will notify the state.

* * * UPDATE FROM THOMAS RAS TO JOE O'HARA AT 1724 ON 2/25/10 * * *

ERDS was restored to operable status at 1652 EST.

The licensee notified the NRC Resident Inspector.

DEGRADED CONDITION - WELD LEAK DUE TO VIBRATING VALVE ATTACHMENT WIRE

"On 2/22/10, we determined that there was pressure boundary leakage on Unit 2 from the leak off line associated with a pressurizer spray valve (2-RC-220). The source of leakage associated with a boron deposit discovered earlier on 2/18/10. The boron deposit formed based on a leak in a Class 1 manual valve packing leak-off line. The leak location was determined to be in the packing leak-off pipe fillet weld to the stem retaining structure of the valve in the packing gland area. The valve (2-RC-220) is a Class 1 pressure boundary. The packing leak-off line is considered an auxiliary connection in the stem retaining structure of the valve.

"At this time, we believe the most probable cause of the 2-RC-220 leak-off line socket weld leak was based on two factors, a small pore in the original socket weld metal and the location of a valve tag attachment wire. The leak location coincided with the location where a valve tag attachment wire laid across the weld. It is possible this wire, vibrating against the weld, opened up a subsurface pore in the weld metal which began to leak sometime after startup from the 2009 RFO [Refueling Outage] (March 2009). Since the failure may have occurred due to a material problem that resulted in abnormal degradation of a principal safety barrier (i.e., it is necessary to take corrective actions to restore the weld's integrity), this event is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A). The valve was overhauled in the 2009 RFO and subsequently passed VT-2 inspection. The overhaul did not include any welding on the affected joint.

"Unit 2 is in Mode 5 to allow repairs to be made to this weld."

The licensee will notify the NRC Resident Inspector.

INVALID ACTUATION OF STANDBY GAS TREATMENT SYSTEM

"This report is being made under 10CFR50.73(a)(2)(iv)(B)(2). On February 23, 2010 at 1050 EST procedure 52PM-C71-001-0, RPS M/G Set System Preventative Maintenance, was being performed. During restoration of RPS Buses on Unit 1, only the Unit 1 required logic was reset. The Unit 2 logic was also required to be reset but was not. Procedure 52PM-C71-001-0, RPS M/G Set System Preventive Maintenance, did not clearly require the reset of both Unit 1 and Unit 2 logic. The procedure has been revised to make this requirement clear. Continuation of steps in the procedure required links to be closed which resulted in SBGT starting on Unit 1 and Unit 2 from Unit 2 logic. Unit 1 and Unit 2 Reactor Building ventilation isolated. This was not due to a valid signal. The automatic actuation of the standby gas treatment system (SBGT) and the isolation of Unit 1 and 2 secondary containment isolation dampers is considered an invalid actuation since the parameters that cause this actuation to occur had not been exceeded. For this reason the actuation is considered invalid and a report to the NRC is not required by 10CFR50.72(b)(3)(iv); however, because the secondary containment isolation signals affected containment isolation valves in more than one system (Unit 1 and 2 components affected) the event is reportable as required by 10CFR50.73(a)(2)(iv)(B)(2). A licensee event report (LER) is required, but can be a telephone notification as allowed by 10CFR50.73. In the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than actuation of the reactor protection system (RPS) when the reactor is critical, the licensee may, at its option, provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.

"The four Standby Gas Treatment (SBGT) fans auto started and both Unit 1 and Unit 2 reactor building and refueling floor normal ventilation systems automatically shutdown and isolated. The SBGT Initiation and the ventilation system shutdown were both complete actuations."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - BRACHYTHERAPY UNDERDOSE TO PROSTATE GLAND

On 2/23/10, a patient went to Memorial Healthcare Hospital for brachytherapy treatment to the prostate gland. The prescribed treatment was 125 Gy (75 seeds) to the prostate gland. Due to swelling, the enlarged organ resulted in a lower radiation dose within the prostate. Even though all 75 seeds were implanted, the actual dose to the patient was 81.07 Gy. On 4/12/10 the physician notified the patient of the underdose and made arrangements for a second treatment. On 5/4/10 the second brachytherapy treatment of 57.26 Gy (8 seeds) was performed on the patient. In evaluating the patient's second treatment results, no further action was required.

This event is being reported due to a finding from an NRC audit.


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.