Event Notification Report for June 03, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/02/2010 - 06/03/2010
Power Reactor
Event Number: 45975
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: MICHAEL STIDMAN
HQ OPS Officer: BILL HUFFMAN
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: MICHAEL STIDMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/03/2010
Notification Time: 17:14 [ET]
Event Date: 06/03/2010
Event Time: 10:50 [CDT]
Last Update Date: 06/03/2010
Notification Time: 17:14 [ET]
Event Date: 06/03/2010
Event Time: 10:50 [CDT]
Last Update Date: 06/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PATTY PELKE (R3DO)
PATTY PELKE (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
SECONDARY CONTAINMENT BRIEFLY DEGRADED
"On June 3rd, 2010, at 1050 CST, both doors in Airlock 413 from Secondary Containment (SCT) to the Rad Waste 985' Pump Room were opened simultaneously for approximately five seconds and subsequently re-closed. This condition caused an unplanned entry into Technical Specification 3.6.4.1.A for SCT. The condition could have prevented the Standby Gas Treatment system from developing a negative pressure within SCT following a design basis accident.
"This negative pressure is required to prevent ground level releases of radioactivity and minimize onsite and offsite dose consequences following an accident, The Standby Gas Treatment system remained operable throughout the event. The site continues to assess the situation."
The licensee has notified the NRC Resident Inspector and will also notify State authorities.
"On June 3rd, 2010, at 1050 CST, both doors in Airlock 413 from Secondary Containment (SCT) to the Rad Waste 985' Pump Room were opened simultaneously for approximately five seconds and subsequently re-closed. This condition caused an unplanned entry into Technical Specification 3.6.4.1.A for SCT. The condition could have prevented the Standby Gas Treatment system from developing a negative pressure within SCT following a design basis accident.
"This negative pressure is required to prevent ground level releases of radioactivity and minimize onsite and offsite dose consequences following an accident, The Standby Gas Treatment system remained operable throughout the event. The site continues to assess the situation."
The licensee has notified the NRC Resident Inspector and will also notify State authorities.
General Information or Other
Event Number: 46116
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket: 09-0003
NRC Notified By: KENATH O. TRAEGDE
HQ OPS Officer: DONG HWA PARK
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket: 09-0003
NRC Notified By: KENATH O. TRAEGDE
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/22/2010
Notification Time: 09:24 [ET]
Event Date: 06/03/2010
Event Time: 00:00 [EDT]
Last Update Date: 07/22/2010
Notification Time: 09:24 [ET]
Event Date: 06/03/2010
Event Time: 00:00 [EDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - POTENTIALLY LOST RADIOACTIVE MATERIAL
The following was received via fax from the State of Massachusetts:
"On June 3, 2010, two packages containing I-125 seeds were received by the Medical Physicist [MP], who brought them to the radiation oncology hot lab. The MP removed the paperwork and left the packages in the lab while he went back to his office to update the inventory system. He returned to the hot lab to place the cartridges containing the seeds in the vault. He put one cartridge in the vault next to a cartridge that was left over from a canceled treatment. The MP thought that the other cartridge already in the vault was from one of the packages just received, and proceeded to remove the labels from the packages and survey the packages before discarding them. Since the seeds are shielded by a stainless steel cartridge, the survey measurement was indistinguishable from background. The event was discovered by him on Tuesday, June 8, when he was preparing for a treatment and noticed the serial numbers on the cartridges did not match the ones in the inventory system. He reported his findings to the Radiation Safety Officer. The event was reported to Massachusetts Radiation Control Program on Thursday, June 10.
"Approximately 43 milliCuries of I-125 seeds were disposed in the clean trash system. Attempts to locate the material in the trash were unsuccessful and they concluded on Tuesday, June 8, that the package had left the premises via the trash."
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
The following was received via fax from the State of Massachusetts:
"On June 3, 2010, two packages containing I-125 seeds were received by the Medical Physicist [MP], who brought them to the radiation oncology hot lab. The MP removed the paperwork and left the packages in the lab while he went back to his office to update the inventory system. He returned to the hot lab to place the cartridges containing the seeds in the vault. He put one cartridge in the vault next to a cartridge that was left over from a canceled treatment. The MP thought that the other cartridge already in the vault was from one of the packages just received, and proceeded to remove the labels from the packages and survey the packages before discarding them. Since the seeds are shielded by a stainless steel cartridge, the survey measurement was indistinguishable from background. The event was discovered by him on Tuesday, June 8, when he was preparing for a treatment and noticed the serial numbers on the cartridges did not match the ones in the inventory system. He reported his findings to the Radiation Safety Officer. The event was reported to Massachusetts Radiation Control Program on Thursday, June 10.
"Approximately 43 milliCuries of I-125 seeds were disposed in the clean trash system. Attempts to locate the material in the trash were unsuccessful and they concluded on Tuesday, June 8, that the package had left the premises via the trash."
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
General Information or Other
Event Number: 46022
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: PA-0233
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: PA-0233
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/17/2010
Notification Time: 13:51 [ET]
Event Date: 06/03/2010
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2010
Notification Time: 13:51 [ET]
Event Date: 06/03/2010
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - HIGH DOSE RATE TREATMENT ADMINISTERED TO AN UNINTENDED AREA
The following report was received via facsimile from the Commonwealth of Pennsylvania:
"The licensee called the PaDEP [Pennsylvania Department of Environmental Protection] Southcentral Regional Office on the morning of June 16, 2010, to provide a 24-hour verbal notice of a medical event. The licensee also notified the patient and attending physician on June 16, 2010. The event involves a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045.
"On June 3, 2010, a patient was undergoing HDR [High Dose Rate] treatment for ovarian cancer. The area to be treated was incorrectly entered into the HDR computer and resulted in the patient receiving a dose to an unintended area. This event was discovered during the second fraction of treatment on June 15, 2010. Cause of the event was human error.
"The Department is awaiting more event details at this time and plans to send regional staff to conduct an inspection on June 21, 2010. Final event details will be communicated in a NMED report."
PA Event No.: PA100012
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 report was received via facsimile from the Commonwealth of Pennsylvania:
"The licensee called the PaDEP [Pennsylvania Department of Environmental Protection] Southcentral Regional Office on the morning of June 16, 2010, to provide a 24-hour verbal notice of a medical event. The licensee also notified the patient and attending physician on June 16, 2010. The event involves a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045.
"On June 3, 2010, a patient was undergoing HDR [High Dose Rate] treatment for ovarian cancer. The area to be treated was incorrectly entered into the HDR computer and resulted in the patient receiving a dose to an unintended area. This event was discovered during the second fraction of treatment on June 15, 2010. Cause of the event was human error.
"The Department is awaiting more event details at this time and plans to send regional staff to conduct an inspection on June 21, 2010. Final event details will be communicated in a NMED report."
PA Event No.: PA100012
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.