Event Notification Report for July 13, 2010

AGREEMENT STATE REPORT - MISSING BRACHYTHERAPY SOURCES

"On July 15, 2010 the Director of Radiological Services at Riverside Medical Center (IL-01242-01), Kankakee, IL called the Agency [Illinois Emergency Management Agency] to advise that they were missing several sealed sources associated with their inactive brachytherapy program. She had been contacted by her radiation safety officer, who made the initial discovery on Tuesday, July 13, 2010. The staff began a visual search the same day.

"The Riverside Medical Center Administration was notified the following day and directed that additional searches be conducted of more potential locations as the old storage area had since been demolished as part of a facility remodeling project and the safe could have been relocated to another area of the Medical Center. Housekeeping, Maintenance, Facility Management, Radiology and Security Departments at the Medical Center were directed to take part in the search as well.

"Prior to the remodeling, 14 sources of Cs-137 were stored in a lead lined 'safe' which had been locked and secured in a basement storage room of the facility. The new RSO had been in the process of conducting a routine inventory/leak test of the sources when the discovery was made. The key to the safe was still in the possession of the RSO. The 'safe' is approximately 1.5'x1.5'x2.0'. Its weight precludes one or two individuals from removing the safe without additional mechanical assistance. It was marked and labeled with appropriate warning signs.

"The specific inventory of sources is as follows with activities corrected as of today's date; 2 sources of 46 milliCi, 4 sources of 31 milliCi, 4 sources of 23 milliCi and 4 sources of 16 milliCi. The manufacturer's safety sheets infers that these sources have a dose rate of 3.6 milliR/h at a distance of 1 foot for each milliCi of activity (46 milliCi; 167 milliR/h). The sources are nickel plated and appear metallic. The radioactivity is doubly encapsulated within stainless steel. Individually the sources are less than a tenth of an inch (3 millimeters) in diameter and less than an inch (20 millimeters) in length. The sources were last used for a medical treatment in October of 2003 but were included in routine inventories and leak tests. The licensee has no information to suggest any nefarious activity associated with the missing storage safe/sources and currently suspects it may have been removed from the site as part of the construction debris associated with last year's remodeling. A consultant has been contracted to perform additional monitoring at their facility with more sensitive radiation instruments in hopes of locating the storage safe.

"The Agency [Illinois Emergency Management Agency] is monitoring the licensee's search efforts. Sources of this nature are likely to set off radiation monitor alarms which are established at scrap metal facilities and some landfills however, an intact storage safe with the sources still inside is less likely to set off such alarms, due to its inherent shielding to protect medical staff. Maximum surface readings from the safe as measured previously by Agency personnel during site inspections are approximately 35 milliR/h with readings falling to 0.5 to 2 milliR/h at one foot. All sources were physically confirmed as being present by the Agency during a 2005 inspection."

Illinois Report Number: IL10049

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

CONTAINMENT OVERPRESSURE NOT ENSURED IN THE APPENDIX R ANALYSIS

"A review of the Appendix R analyses conducted as part of the transition to National Fire Protection Association (NFPA) 805 indicates a potential for the loss of Containment Overpressure (COP) if drywell cooling is not secured or due to fire induced spurious operation of certain primary containment isolation valves. During all Appendix R scenarios, the plant is analyzed to conduct post fire plant cool down with the MSIVs closed, and with Torus cooling provided by the Residual Heat Removal (RHR) system. Based on current design basis calculations, should the containment be depressurized due to a 'smart fire' adequate Net Positive Suction Head (NPSH) may not be available to support Residual Heat Removal (RHR) pump operation during an Appendix R fire event. The design calculations credit COP during Appendix R fire events to provide adequate NPSH to the RHR pumps, as Torus temperature may reach approximately 217 degrees, with a corresponding containment pressure of approximately 10 psig.

"There are five scenarios identified where a potential exists for COP loss. One or more of these scenarios could affect several Appendix R analysis areas. The loss of COP could affect safe shutdown capability during an Appendix R fire event. This condition is being reported under 10 CFR 50.72 (b)(3)(ii) as a condition that results in the plant being in an unanalyzed condition which significantly degrades plant safety.

"Hourly fire patrols have been established for the susceptible fire areas that do not contain both fire detection and suppression equipment. This includes several areas of the reactor and control buildings.

"This issue is a noncompliance with the current design basis, and does not result in the inoperability of any Technical Specification nor Technical Requirements Manual systems."

The licensee has notified the NRC Resident Inspector.

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 0810 EDT on Tuesday, July 13, 2010, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems have been removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance is scheduled to be completed by 1800 EDT on Tuesday, July 13, 2010.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DEAN BRUCK TO CHARLES TEAL ON 7/13/10 AT 1730 EDT * * *

"The TSC ventilation system maintenance was completed satisfactorily and the system was restored to service at 1730 EDT."

Notified R3DO (Dickson).

KENTUCKY AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was obtained from the State of Kentucky via email:

"The event timetable began on 12 July 2010 when the Medical Physicist entered the pre-treatment information into the facilities brachytherapy software package (VariSeed«, Varian Inc). The information included patient demographics, treatment date and radioisotope information; in this case I-125 encased in titanium for a treatment date of 13 July 2010. The medical procedure was carried out successfully and 97 seeds were implanted. This number of seeds is within the expected limit of what is normally encountered during these procedures and thus did not stand out as a triggering event for a double check.

"During a routine post-procedure review, conducted on 14 July 2010, the medical physicist identified a potential issue and began the chain of notification as required by the radiation safety office; medical, administrative and safety.

"The discrepancy arose from the identification of source activity, as indicated on the written directive versus the information printed on the post-procedure information sheet. The information had inadvertently been entered into the pre-procedure planning software in units of milliCurie while the units of measure were identified as units of 'U' [Air-Kerma], leading to a discrepancy in the delivered dose of approximately +27%. The specific information in this case indicated the strength was 0.410 U (0.323 mCi) while in reality the actual source strength was 0.521 U (0.410 mCi).

"The facility conducted a root-cause analysis that indicated two areas of concern for a root cause. The initial identified area of concern is the ability to enter information into an automated system in either of two separate units; 'U' or milliCurie. This was followed closely by the lack of a documented double verify means; which although always important to any therapeutic intervention, would have negated the incident in this case. Since the software does not allow for the exclusion of one unit in favor of the other, the root-cause is the failure to have in place a procedure that included the documented double-verification of the dose strength used in the calculations.

"In order to negate the recurrence of this type of error, the oncology physics section has implemented the following procedure. The therapeutic seeds will be ordered and received as is currently performed. The medical physicist will enter the information into the software package using the vendor supplied source strength of the implantable seeds; using the 'U' [Air-Kerma] value only. The Air-Kerma value has been chosen as the unit of preference because this is rapidly becoming the professional unit of choice by the medical physics community and is the default unit of the VariSeed« software package. Once in the operating room a time-out will be conducted between the medical physicist and the medical dosimetrist. The dosimetrist will observe the software settings while the medical physicist reads aloud the information contained in the 'Seed Count and Strength Verification' form including the seed strength; in 'U' [Air-Kerma], and procedure date. Both persons will then sign the form. The remainder of the process will remain unchanged.

"The patient was contacted by the radiation oncologist the morning of 15 July 2010 and returned for immediate CT imaging of the pelvis on 16 July 2010. The error was explained to the patient, as well as the urologist who assisted in the procedure, and additional monitoring of the prostate, rectum and urethra are to be conducted to better determine a dose distribution. At this point a general dose estimate is that the patient received 3,800 Rem greater than was intended. Although this estimate may be decreased or otherwise adjusted based on the serial monitoring to be conducted over the six months post-procedure.

"The procedure has been implemented and the physics section, including the radiation oncologist, have been in-serviced as of 26 July 2010."

The State of Kentucky received the above notification from the licensee on July 28, 2010. According to the State of Kentucky, the licensee did not originally report this event (via telephone on July 15, 2010) as a medical event therefore the State did not report the event to the NRC Operations Center. During an interoffice review, the State determined that a miscommunication had occurred and they should have reported this event to the NRC.

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.