Event Notification Report for November 23, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/22/2010 - 11/23/2010
Power Reactor
Event Number: 46433
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: MARK EGHIGIAN
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: MARK EGHIGIAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/23/2010
Notification Time: 14:53 [ET]
Event Date: 11/23/2010
Event Time: 11:45 [EST]
Last Update Date: 11/23/2010
Notification Time: 14:53 [ET]
Event Date: 11/23/2010
Event Time: 11:45 [EST]
Last Update Date: 11/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BILLY DICKSON (R3DO)
BILLY DICKSON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
OTHER GOVERNMENT AGENCY NOTIFICATION DUE TO SEWAGE LEAK
"On 11/23/10 at 1145 EST, a verbal report to the Michigan Department of Natural Resources & Environment (MDNRE) was made relating to a sewage leak to the ground from the Training Building restrooms. The onsite Facilities Maintenance Journeyman discovered mud and stones while clearing a drain to relieve a blockage. An immediate repair of the broken drain is being implemented. The plant is currently in Mode 4, in Refueling Outage 14 (RF14). Since a verbal report was made to the MDNRE, this is considered a News Release / Notification of Other Government Agency, and is reportable under 10CFR50.72(b)(2)(xi)."
The licensee notified the NRC Resident Inspector. The licensee also notified the Monroe County Health Department.
"On 11/23/10 at 1145 EST, a verbal report to the Michigan Department of Natural Resources & Environment (MDNRE) was made relating to a sewage leak to the ground from the Training Building restrooms. The onsite Facilities Maintenance Journeyman discovered mud and stones while clearing a drain to relieve a blockage. An immediate repair of the broken drain is being implemented. The plant is currently in Mode 4, in Refueling Outage 14 (RF14). Since a verbal report was made to the MDNRE, this is considered a News Release / Notification of Other Government Agency, and is reportable under 10CFR50.72(b)(2)(xi)."
The licensee notified the NRC Resident Inspector. The licensee also notified the Monroe County Health Department.
Agreement State
Event Number: 46543
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2011
Notification Time: 15:49 [ET]
Event Date: 11/23/2010
Event Time: 00:00 [CST]
Last Update Date: 01/14/2011
Notification Time: 15:49 [ET]
Event Date: 11/23/2010
Event Time: 00:00 [CST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
GLENDA VILLAMAR (FSME)
MICHAEL KUNOWSKI (R3DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT
The following report was received from the State of Illinois via email:
"On January 13 [2011], the licensee's Radiation Safety Officer contacted the Agency [Illinois Emergency Management] to report an apparent medical event that had been discovered during routine post surgery follow up. A patient had undergone treatment for prostate cancer utilizing permanent brachytherapy I-125 seed placement. A total of 102 seeds were inserted into the region in order to deliver a prescribed dose of 14,500 Rad. Manual insertion of the 0.4 milliCi I-125 seeds was done by ultrasound guided placement of the needle template. A C-arm x-ray scan was done post implant of the 0.4mm x 1mm seeds. Visualization of the seed placement was problematic in the post operation scan. Initial estimates were that the seeds may have been inferior to the ideal placement, but still acceptable. However, engorgement of the surrounding tissue and prostate due to the surgical procedure made visualization difficult and performance of additional dosimetry was deemed inappropriate and of little value. The patient was kept appraised of the situation beginning just prior to discharge and advised of the need for continued follow up. As the patient healed, additional scans were scheduled at the 4 week post treatment mark. Those scans suggested the seed placement to be 4-5 cm inferior of the treatment plan. Although the inferior placement of the seeds resulted in avoiding doses to the rectum and bladder as intended in the original treatment plan, as wells as the urethra, the dose to the prostate was suboptimal. Regions receiving elevated dose were the soft tissue at the base of the penis and the penile bulb. Dosimetry values for dose to the prostate provided by the licensee at this time are rough estimates, but are less than 80% of the intended dose.
"Currently, the patient is asymptomatic. No prediction of long term effects has been made at this time. Physicians are considering the application of external x-ray beam to provide a more effective treatment to the tumor site. This matter remains under investigation by the licensee and the Illinois Emergency Management Agency. The licensee is obliged to file a written report [to the Illinois Emergency Management Agency] in compliance with the rules within 15 days.
Given: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: ND
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 4400 rad 44 Gy
Intended: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: PROSTATE
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 14500 rad 145 Gy
% Dose Exceeds Prescribed: 0
% Dose is Less Than Prescribed: 70
Effect on Patient: UNKNOWN
The patient was informed of the underdose.
IL Report No.: IL11-004
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 from the State of Illinois via email:
"On January 13 [2011], the licensee's Radiation Safety Officer contacted the Agency [Illinois Emergency Management] to report an apparent medical event that had been discovered during routine post surgery follow up. A patient had undergone treatment for prostate cancer utilizing permanent brachytherapy I-125 seed placement. A total of 102 seeds were inserted into the region in order to deliver a prescribed dose of 14,500 Rad. Manual insertion of the 0.4 milliCi I-125 seeds was done by ultrasound guided placement of the needle template. A C-arm x-ray scan was done post implant of the 0.4mm x 1mm seeds. Visualization of the seed placement was problematic in the post operation scan. Initial estimates were that the seeds may have been inferior to the ideal placement, but still acceptable. However, engorgement of the surrounding tissue and prostate due to the surgical procedure made visualization difficult and performance of additional dosimetry was deemed inappropriate and of little value. The patient was kept appraised of the situation beginning just prior to discharge and advised of the need for continued follow up. As the patient healed, additional scans were scheduled at the 4 week post treatment mark. Those scans suggested the seed placement to be 4-5 cm inferior of the treatment plan. Although the inferior placement of the seeds resulted in avoiding doses to the rectum and bladder as intended in the original treatment plan, as wells as the urethra, the dose to the prostate was suboptimal. Regions receiving elevated dose were the soft tissue at the base of the penis and the penile bulb. Dosimetry values for dose to the prostate provided by the licensee at this time are rough estimates, but are less than 80% of the intended dose.
"Currently, the patient is asymptomatic. No prediction of long term effects has been made at this time. Physicians are considering the application of external x-ray beam to provide a more effective treatment to the tumor site. This matter remains under investigation by the licensee and the Illinois Emergency Management Agency. The licensee is obliged to file a written report [to the Illinois Emergency Management Agency] in compliance with the rules within 15 days.
Given: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: ND
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 4400 rad 44 Gy
Intended: Therapeutic Procedure: BRACHY, MANUAL IMPLANT
Organ: PROSTATE
Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 14500 rad 145 Gy
% Dose Exceeds Prescribed: 0
% Dose is Less Than Prescribed: 70
Effect on Patient: UNKNOWN
The patient was informed of the underdose.
IL Report No.: IL11-004
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.