Event Notification Report for December 22, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/21/2010 - 12/22/2010
Power Reactor
Event Number: 46505
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: MICHAEL MONACELLI
HQ OPS Officer: JOHN KNOKE
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: MICHAEL MONACELLI
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/22/2010
Notification Time: 22:12 [ET]
Event Date: 12/22/2010
Event Time: 20:00 [EST]
Last Update Date: 12/22/2010
Notification Time: 22:12 [ET]
Event Date: 12/22/2010
Event Time: 20:00 [EST]
Last Update Date: 12/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (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 |
FITNESS FOR DUTY REPORT INVOLVING A SUPERVISOR
A licensed operator had a confirmed positive for a Controlled Substance during a random fitness-for-duty test. The employee's unescorted access has been suspended. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector has been notified.
A licensed operator had a confirmed positive for a Controlled Substance during a random fitness-for-duty test. The employee's unescorted access has been suspended. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 46512
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER GOOD SAMARITAN MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-478
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GOODWIN
HQ OPS Officer: STEVE SANDIN
Licensee: BANNER GOOD SAMARITAN MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-478
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GOODWIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/27/2010
Notification Time: 11:13 [ET]
Event Date: 12/22/2010
Event Time: 12:30 [MST]
Last Update Date: 12/27/2010
Notification Time: 11:13 [ET]
Event Date: 12/22/2010
Event Time: 12:30 [MST]
Last Update Date: 12/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
GLENDA VILLAMAR (FSME)
THOMAS FARNHOLTZ (R4DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT INVOLVING AN HDR MISADMINISTRATION
The following report was received from the State of Arizona via fax:
"At approximately 12:30 PM December 22, 2010, the Licensee phoned the Agency [Arizona Radiation Regulatory Agency] to report an HDR [High Dose Radiation] misadministration. A breast cancer patient was undergoing treatment with a Nucletron MicroSelectron-HDR. A Savi-8 Accelerated Partial Breast Irradiation Device was connected to the HDR. This is manufactured by Cianno. The source apparently punched through the catheter and moved along the skin surface during the treatment. The patient did not notice the source was outside the tube. The source retracted normally to the shielded position. The physicist estimates that the patient's skin received 5 Gray if the source moved along the skins surface but if the source stuck in one position the patient's skin received 50 Gray. According to the licensee the catheter is easily kinked which can cause this failure. This has happened before but is the first time that this has resulted in an exposure. In the past, the licensee would repair the catheter with heat shrink tubing.
"The Agency continues to investigate the actions of the licensee.
"The U.S. NRC and the Arizona Governor's office have been notified of this event.
"Press coverage is not anticipated."
Arizona First Notice: 10-016
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 Arizona via fax:
"At approximately 12:30 PM December 22, 2010, the Licensee phoned the Agency [Arizona Radiation Regulatory Agency] to report an HDR [High Dose Radiation] misadministration. A breast cancer patient was undergoing treatment with a Nucletron MicroSelectron-HDR. A Savi-8 Accelerated Partial Breast Irradiation Device was connected to the HDR. This is manufactured by Cianno. The source apparently punched through the catheter and moved along the skin surface during the treatment. The patient did not notice the source was outside the tube. The source retracted normally to the shielded position. The physicist estimates that the patient's skin received 5 Gray if the source moved along the skins surface but if the source stuck in one position the patient's skin received 50 Gray. According to the licensee the catheter is easily kinked which can cause this failure. This has happened before but is the first time that this has resulted in an exposure. In the past, the licensee would repair the catheter with heat shrink tubing.
"The Agency continues to investigate the actions of the licensee.
"The U.S. NRC and the Arizona Governor's office have been notified of this event.
"Press coverage is not anticipated."
Arizona First Notice: 10-016
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.