Event Notification Report for November 21, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/20/2012 - 11/21/2012
Power Reactor
Event Number: 48529
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM ANDERSON
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM ANDERSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2012
Notification Time: 13:01 [ET]
Event Date: 11/21/2012
Event Time: 10:36 [EST]
Last Update Date: 11/21/2012
Notification Time: 13:01 [ET]
Event Date: 11/21/2012
Event Time: 10:36 [EST]
Last Update Date: 11/21/2012
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):
DAVID AYRES (R2DO)
DAVID AYRES (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO CHLORINE LEAK
"A chlorine leak was discovered in an area near the Unit 2 cooling towers. The leak has been isolated; the amount leaked is under investigation. Sodium bisulfite has been used to neutralize the [leaked] chlorine. The Georgia Environmental Protection Division and U.S. Coast Guard have been notified."
The licensee has notified the NRC Resident Inspector.
"A chlorine leak was discovered in an area near the Unit 2 cooling towers. The leak has been isolated; the amount leaked is under investigation. Sodium bisulfite has been used to neutralize the [leaked] chlorine. The Georgia Environmental Protection Division and U.S. Coast Guard have been notified."
The licensee has notified the NRC Resident Inspector.
Agreement State
Event Number: 48530
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON SUBURBAN HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-099-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VELEZ
HQ OPS Officer: HOWIE CROUCH
Licensee: NORTON SUBURBAN HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-099-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VELEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2012
Notification Time: 15:09 [ET]
Event Date: 11/21/2012
Event Time: 00:00 [CST]
Last Update Date: 11/21/2012
Notification Time: 15:09 [ET]
Event Date: 11/21/2012
Event Time: 00:00 [CST]
Last Update Date: 11/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DWYER (R1DO)
FSME RESOURCE (EMAI)
JAMES DWYER (R1DO)
FSME RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was obtained from the Commonwealth of Kentucky via facsimile:
"Kentucky Radiation Health Branch was notified on November 21, 2012 by the [licensee's] Medical Physicist, that a medical event occurred during the final hours of a gynecological radiation implant using Cs-137. The 40 hour procedure was scheduled to end today at 0915 CST. Upon arrival at 0910 to remove the applicators, the patient stated [that] shortly after 0600 she felt something had moved or urination or gel had come out of her. As the Medical Physicist pulled back the patient's gown, she saw the packing from the implant completely out of the patient. The top of the packing was approximately 1cm from the perineum. The sources were quickly removed from the applicators and put in a shielded transport container. The Medical Physicist's initial dose estimate to the skin on the patient's thigh and surrounding area is close to 450 cGy based on the applicator being out for 3 hours. There were a total of 5 sources used, 3 in the tandem all had the same activity (96.11 cGy*cm2/hr) and one in each ovoid, both having an activity of 29.63 cGy*cm2/hr. Radiation survey measurements of the applicators, patient, and room were below background. The RSO, patient, and prescribing physician are aware of the event that occurred and a follow-up is scheduled. The State will continue to keep NRC informed of the status of our investigation."
KY Event Report ID# KY120014
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 information was obtained from the Commonwealth of Kentucky via facsimile:
"Kentucky Radiation Health Branch was notified on November 21, 2012 by the [licensee's] Medical Physicist, that a medical event occurred during the final hours of a gynecological radiation implant using Cs-137. The 40 hour procedure was scheduled to end today at 0915 CST. Upon arrival at 0910 to remove the applicators, the patient stated [that] shortly after 0600 she felt something had moved or urination or gel had come out of her. As the Medical Physicist pulled back the patient's gown, she saw the packing from the implant completely out of the patient. The top of the packing was approximately 1cm from the perineum. The sources were quickly removed from the applicators and put in a shielded transport container. The Medical Physicist's initial dose estimate to the skin on the patient's thigh and surrounding area is close to 450 cGy based on the applicator being out for 3 hours. There were a total of 5 sources used, 3 in the tandem all had the same activity (96.11 cGy*cm2/hr) and one in each ovoid, both having an activity of 29.63 cGy*cm2/hr. Radiation survey measurements of the applicators, patient, and room were below background. The RSO, patient, and prescribing physician are aware of the event that occurred and a follow-up is scheduled. The State will continue to keep NRC informed of the status of our investigation."
KY Event Report ID# KY120014
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
Event Number: 48531
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SOUTHERN OHIO MEDICAL CENTER
Region: 3
City: PORTSMOUTH State: OH
County:
License #: 02120 74 0002
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DONALD NORWOOD
Licensee: SOUTHERN OHIO MEDICAL CENTER
Region: 3
City: PORTSMOUTH State: OH
County:
License #: 02120 74 0002
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/21/2012
Notification Time: 17:50 [ET]
Event Date: 11/21/2012
Event Time: 00:00 [EST]
Last Update Date: 11/21/2012
Notification Time: 17:50 [ET]
Event Date: 11/21/2012
Event Time: 00:00 [EST]
Last Update Date: 11/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILLY DICKSON (R3DO)
FSME RESOURCE (EMAI)
BILLY DICKSON (R3DO)
FSME RESOURCE (EMAI)
AGREEMENT STATE REPORT - POTENTIAL DEFECT OF HDR UNIT
"At 4:45PM on November 21, 2012 the Radiation Safety Officer of the Southern Ohio Medical Center (OH license number 02120 74 0002) located in Portsmouth, OH called the Ohio Department of Health Bureau of Radiation Protection to make a telephone notification of a potential defect with a Nucletron microselectron HDR unit (SN 10281) containing 7.02 Ci of Iridium-192.
"The following event telephone report was made in accordance with OAC 3701:1-38-23(b)(2) (equivalent to NRC 10 CFR Part 21.xx).
"The nature of the defect was that prior to initiation of a patient treatment today, the computer console error code indicated a communication problem between the computer console and the HDR unit. The software indicated that the computer system needed to be rebooted which the licensee did. Upon restarting the computer it indicated a delivered treatment time of 24.6 seconds without the licensee initiating the treatment. The licensee did not see the radiation monitor light up, and entered and surveyed the room and patient with a handheld survey instrument. The licensee does not believe that the source left the shielded position.
"The licensee was able to complete the treatment fraction as planned, which was fraction number ten of ten fractions of 390 seconds. This did not result in a medical event.
"The Radiation Safety Officer notified their management and the manufacturer."
Ohio Event Report Number: 2012-033.
"At 4:45PM on November 21, 2012 the Radiation Safety Officer of the Southern Ohio Medical Center (OH license number 02120 74 0002) located in Portsmouth, OH called the Ohio Department of Health Bureau of Radiation Protection to make a telephone notification of a potential defect with a Nucletron microselectron HDR unit (SN 10281) containing 7.02 Ci of Iridium-192.
"The following event telephone report was made in accordance with OAC 3701:1-38-23(b)(2) (equivalent to NRC 10 CFR Part 21.xx).
"The nature of the defect was that prior to initiation of a patient treatment today, the computer console error code indicated a communication problem between the computer console and the HDR unit. The software indicated that the computer system needed to be rebooted which the licensee did. Upon restarting the computer it indicated a delivered treatment time of 24.6 seconds without the licensee initiating the treatment. The licensee did not see the radiation monitor light up, and entered and surveyed the room and patient with a handheld survey instrument. The licensee does not believe that the source left the shielded position.
"The licensee was able to complete the treatment fraction as planned, which was fraction number ten of ten fractions of 390 seconds. This did not result in a medical event.
"The Radiation Safety Officer notified their management and the manufacturer."
Ohio Event Report Number: 2012-033.