Event Notification Report for July 22, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/21/2013 - 07/22/2013
Agreement State
Event Number: 49325
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: WESLEY LONG HOSPITAL
Region: 1
City: GREENSBORO State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: PETE SNYDER
Licensee: WESLEY LONG HOSPITAL
Region: 1
City: GREENSBORO State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: PETE SNYDER
Notification Date: 09/05/2013
Notification Time: 18:50 [ET]
Event Date: 07/22/2013
Event Time: 10:00 [EDT]
Last Update Date: 09/05/2013
Notification Time: 18:50 [ET]
Event Date: 07/22/2013
Event Time: 10:00 [EDT]
Last Update Date: 09/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - BRACHYTHERAPY SEED LOST
On July 22, 2013, it was discovered that one I-125 0.5 mCi prostate implant seed from a procedure that took place on July 10, 2013, was unaccounted for. Cartridges are assumed to be preloaded with 100 seeds with delivery documentation attesting to the count.
Fluoroscopic x-rays confirmed that seventy two (72) I-125 seeds were implanted in a patient following brachytherapy prostate seed implantation using a Nucletron seed Selectron implantation system on July 10, 2013.
During the initial seed calibration process one (1) seed was disposed into a sterile pig. The implant went smoothly except at one point where due to patient movement three (3) seeds were ejected into a sterile pig.
On July 22, 2013, the medical physicist unloading the seeds from the cartridge found 23 seeds which was 1 less than expected. Surrounding hallways, rooms, and the implant robotic equipment along with the equipment storage area and sterilization areas were surveyed but no additional seeds were discovered.
No foul play is suspected and no unusual levels of radiation have been detected from the operating room or radiation oncology staff.
As a corrective action the licensee will x-ray incoming seed cartridges to take a physical count of the seeds prior to the procedure. Immediately following the implant procedures seed cartridges will be removed from the delivery system and a second x-ray image will be acquired to perform another physical inventory. Images will be retained for record keeping.
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.
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
On July 22, 2013, it was discovered that one I-125 0.5 mCi prostate implant seed from a procedure that took place on July 10, 2013, was unaccounted for. Cartridges are assumed to be preloaded with 100 seeds with delivery documentation attesting to the count.
Fluoroscopic x-rays confirmed that seventy two (72) I-125 seeds were implanted in a patient following brachytherapy prostate seed implantation using a Nucletron seed Selectron implantation system on July 10, 2013.
During the initial seed calibration process one (1) seed was disposed into a sterile pig. The implant went smoothly except at one point where due to patient movement three (3) seeds were ejected into a sterile pig.
On July 22, 2013, the medical physicist unloading the seeds from the cartridge found 23 seeds which was 1 less than expected. Surrounding hallways, rooms, and the implant robotic equipment along with the equipment storage area and sterilization areas were surveyed but no additional seeds were discovered.
No foul play is suspected and no unusual levels of radiation have been detected from the operating room or radiation oncology staff.
As a corrective action the licensee will x-ray incoming seed cartridges to take a physical count of the seeds prior to the procedure. Immediately following the implant procedures seed cartridges will be removed from the delivery system and a second x-ray image will be acquired to perform another physical inventory. Images will be retained for record keeping.
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.
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
Power Reactor
Event Number: 49209
Facility: WATTS BAR
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GORDON ARENT
HQ OPS Officer: JOHN SHOEMAKER
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GORDON ARENT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/22/2013
Notification Time: 09:55 [ET]
Event Date: 07/22/2013
Event Time: 09:55 [EDT]
Last Update Date: 07/22/2013
Notification Time: 09:55 [ET]
Event Date: 07/22/2013
Event Time: 09:55 [EDT]
Last Update Date: 07/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.55(e) - CONSTRUCT DEFICIENCY
10 CFR Section:
50.55(e) - CONSTRUCT DEFICIENCY
Person (Organization):
EUGENE GUTHRIE (R2DO)
EUGENE GUTHRIE (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Under Construction | 0 | Under Construction |
POTENTIAL PROGRAMMATIC BREAKDOWN OF THE QUALITY ASSURANCE PROGRAM
"As a result of an extent of condition review for potential programmatic breakdown issues in response to an apparent violation 05000391/2013611-02 related to TVA's Commercial Grade Dedication Program. TVA has identified a previous Problem Evaluation Reports (PERS) that constitute significant breakdown in a portion of the Quality Assurance program. This review was initiated upon discovery of a misinterpretation of 10 CFR 50.55(e) where it was thought that to be reportable a 'significant breakdown in a portion of the Quality Assurance program' had to be associated with a confirmed substantial safety hazard.
"The subject of the previous PER is as follows;
"On May 31, 2011, TVA identified a number of revised Drawing Revision Authorizations (DRAs) that had not been incorporated into work orders to ensure field work required by the DRA revision was implemented in the field. This condition was documented as PER 378571. TVA has concluded that a significant breakdown in a portion of the Quality Assurance program had occurred that could have produced a defect in a basic component. However, TVA has subsequently determined that no safety significance can be attributed to this condition. This issue has been resolved and PER 378571 was closed on February 19, 2013.
"These items are being reported in accordance with 10 CFR 50.55(e) as significant breakdown in a portion of the Quality Assurance program."
The licensee has notified the NRC Resident Inspector.
"As a result of an extent of condition review for potential programmatic breakdown issues in response to an apparent violation 05000391/2013611-02 related to TVA's Commercial Grade Dedication Program. TVA has identified a previous Problem Evaluation Reports (PERS) that constitute significant breakdown in a portion of the Quality Assurance program. This review was initiated upon discovery of a misinterpretation of 10 CFR 50.55(e) where it was thought that to be reportable a 'significant breakdown in a portion of the Quality Assurance program' had to be associated with a confirmed substantial safety hazard.
"The subject of the previous PER is as follows;
"On May 31, 2011, TVA identified a number of revised Drawing Revision Authorizations (DRAs) that had not been incorporated into work orders to ensure field work required by the DRA revision was implemented in the field. This condition was documented as PER 378571. TVA has concluded that a significant breakdown in a portion of the Quality Assurance program had occurred that could have produced a defect in a basic component. However, TVA has subsequently determined that no safety significance can be attributed to this condition. This issue has been resolved and PER 378571 was closed on February 19, 2013.
"These items are being reported in accordance with 10 CFR 50.55(e) as significant breakdown in a portion of the Quality Assurance program."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 49210
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRISTOPHER ROBINSON
HQ OPS Officer: DONALD NORWOOD
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRISTOPHER ROBINSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/22/2013
Notification Time: 23:14 [ET]
Event Date: 07/22/2013
Event Time: 11:45 [CDT]
Last Update Date: 07/22/2013
Notification Time: 23:14 [ET]
Event Date: 07/22/2013
Event Time: 11:45 [CDT]
Last Update Date: 07/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DON ALLEN (R4DO)
DON ALLEN (R4DO)
| 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 LICENSED EMPLOYEE
A licensed employee had a confirmed positive test for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.
A licensed employee had a confirmed positive test for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The licensee notified the NRC Resident Inspector.