Event Notification Report for March 10, 2014

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTIUM-90

The following information was provided by the State of Pennsylvania via email:

"Event type: [On March 10, 2014], A medical event involving the administration of yttrium-90 (Y-90) SirSpheres which is reportable under 10CFR35.3045(a)(3). Specifically, the licensee reported that an unintended organ received, as of yet, an undetermined dose during a prescribed treatment.

"Notifications: On March 10, 2014, the Department [PA Department of Environmental Protection] received notification about this medical event.

"Event Description: The patient underwent a Y-90 microsphere treatment. A gastric ulcer developed seemingly as a result of spheres migrating to the stomach.

"Cause of the Event: Non-target flow of microspheres through an aberrant hepatic arterial vasculature supplying the stomach.

"Actions: Details of the event are being developed. Further information will be given when received. The Department plans to do a reactive inspection."

PA Report ID NO: PA-140007

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.

REACTOR SCRAM DUE TO ACTUATION OF THE ALTERNATE ROD INSERTION SYSTEM

"At 1628 EDT Nine Mile Point (NMP) Unit 2 experienced an actuation of the Alternate Rod Insertion (ARI) system which resulted in a reactor scram. Coincident with the scram, the Reactor Core Isolation Cooling (RCIC) system initiated.

"Prior to the event, maintenance personnel were working in the vicinity of a reactor vessel level instrumentation rack and may have agitated the common drain line of the transmitters. A prompt investigation is underway to investigate the incident.

"The actuation signal for the RCIC system was invalid because reactor vessel level did not reach level two and the actuation was not in response to actual plant conditions or parameters.

"The reactor scram is reportable in accordance with 10 CFR 50.72(b)(2)(iv)(B) as, 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical.'

"The event has been entered into the NMP corrective action program as CR-2014-001963.

"The NRC Resident Inspector has been notified."

The licensee has notified the State of New York.

The reactor is shutdown with all rods inserted. Decay heat is being rejected to the condenser and reactor water level is being maintained by condensate, feedwater, reactor water clean up, and control rod drive systems.

POSTULATED HOT SHORT FIRE EVENT THAT COULD ADVERSELY IMPACT SAFE SHUTDOWN EQUIPMENT

"An extent of condition review identified that there were unfused 250 VDC circuits for the battery charger ammeters and the control circuits for various DC lube oil pumps which left the turbine building and went through the respective cable spreading room and up into the Control Room. These circuits are protected by 200 amp fuses and in some cases 100 amp fuses. The concern is that under the fire safe shutdown rules, it is postulated that a fire in one fire area can damage these circuits and cause short circuits without protection that would overheat the cables and possibly result in secondary fires in other fire areas where the cables are routed. The secondary fires could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10 CFR 50 Appendix R.

"This condition is reportable as an 8-hour ENS report in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. Compensatory measures (fire watches) have been implemented for affected areas of the plant."

The licensee has notified the NRC Resident Inspector.

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The following was received from the State of Colorado via email:

"At appx. 5:30 MST on 3/10/14 the licensee's employee noticed that the window in his vehicle had been broken and the contents stolen. This included a CPN Model MC-1-DR portable nuclear gauge (Serial Number : MD10800432) containing two licensed sources (10 mCi Cs-137 and 50 mCi Am:Be).

"The vehicle was parked at the employees residence. The gauge was contained within a locked transport container. Although, the vehicle was locked there was no secondary tangible barrier preventing unauthorized removal of the gauge.

"The event was reported to the Wheatridge police on the morning of 3/10/14 and to the Colorado Department of Public Health and Environment at appx. 8:15 a.m. MST 3/10/14.

"The Colorado Department of Public Health and Environment received a follow up call at appx. 11:00 a.m. MST 3/10/14, indicating that the gauge was located by a member of the public and recovered by the licensee.

"The gauge was still in the locked transport container when it was recovered and there was no signs of damage to the case or indications that an attempt was made to open the case.

"A site visit will be conducted by a Colorado Department of Public Health and Environment inspector to interview staff and complete the investigation of the incident in the near future."

Event Report ID Number: CO14-I14-03

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

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN EXCESSIVE DOSE DELIVERED TO THE WRONG SITE

The following report was received from the State of Illinois via email:

"On March 25, 2015, Agency [Illinois Emergency Management Agency] representatives were advised via voicemail message by a medical physicist associated with the licensee's facility that a medical event had occurred at a point in the past. The medical physicist had been conducting a retrospective review of cases performed at the site which were similar to another case that had resulted in a medical event at another facility.

"The review included all 5 cases performed at the licensee's facility since August of 2013 when treatments were first started. The treatment protocols involved using a Strut Adjusted Volume Implant (SAVI) catheter, a Nucletron high dose rate afterloader and the Oncentra treatment planning system which was also used in the similar situation. They determined that at least one of the treatments conducted March 10-14, 2014, involved an error of greater than 20 percent which would meet the criteria of a medical event and dose to an unintended organ exceeding 50 rem.

"On March 26, 2015, a radiation oncologist from the licensee contacted the Agency with information to confirm the medical event. The patient had been treated twice a day for five days for a total intended V95 dose of 34 Gy in ten equal fractions. The target only received 43 percent of the intended dose with the majority instead being delivered to the catheter insertion site (approximately 30 Gy). It was determined that although the patient had later returned on June 24, 2014, with pain and redness at the incision site of the left breast, the cause of damage to the 21 cc tissue area was not attributed to radiation damage. The patient was referred to their surgeon who excised the affected area during an outpatient procedure.

"The licensee has suspended treatments using the protocol pending a full investigation and evaluation of appropriate corrective measures to prevent a recurrence by a physicist not associated with the treatments. The Agency is conducting its own investigation as well. This matter remains open at this time."

This event strongly parallels that of an event which the State of Illinois reported on February 13, 2015, see EN #50818.

Illinois State Item Number: IL15009

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.