Event Notification Report for May 19, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/18/2014 - 05/19/2014
Agreement State
Event Number: 50126
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: WATSON CLINIC
Region: 1
City: LAKELAND State: FL
County:
License #: 2619-1
Agreement: Y
Docket:
NRC Notified By: RICHARD DAVIS
HQ OPS Officer: STEVE SANDIN
Licensee: WATSON CLINIC
Region: 1
City: LAKELAND State: FL
County:
License #: 2619-1
Agreement: Y
Docket:
NRC Notified By: RICHARD DAVIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/20/2014
Notification Time: 15:00 [ET]
Event Date: 05/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/20/2014
Notification Time: 15:00 [ET]
Event Date: 05/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 05/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - PATIENT RECEIVED UNINTENDED SHALLOW SKIN DOSE
The following information was received from the State of Florida via email:
"[On] Monday May 19, 2014, on follow-up visit, the patient presented with burns on the thighs and the labia. [The] Radiation Oncologist ordered an immediate investigation: High Dose Remote After Loader (HDR) Prescription event. No further action will be taken on this incident."
The patient received 21Gy in three (3) fractions. Following completion of treatment, a review of the Treatment Planning on Oncentra TPS revealed a reference length of 1223 mm instead of 1323 (expected value +/- 1 mm). The reference length used in the TPS was measured prior to CT with the SPS (Source Position Simulator) by two physicists. Therefore, the radiation was 10 cm short from reaching the target which explains the occurrence of burns on the patient's thighs.
"The three prescribed fractions were delivered on: 3/31/14, 04/07/14 and 04/14/14."
Florida Incident Number: FL14-043
The device used is an HDR containing Ir-192 with a Capri Applicator.
A corrective action plan has been developed by the licensee to prevent recurrence. The licensee informed both the prescribing physician and the patient. No long-term adverse health effects are expected.
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 received from the State of Florida via email:
"[On] Monday May 19, 2014, on follow-up visit, the patient presented with burns on the thighs and the labia. [The] Radiation Oncologist ordered an immediate investigation: High Dose Remote After Loader (HDR) Prescription event. No further action will be taken on this incident."
The patient received 21Gy in three (3) fractions. Following completion of treatment, a review of the Treatment Planning on Oncentra TPS revealed a reference length of 1223 mm instead of 1323 (expected value +/- 1 mm). The reference length used in the TPS was measured prior to CT with the SPS (Source Position Simulator) by two physicists. Therefore, the radiation was 10 cm short from reaching the target which explains the occurrence of burns on the patient's thighs.
"The three prescribed fractions were delivered on: 3/31/14, 04/07/14 and 04/14/14."
Florida Incident Number: FL14-043
The device used is an HDR containing Ir-192 with a Capri Applicator.
A corrective action plan has been developed by the licensee to prevent recurrence. The licensee informed both the prescribing physician and the patient. No long-term adverse health effects are expected.
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.
Power Reactor
Event Number: 50123
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMANN
HQ OPS Officer: STEVE SANDIN
Region: 3 State: MN
Unit: [] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMANN
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/19/2014
Notification Time: 18:16 [ET]
Event Date: 05/19/2014
Event Time: 12:36 [CDT]
Last Update Date: 05/19/2014
Notification Time: 18:16 [ET]
Event Date: 05/19/2014
Event Time: 12:36 [CDT]
Last Update Date: 05/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
STEVE ORTH (R3DO)
STEVE ORTH (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Standby | 0 | Hot Standby |
CONTAINMENT DECLARED INOPERABLE DUE TO CONTAINMENT FAN COIL LEAK
"At approximately 1236 CDT on May 19, 2014, a cooling water leak was identified on 23 Containment Fan Coil Unit flange. Unit 2 Containment was declared inoperable, which required entry into Technical Specifications (TS) LCO 3.6.1 Condition A, Containment inoperable, in MODES 1, 2, 3, and 4. Immediate actions were taken to isolate the Fan Coil Unit and was isolated within 1 hour from the initial identification of the leak and TS 3.6.1 Condition A was exited. This restored Containment to an Operable status. A Work Request (WR) was initiated to repair the leak, and to restore the 23 Containment Fan Coil Unit to an operable condition.
"This condition is reportable under 10 CFR 50.72(b)(3)(v)(C), Event or Condition that Could Have Prevented Fulfillment of a Safety Function.
"The plant remains safe, and this condition does not pose any additional risk to the public. Additionally, our defense in depth strategies are relied upon to take actions to protect the health and safety of the public.
"The licensee has notified the NRC Resident Inspector."
"At approximately 1236 CDT on May 19, 2014, a cooling water leak was identified on 23 Containment Fan Coil Unit flange. Unit 2 Containment was declared inoperable, which required entry into Technical Specifications (TS) LCO 3.6.1 Condition A, Containment inoperable, in MODES 1, 2, 3, and 4. Immediate actions were taken to isolate the Fan Coil Unit and was isolated within 1 hour from the initial identification of the leak and TS 3.6.1 Condition A was exited. This restored Containment to an Operable status. A Work Request (WR) was initiated to repair the leak, and to restore the 23 Containment Fan Coil Unit to an operable condition.
"This condition is reportable under 10 CFR 50.72(b)(3)(v)(C), Event or Condition that Could Have Prevented Fulfillment of a Safety Function.
"The plant remains safe, and this condition does not pose any additional risk to the public. Additionally, our defense in depth strategies are relied upon to take actions to protect the health and safety of the public.
"The licensee has notified the NRC Resident Inspector."
Non-Agreement State
Event Number: 50240
Rep Org: U.S. AIR FORCE
Licensee: U.S. AIR FORCE
Region: 1
City: ROSSYLN State: VA
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: MAJOR EDWARD KELLY
HQ OPS Officer: VINCE KLCO
Licensee: U.S. AIR FORCE
Region: 1
City: ROSSYLN State: VA
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: MAJOR EDWARD KELLY
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2014
Notification Time: 15:33 [ET]
Event Date: 05/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 06/30/2014
Notification Time: 15:33 [ET]
Event Date: 05/19/2014
Event Time: 00:00 [EDT]
Last Update Date: 06/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO VIA FAX
BOB HAGAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO VIA FAX
LOST NICKEL-63 ION SCAN SOURCE
"Originally, an Ionscan 400, S/N 10586, was sent to Smith Detection for repair in October 2011. From that time until May 2014, Security Forces personnel believed that the device was still at Smith Detection awaiting repair. In May 2014, [The Air Force] was able to determine that according to Smith Detection records, following repair, the device had been returned to Lackland AFB in October 2012. Security Forces has no record of receiving the device and no notification that the device had been shipped. Thorough searches of Security Forces storage and use areas have been conducted without finding the device. One theory is that the device was sent to an old address for Security Forces. The building at that address has been searched without finding the device."
Ionscan 400 contains a NI-63 source with an activity of 15 milliCi. The Ionscan 400 serial number is 10586. The sealed source and device registry number (SS&DR) associated with the Ionscan 400 is NR-0163-D-801-G. The device is used to screen passengers for hazardous material. The licensee will be notifying the NRC Region IV (Cook).
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
"Originally, an Ionscan 400, S/N 10586, was sent to Smith Detection for repair in October 2011. From that time until May 2014, Security Forces personnel believed that the device was still at Smith Detection awaiting repair. In May 2014, [The Air Force] was able to determine that according to Smith Detection records, following repair, the device had been returned to Lackland AFB in October 2012. Security Forces has no record of receiving the device and no notification that the device had been shipped. Thorough searches of Security Forces storage and use areas have been conducted without finding the device. One theory is that the device was sent to an old address for Security Forces. The building at that address has been searched without finding the device."
Ionscan 400 contains a NI-63 source with an activity of 15 milliCi. The Ionscan 400 serial number is 10586. The sealed source and device registry number (SS&DR) associated with the Ionscan 400 is NR-0163-D-801-G. The device is used to screen passengers for hazardous material. The licensee will be notifying the NRC Region IV (Cook).
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