Event Notification Report for February 04, 2016

AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION

The following was received from Florida via email:

"Licensee reported a possible medical event on Feb. 4th, while performing a Gamma Knife treatment. The treatment was planned for 11 sites to receive 18 Gy, and 5 sites to receive 11 Gy. After the completion of 15 sites, the treatment was stopped to re-sedate the patient, (at this time the stereotactic frame was still in position). Two minutes after starting the final site with 11 Gy, the patient awoke and started moving significantly. The patient was instructed to stay still for the remainder of the treatment. When the patient was brought out of the device the frame was not in the original position. It is not known if the frame became dislodged during the treatment, or if it occurred when exiting the device. If movement of the frame occurred during treatment: site 16 would have received a 74.5 percent underdose of 2.8 Gy and an approximated cerebellar volume of 0.7cc was treated with 9.3 Gy. Any further investigation will be referred to Licensing and Materials."

Florida Incident # FL16-024

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.

AUTOMATIC REACTOR TRIP DUE TO MAIN TURBINE TRIP

"This 4 and 8 hour notification is being made to report that Salem Unit 2 suffered an unplanned automatic reactor trip and subsequent automatic Auxiliary Feedwater system actuation. The trip was initiated due to a Main Turbine trip above P-9 (49% power). The Main Turbine trip was caused by a Main Generator Protection signal.

"Salem Unit 2 is currently stable in Mode 3. Reactor Coolant system pressure is 2235 PSIG and Reactor Coolant system temperature is 547 F with decay heat removal via the Main Steam Dump and Auxiliary Feedwater Systems. Unit 2 has no active shutdown tech spec action statements in effect. All control rods inserted on the reactor trip. All ECCS and ESF systems functioned as expected.

"No major secondary equipment was tagged for maintenance prior to this event. The 24 Service Water pump is tagged for scheduled preventive maintenance and did not affect post trip plant response. No personnel were injured during this event."

The licensee has notified the NRC Resident Inspector and will notify the Lower Alloway Creek Township.

AGREEMENT STATE - LOST SHIPMENT OF CS-131 BRACHYTHERAPY SEEDS

The following report was received from the Washington Department of Health, Office of Radiation Protection via email:

"[On] 2/4/16, [a common carrier] has lost track of a RAM [radioactive material] Cs-131 brachytherapy seed shipment sent for a patient near Atlanta, GA. The seeds did not reach their destination in time for the implant in a patient at a clinic approximately 1 to 1.5 hrs from Atlanta, so the customer alerted IsoRay. According to IsoRay's Radiation Safety Officer, [the common carrier] is looking for the package. [The common carrier] thinks there is a possibility that the shipment may have been mistakenly transferred from the [common carriers] plane to the US Postal Service at the air field in Atlanta. IsoRay's Radiation Safety Officer called Washington State at [approximately] 9:40 AM [EST] to report the loss. Additional information is forthcoming."

Washington Incident Number: WA-16-004

* * * UPDATE FROM ANINE GRUMBLES TO DANIEL MILLS AT 1750 EST ON 2/08/2016 * * *

The following was received from Washington via email:

"Quantity of seeds in order: 48
"Air kerma strength in micrograys per sq. meter/hr (U) - 2.02 - 2.08 = total 98 U
"Total apparent activity= 154 mCi (range from 3.17 - 3.26 mCi/seed)
"T1/2 = 9.69 days [half-life]"

Notified R4DO (O'Keefe), NMSS_EVENTS_NOTIFICATION (email), and CNSC Canada (email).

* * * UPDATE FROM ANINE GRUMBLES TO DANIEL MILLS AT 1640 EST ON 2/17/2016 * * *

The following was received from Washington via email:

"According to the Radiation Safety Officer at the seed manufacturer/distributor, IsoRay, the US Postal Service delivered the lost package to the intended user at the end of last week. The source had decayed to the point of being useless. The customer is going to send shipment back to IsoRay.'"

Notified R4DO (Vasquez), NMSS_EVENTS_NOTIFICATION (email), and CNSC Canada (email).

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 UNDERDOSE

The following was received from Kentucky via fax:

"KY RHB [Kentucky Radiation Health Branch] was notified via telephone by the radiation oncologist at the facility [Licensee] of a possible medical event. The medical event involved a patient treated for prostate cancer with I-125 [Iodine 125] seeds. The 30 day post-implant dosimetry determined the dose delivered to the target organ based on D90 was less than 80 percent [of prescribed dose]. The state [Kentucky] will continue to keep NRC informed of the status of the investigation."

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.

NON LICENSED SUPERVISOR IN VIOLATION OF THE FITNESS FOR DUTY POLICY

A non-licensed supervisor tested positive for a drugs during a random Fitness for Duty test. The individual's access to the plant has been suspended. The NRC Resident Inspector has been informed.

AGREEMENT STATE REPORT - LEAKING NI-63 SEALED SOURCE

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

"Radiation Safety staff at WSU [Washington State University] discovered a GC ECD [Gas Chromatography - Electron Capture Detector] to be leaking during the semi annual sealed source leak test. The sealed source leak test revealed 0.00686 microCuries of removable contamination. The source was removed from the laboratory where it was stored in a box and immediately transferred to radioactive waste, pending disposal. The ECD had been stored in a box and had not been used for several years. Both the source location and the GC were surveyed to ensure contamination was not present. Survey results were well below regulatory limits."

The source manufacturer/model number: Hewlett Packard model 5890A, serial number M2044. The sealed source contains 0.015 Ci of Ni-63.

WA Incident Number: WA-16-005