United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2003 > September 8

Event Notification Report for September 8, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/05/2003 - 09/08/2003

** EVENT NUMBERS **


39941 40091 40103 40128 40134 40135 40138 40139

To top of page
Hospital Event Number: 39941
Rep Org: GUTHRIE HEALTH CARE
Licensee: GUTHRIE HEALTH CARE
Region: 1
City: SAYRE State: PA
County:
License #: 37-01893-01
Agreement: N
Docket:
NRC Notified By: JOON PARK
HQ OPS Officer: FANGIE JONES
Notification Date: 06/16/2003
Notification Time: 09:20 [EST]
Event Date: 06/12/2003
Event Time: [EDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
RAYMOND LORSON (R1)
DOUG BROADDUS (NMSS)

Event Text

DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE

A patient was referred for treatment, due to reoccurring prostate cancer, to the hospital where he had previously had treatment. Seeds were implanted around May 2001. A scan of the previous treatment of implanted seeds determined that many of the seeds were not located in the prostate, but in adjacent tissue where they would have been ineffective in treatment. Also, a review of the records indicated a scan was performed in early 2002, but was not followed up on. The patient and referring physician have been informed. The hospital is conducting an investigation into the event and also developing a plan to provide appropriate treatment for the patient.

* * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * *

Post-op dosimetry on one patient was determined to be a misadministration. The dose that covered the prostate was more than 20 percent different from the prescription as well as the penile bulb dose being close to 50 percent of the prescription dose. Efforts are being made to contact the affected patient. The licensee will continue efforts to obtain post-op dosimetry on the rest of the patients related to this incident so that evaluations for misadministration can be performed.

Notified R1DO (Della Greca) and NMSS EO (Pierson).

* * * UPDATE ON 07/25/03 AT 0921 EDT FROM JOON PARK TO JOHN MACKINNON * * *

Post-op dosimetry for two patients were determined to be a misadministration. The patients had their prostates treated some time in the year 2001. The iodine-125 seeds were placed 2 to 3 centimeters below the area where they were supposed to be located. The improper location of the iodine-125 seeds caused more than 50% of the prescribed dose to be delivered to an un-intended organ. The patients will be notified.

Notified R1DO (Dan Holody) and NMSS EO (Trish Holahan).

* * * UPDATE ON 07/30/03 AT 0911 EDT FROM JOON PARK TO ARLON COSTA * * *

Two additional patients of a group of seven were identified as having received a misadministration of iodine-125 to an unintended organ. The patients will be notified of this misadministration. The licensee is in the process of clarifying and document the issues related to this incident.

Notified R1DO (James Moorman) and NMSS EO (Tom Essig).

* * * UPDATE ON 08/07/03 AT 1535 EDT FROM CHARLES LEE TO NATHAN SANFILIPPO * * *

Another patient has been identified who received a misadministration of iodine-125 to the prostate. The prescribed dose was 144 Gy, and it was delivered using 76 seeds and 27 needles as planned prior to the implant date. After reviewing the CT, which was done on Feb. 27, 2001, the V100 of the prostate received 29% of the prescribed dose. The penile bulb at 72 Gy received 44.8%. The licensee indicated that they have looked into 8 patients who may have been misadministered, of which, one was not declared a misadministration. The other seven appear in this notification. There are 23 total patients that the licensee intends to review.

Notified R1DO (Clifford Anderson) and NMSS EO (Fred Brown).

* * * UPDATE ON 08/14/03 AT 1150 EDT BY CHARLES LEE TO JOHN MACKINNON * * *

Twelve more patients have been added to the number of patients. Patients are identified by a six digit number.

Patient# [deleted]- On this date, March 21, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 77 seeds and 26 needles as planned prior to the implant, The V 100 of the prostate received 39% of the prescribed dose and the V50 of the penile bulb received 88%.
Patient# [deleted]- On this date, May 23, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed close was delivered using 53 seeds and 18 needles as planned prior to the implant. The V100 of the prostate received 62% of the prescribed dose and the V50 of the penile bulb received 57%,
Patient# [deleted]- On this date, December. 13, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 86 seeds and 21 needles as planned prior to the implant. The V 100 of the prostate received 70% of the prescribed dose and the V50 of the penile bulb received 99%.
Patient# [deleted]- On this date, February 22, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 77 seeds and 25 needles as planned prior to the implant. The V100 of the prostate received 52.5% of the prescribed dose and the V50 of the penile bulb received 80%.
Patient# [deleted]- On this date, March 15, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 67 seeds and 27 needles as planned prior to the implant. The V 100 of the prostate received 59% of the prescribed dose and the V50 of the penile bulb received 86.5%.
Patient# [deleted]- On this date, July 5, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 62 seeds and 21 needles as planned prior to the implant. The VI 00 of the prostate received 49% of the prescribed dose.
Patient# [deleted]- On this date, February 8, 2001, the former physician, prescribed a dose of 144-Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 45 seeds and 18 needles as planned prior to the implant. The V 100 of the prostate received 68% of the prescribed dose.
Patient# [deleted]- On this date, September 5, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 58 seeds and 20 needles as planned prior to the implant. The V100 of the prostate received 59.5% of the prescribed dose.
Patient# [deleted]- On this date, May 31, 2001, the former physician, prescribed a dose of 14-4Gy to the prostate using 1-125 seeds. The prescribed dose was delivered using 60 seeds and 17 needles as planned prior to the implant. The V1 00 of the prostate received 68% of the prescribed. Dose.
Patient# [deleted]- On this date, January 22, 2001, the former physician, prescribed a dose of 144Gy to the prostate using I-125 seeds. The prescribed dose was delivered using 54 seeds and 3, 8 needles as planned prior to the implant. The V100 of the prostate received 73% of the prescribed dose,
Patient# [deleted]- On this date, January 10, 2001, the former physician, prescribed a dose of 144Gy to the prostate using I-125 seeds. The prescribed dose was delivered using 58 seeds and 19 needles as planned prior to the implant. The VI 00 of the prostate received 54% of the prescribed dose.
Patient# [deleted]- On this date, June 21, 2001, the former physician, prescribed a dose of 144Gy to the prostate using 1-125 seeds, The prescribed dose was delivered using 82 seeds 28 needles as planned prior to the implant, The V 100 of the prostate received 73% of the prescribed dose.

Notified R1DO (Glenn Meyer) & NMSS EO (Linda Psyk).

* * * UPDATE AT 1124 EDT ON 9/5/2003 FROM C. LEE TO ERIC THOMAS * * *

Patient # [deleted] - On 10/3/2001, the former physician prescribed a dose of 144 Gy to the prostate using I-125 seeds. The dose was delivered using 67 seeds and 23 needles as planned prior to the implant. The V100 of the prostate received 72.5% of the prescribed dose.

Patient # [deleted] - On 10/4/2001, the former physician prescribed a dose of 144 Gy to the prostate using I-125 seeds. The dose was delivered using 74 seeds and 30 needles as planned prior to the implant. The V100 of the prostate received 66.7% of the prescribed dose.

Notified R1DO (Pam Henderson) and NMSS EO (Tom Essig)

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40091
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: HARRINGTON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/20/2003
Notification Time: 12:45 [EST]
Event Date: 08/20/2003
Event Time: 10:45 [CDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
THOMAS KOZAK (R3)
MATT HAHN (IAT)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNAUTHORIZED ACCESS

Actual individual had been granted unescorted access to a vital area. Compensatory measures immediately taken upon discovery.

NRC Senior Resident Inspector was notified of the event notification by the licensee.

* * * RETRACTION ON 09/05/03 AT 1008 EDT FROM HARRINGTON TO JOHN MACKINNON * * *

Based on subsequent review, the licensee has determined that there was no security violation. This event has been retracted. For additional information, contact the Headquarters Operation Officer. R3DO (R. Gardner) & IAT (A. Davis) notified.

NRC Resident Inspector was notified of this event by the licensee.

To top of page
Other Nuclear Material Event Number: 40103
Rep Org: STATE OF WEST VIRGINIA
Licensee: CAMDEN CLARK MEMORIAL HOSPITAL
Region: 2
City: PARKERSBURG State: WV
County:
License #: 47-09772-02
Agreement: N
Docket:
NRC Notified By: DAN HILL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 08/26/2003
Notification Time: 12:27 [EST]
Event Date: 08/25/2003
Event Time: 15:00 [EDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MIKE ERNSTES (R2)
DOUG BROADDUS (NMSS)

Event Text

XENON-133 RELEASED TO COLD TRASH

THE EVENT BELOW WAS REPORTED TO NRC REGION 2 BY DAN HILL OF THE STATE OF WEST VIRGINIA.

Initial notification to NRC Region II by State of West Virginia. Source was recovered by the licensee and State of West Virginia on 08/25/03. Activity measured in the licensee's dose calibrator was 10.49 miiicuries at approximately 3 PM on 08/25/03. Outer pig still had radioactive marking and listed 100 millicuries of activity. Pig originally contained 5 vials, 20 millicuries each (nominal). Only one vial remained in the improperly disposed pig. Trash was normal waste, not biomedical. Discovered when a landfill alarm was set off.

* * * Update on 09/05/03 at 1130 EDT by Licensee Ashford Broadwater III to MacKinnon * * *

Ashford Broadwater III of Camden Clark Memorial Hospital stated that on 08/26/03 at approximately 0845 EDT he was notified by the State of West Virginia Radiation Protection that a dumpster from their Hospital set off a radiation alarm at a local land fill. Mr. Broadwater III met a representative from the State of West Virginia at the landfill around 1130 EDT. The dumpster was dumped and an unused vial of Xenon-133 was found along with the lead pig that it came in. The total activity of the Xenon-133 on 08/20/03 at noon was 20 millicuries. Its half life is 5.3 days. The vial of Xenon-133 was taken back to the Hospital by 1230 EDT. The licensee has revised their procedures to prevent this incident from happening in the future. NRC R2DO (Paul Fredrickson) & NMSS EO (Tom Essig) notified.

To top of page
General Information or Other Event Number: 40128
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: TOBEY HOSPITAL
Region: 1
City: WAREHAM State: MA
County:
License #: 44-0034
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 09/03/2003
Notification Time: 15:11 [EST]
Event Date: 08/27/2003
Event Time: 11:30 [EDT]
Last Update Date: 09/03/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
TOM ESSIG (NMSS)

Event Text

MASSACHUSETTS AGREEMENT STATE REPORT -- CONTAMINATED DELIVERY

Upon receiving a package (small gray suitcase) of bulk Techneticum-99m (75 millicuries), a technician at Tobey Hospital detected high surface contamination readings on the case. The case was not open and showed no damage. Hospital staff isolated the case until the shipper could arrive.

The shipper, Mallinckrodt, arrived at the hospital and performed their own tests on the package. There were two "hot spots" detected: one 3.5 to 4.0 millirem/hr on contact on the plastic auxiliary pouch, and one 0.3 to 0.4 millirem/hr on the side of the suitcase. Upon opening the package, a survey of the Tc-99m pig and inside foam showed almost no contamination.

The driver of the delivery truck and the vehicle were immediately surveyed and showed no detectable activity. Surveys of the hospital lab and the lab where the suitcase was packed both showed no evidence of contamination. At this time, it is uncertain as to where the contamination originated. The package has been isolated and will be allowed to decay to background before the case is returned to service.

To top of page
Power Reactor Event Number: 40134
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GORDON E. ROBINSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/05/2003
Notification Time: 11:22 [EST]
Event Date: 09/05/2003
Event Time: 09:33 [EDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAMELA HENDERSON (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLENT INJECTION (HPCI) DECLARED INOPERABLE.

"At 09:30 EDT, Unit 1 was performing the HPCI Quarterly Flow verification surveillance. Shortly after the initiation of the system an abnormally loud bang was heard. System flow of approximately 5200 gpm and discharge pressure of approximately 1300 psi was achieved at approximately 09:33. Approximately 4 seconds after reaching rated system flow HPCI discharge pressure increased to approximately 1675 psi and system flow dropped to approximately 2700 gpm. HPCI had been declared inoperable at 08:35 EDT to perform the surveillance and will remain inoperable until the cause of the loss of system flow is corrected. Because HPCI is a single train ECCS [Emergency Core Cooling System] safety system, this event results in the loss of an entire safety function which requires an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(v) and the guidance provided under NUREG-1022, rev. 2.

"There are no other ECCS systems presently out of service."

Reactor Core Isolation Cooling (RCIC) is fully operable and HPCI entered Tech Spec 3.5.1 (14 day Limiting Condition of Operation). All other ECCS systems are fully operable.

The NRC Resident Inspector was notified of this event by the licensee.

To top of page
Power Reactor Event Number: 40135
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THAD REAMES
HQ OPS Officer: RICH LAURA
Notification Date: 09/05/2003
Notification Time: 12:10 [EST]
Event Date: 09/05/2003
Event Time: 10:30 [EDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
PAUL FREDRICKSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE MEDICAL EVENT AT McGUIRE

"Transport of a potentially radioactively contaminated person to Carolinas Medical Center due to head and neck injury. This is a conservative classification. Initial frisks of the injured individual did not reveal any contamination. His back could not be frisked because he was on a stretcher with potential head and neck injuries."

The licensee notified the NRC Resident Inspector.

*****UPDATE ON 9/5/03 AT 13:00 FROM REAMER TO LAURA*****

Further radiological surveys determined the individual was not contaminated.

To top of page
Power Reactor Event Number: 40138
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MCDONNELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 09/06/2003
Notification Time: 17:11 [EST]
Event Date: 09/06/2003
Event Time: 11:51 [EDT]
Last Update Date: 09/06/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CLIFF ANDERSON (REG)
FRANK GILLESPIE (NRR)
TIM MCGINTY (IRO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 33 Power Operation

Event Text

HPCI DECLARED INOPERABLE DUE TO LOSS OF THE 480V BUS.

While operating at 100% power, the plant sustained a loss of the 480 bus "B1". As a result of the loss of power, HPCI has been isolated due to the inability to auto isolate on a primary containment isolation signal. The SBGT was initiated to restore building ventilation. The Reactor Water Clean Up System was manually isolated due to the loss of power. The "A" recirculation pump tripped as a result of the loss of power. The loss of the 480V bus is being investigated at this time.

The NRC Resident Inspector was notified.

*****UPDATE ON 9/6/03 AT 1805 FROM McDONNELL TO LAURA*****

"Due to the loss of power to the RCIC quadrant coolers, the RCIC system is inoperable but available."

The NRC Resident Inspector was notified.

To top of page
Fuel Cycle Facility Event Number: 40139
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 3
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: THOMAS WHITE
HQ OPS Officer: RICH LAURA
Notification Date: 09/07/2003
Notification Time: 18:15 [EST]
Event Date: 09/07/2003
Event Time: 07:50 [CDT]
Last Update Date: 09/07/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
RONALD GARDNER (R3)
JANET SCHLUETER (NMSS)
TIM MCGINTY (IRO)

Event Text

CRITICALITY CONTROLS DEGRADATION AT PADUCAH

"At 0750 on 9/7/03, it was discovered that the Recirculating Cooling Water (RCW) Supply valve for C333 Unit 6 Cell 2 was not positioned correctly for the current condition of the cell, in violation of NCSA CAS-011. On 9/3/03, the cell was in a fluorinating environment with the Odd R-114 system drained and evacuated for leak repairs, Odd RCW valves closed, the Even R-114 system was not drained with the Even RCW valves open satisfying the conditions of CAS-002. It was determined that the cell needed to have a UF6 negative obtained for maintenance work. The UF6 negative was initiated without closing the Even RCW Supply valve, tagging both the Supply and Return valve, and without performing the independent checks for valve position, which violates NCSA CAS-002. Once the UF6 negative was obtained, the cell transitioned to NCSA CAS-011 without satisfying the RCW isolation controls of that NCSA. Both RCW isolation controls require that the RCW Supply valve be tagged closed and that the RCW Return valve be tagged open and both valves independently verified to be positioned correctly. The NRC Senior Resident Inspector has been notified of this event.

"SAFETY SIGNIFICANCE OF EVENTS: Since the process condition (lack of moisture in the coolant, and therefore in the process gas system) was maintained, the safety significance of this incident is low.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO OF NOW CRITICALITY OF HOW CRITICALITY COULD OCCUR): Once the fluorinating environment is removed from a process cell, moisture that may leak into the process gas system could potentially moderate any uranium that may be present. Sufficient water would have to leak into the process gas system and moderate a critical mass of uranium.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC
Double contingency is maintained by implementing two controls on mass.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency is based on ensuring that a coolant condenser leak will not introduce RCW (moderator) into the process gas side of a cell through the coolant. This is accomplished by either maintaining a fluorinating environment in the cell or by restricting /isolating the RCW supply prior to removing the fluorinating environment. This restriction/isolation is accomplished by either removing a supply spool piece or closing and tagging the manual supply valve and tagging open the return valve. Neither of these two RCW alignments was maintained. The second leg of double contingency is based on an independent verification of the RCW alignment relied upon for the first leg of double contingency. The independent verification was not performed. Therefore, this control was lost, Since double contingency is based on two controls on one parameter, double contingency was not maintained.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMPNTED: At 1010 on 9-7-03, the Even RCW Supply valve was tagged closed, the Odd RCW Return valve was tagged open, and both valves were independently verified. The coolant moisture content was checked and was less than minimum detectible moisture. These actions have placed the system back in compliance with NCSA CAS-011."

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012