Event Notification Report for June 03, 2004

AGREEMENT STATE MEDICAL MISADMINISTRATION

The South Carolina Department of Health and Environmental Control was notified on Friday, June 04, 2004 of a possible medical rnisadministration notification which was reported by the Radiation Safety Officer for the Cancer Center of the Carolinas. A Cs-137 brachytherapy radiation dose was administered to a patient where the calculated administered dose differed from the prescribed dose by more than 20%. This apparently occurred when the radiation source was not fully extended to the end of the application catheter. The event is under investigation and updates will be made through the national NMED system as they become available.

PART 21 NOTIFICATION OF FAILURE OF SPRING CHARGING FUNCTION IN CIRCUIT BREAKER

"Limerick has completed the 10CFR Part 21 evaluation of the failure of the spring charging function on an Asea Brown Boveri (ABB) Model HK circuit breaker. The investigation determined that the primary contributor to the failure was the replacement of ABB latch reset torsion spring number 195205A00 with a weaker spring that was supplied with the breaker overhaul kit number 716656T104. Secondary contributors to the failure were normal wear on additional parts in the operating mechanism.

"ABB supplied a six-turn latch reset torsion spring and a five-turn latch reset torsion spring under spring part number 195205A00 and overhaul kit number 716656T104. The spring of concern is a six-turn spring that does not provide as much force as the original six-turn or five-turn spring. When informally tested during the investigation the six-turn spring provided approximately 66 ounces of force and the five-turn spring provided approximately 102 ounces of force. The original six-turn spring provided a force of 88 ounces.

"Limerick's evaluation concluded that installation of the replacement six-turn latch reset torsion spring could create a substantial safety hazard depending on the breaker's application. Therefore, this notification is being submitted pursuant to the requirements of 10CFR21.21(d)(3)(i). The required 10CFR21.21(d)(3)(ii) 30-day written notification will provide more detail when submitted. ABB evaluation of this issue is still in progress."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 6/30/04 @ 1451 HRS. EDT FROM GAMBLE TO CROUCH * * *

"This is a retraction of the Part 21 initial notification made per 10CFR21.21(d)(3)(i) on 6/3/04 at 12:47 EDT (EN# 40788). The issue involved an in-service malfunction of the closing spring charging function of an Asea Brown Boveri (ABB) Model HK circuit breaker following replacement of the latch reset torsion spring (ABB number 195205A00) during breaker maintenance. The spring was supplied with ABB overhaul kit number 716656T104.

"Upon further review of the Part 21 reporting requirements it has been determined that this issue does not require reporting. NUREG-1022 Rev.2 'Event Reporting Guidelines 10CFR50.72 and 50.73' provides guidance for Part 21 reporting in section 5.1.8. The NUREG section references a federal register notice (56 FR 36081, July 31, 1991) in footnote 18, which provided notification of an amendment to 10CFR Parts 21 and 50. The amendment was intended to reduce duplicate reporting of defects.

"The notice provides the following guidance for components that have been installed in operating plants:

"Operating license holders can reduce duplicate evaluation and reporting effort by evaluating deviations in basic components installed in operating plants which produce events which could meet the criteria of 50.72 and 50.73. If the evaluation of events using the criteria of 50.72 and 50.73 results in a finding that the event is reportable and the event is reported via these sections, then as indicated in 21.2(c), the evaluation, notification, recordkeeping, and reporting obligations of part 21 are met. If the event is determined not to be reportable under 50.72 or 50.73, then the obligations of part 21 are met by the evaluation.

"The evaluation using the criteria of 50.72 and 50.73 resulted in a finding that the event was not reportable. There was no reasonable expectation of preventing fulfillment of a safety function, no equipment was declared inoperable, and the principle safety barriers were not seriously degraded.

"Therefore, this event is not reportable using the criteria of 50.72 and 50.73 and the Part 21 evaluation obligation is met."

The licensee has notified the NRC Resident Inspector of this retraction.

The Headquarters Operations officer notified R1DO (Barkley), R2DO (Evans), R3DO (Gardner), R4DO (Whitten), and NRR (Dennig).

ALABAMA AGREEMENT STATE REPORT ON STOLEN GAUGE

"At 4:07 p.m. Gary Brunson of the Alabama Department of Transportation called and reported that a Campbell Pacific gauge, Model MC3, Serial # M32076686 had been discovered stolen from their Guntersville, Alabama Project Office at approximately 6:30 this morning, Thursday, June 3, 2004. Brunson stated the device contained approximately 10 mCi of Cs-137 and 50 mCi of Am-241/Be.

"Brunson further stated he had delayed notifying the Agency until he had a copy of the police report from the Guntersville Police Department, who had investigated the theft. Someone had apparently climbed the fence, then broke into the testing lab building and took a nuclear density gauge and an air flow meter. A Troxler Model 4640 nuclear gauge was sitting beside the Campbell Pacific gauge but was not taken. Because both an air gauge and a density gauge were taken, Mr. Brunson believes the thief was taking something to sell and not taking something from which a radioactive source could be removed, or else they would have taken both nuclear gauges.

"Mr. Brunson agreed that if the device is not located by mid morning tomorrow, Friday, June 4, 2004, that he would work with the Agency to distribute an information notice on the missing device to area law enforcement agencies."

* * * UPDATE 1143 EDT ON 6/4/04 EMAIL FROM J. MCNEES TO W. GOTT * * *

The First Division Office located in Guntersville, AL reported the incident, but the project was in Huntsville, AL, which is part of the First Division.

VEHICLE ACCIDENT WHILE CARRYING A NUCLEAR GAUGE

A pickup truck used by the licensee during inspection services loaded with a Troxler gauge was involved in an accident. The pickup truck hit a tree and its top came loose, along with its contents, landing in an area away from the pickup. A Troxler gauge, inside its storage box, was one of the items tossed out of the pickup truck. The pickup truck caught on fire after the accident. The technician was injured during the accident and was subsequently taken to a local hospital in Springport, MI.

The burnt pickup truck was hauled away to a storage place along with the top with its contents. The Troxler gauge is inside its storage box and does not appear to be damaged. The gauge is a Troxler Model 3430, S/N 75-6542, 8 millicuries Cs-137 and 40 millicuries of Am-241/Be. The licensee's Radiation Safety Officer intends to retrieve the gauge, perform a leak test and return the gauge to the manufacturer. The licensee was requested to call the Operations Center with an update of the leak test results.

* * * Update on 06/09/06 at 0850 EDT by Paul Galdes to MacKinnon * * *

Troxler gauge passed its leak test.

R3DO (M Parker) & NMSS ( Linda Psyk) notified.

AGREEMENT STATE REPORT - MULTIPLE PATIENT OVEREXPOSURE

"A verbal report was received on July 20, 2004, which reported patient doses in excess of 50 Rem to the wrong physical area on treatments involving a Nucletron HDR Microselectron brachytherapy device, Model 080.000, Serial No. 9072. Four patients received wrong doses due to a 7.5 centimeter error in source location from the intended treatment site/plan. Details were vague due to discussion over the phone. A written report would follow.

"The written report date August 2, 2004, was received by this agency on August 6, 2004. The report failed to give details needed by this agency. An Agency investigator was assigned to investigate this incident on August 6, 2004. The investigation conducted on August 18, 2004, determined that an error in catheter length was entered by two different registered therapists as 920 millimeters versus the default and actual length of the catheter of 955 millimeters. The 75 millimeter or 7.5 centimeter error resulted in two sources: a 12.3 curie (02/16/2004) Ir-192 source, Serial No. D35AO131 and a new Ir-192 source installed on 07/08/2004, Serial No. D35A0605, 10.5 curies being positioned outside of each patients body. The error was discovered after one of the four patients developed skin erythema. The patients were to receive boost treatments of 500 centiGray per fraction from the HDR unit to the prescribed location with the total number of fractions varying from 3 to 7 in the physician's written directive. The patients were all being treated for inter uterine cancer. The patients received fractional treatments with the error which varied from 1-5 fractions. Make-up treatments were required on three of the patients to achieve the correct dosage to the treatment site. Some patients received both correct and incorrect treatments from the same therapists.

"The error was discovered on July 8, 2004, when one patient complained of tenderness in one leg. The physician determined that the patient had erythema on her leg, several centimeters from the planned treatment site. The physician's investigation determined the error in catheter length on July 14, 2004, and ordered make-up treatment for his patient on July 15, 2004. A total of four female patients, three radiation oncologists, and three radiation therapists were involved in the treatments and required corrective treatments to three of the four patients. The hospital was reluctant to release dose data on the patients due to concerns of HIPAA privacy standards. After explanation of allowable disclosure to this agency, the Licensee provided the data on October 4, 2004.

"Patient #1 received a non-target tissue dose of 800 rad superficial and 250 rad deep over a three week period. She suffered skin erythema which was treated over a few weeks with rest and a topical ointment. After the erythema was resolved she resumed normal follow-up treatment for her initial disease. Patient #2 received a non-target tissue dose of 400 rad superficial and 150 rad deep over a one week period and exhibited no abnormal reactions. She immediately resumed normal follow-up treatment for her initial disease. Patient #3 received a non-target tissue dose of 1100 rad superficial and 300 rad deep over a three week period. She exhibited no abnormal reactions and resumed normal follow-up treatment for her initial disease. Patient #4 received a non-target tissue dose of 1800 rad superficial and 350 rad deep over a seven week period. She suffered skin erythema and was treated with rest and topical ointment. After the erythema was resolved, she resumed normal follow-up treatment for her initial disease. This is an abnormal occurrence."

Texas Incident # I-8145.

* * * UPDATE FROM J. OGDEN TO M. RIPLEY 0825 ET 10/20/04 * * *

"The correct catheter length is 995 mm vs. the entered length of 920 mm. A difference of 75 mm or 7.5 cm."

Notified R4 DO (Whitten) and NMSS EO (Essig).