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Event Notification Report for October 25, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/22/2004 - 10/25/2004

** EVENT NUMBERS **


41135 41136 41141 41142 41143 41144

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General Information or Other Event Number: 41135
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: VHS SAN ANTONIO PARTNERS, LP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L00455-000
Agreement: Y
Docket:
NRC Notified By: JAMES OGDEN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/19/2004
Notification Time: 16:37 [ET]
Event Date: 06/03/2004
Event Time: [CDT]
Last Update Date: 10/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
TOM ESSIG (NMSS)

Event Text

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).

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General Information or Other Event Number: 41136
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: DURATEK MEMPHIS GROUP
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79171
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2004
Notification Time: 16:15 [ET]
Event Date: 10/05/2004
Event Time: [EDT]
Last Update Date: 10/19/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)
JACK WHITTEN (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING SHIPMENT OF PACKAGES WITH REMOVABLE CONTAMINATION

"On October 18, the licensee called the Division [Tennessee Division of Radiological Health] to report that a shipment brokered by Duratek from their facility in Memphis, TN on September 29 arrived at Laguna Verde Power Station near Veracruz, Mexico on October 5 with three boxes exceeding the removable contamination limits of 49CFR173.443. The boxes contained contaminated equipment, to be used at the Power Station during an outage. The equipment was contaminated with mixed fission/activation products. There was no contamination found on the truck. The boxes were decontaminated onsite."

Tennessee Event report ID No.: TN-04-151

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General Information or Other Event Number: 41141
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES OILFIELD OPERATIONS
Region: 4
City: GALVESTON State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES H. OGDEN, JR.
HQ OPS Officer: MIKE RIPLEY
Notification Date: 10/20/2004
Notification Time: 10:08 [ET]
Event Date: 10/19/2004
Event Time: [CDT]
Last Update Date: 10/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT - THREE WELL LOGGING SOURCES ABANDONED DOWNHOLE

"Well: Mako Steward A-37 State Tract #1, Galveston, County, Texas
9,150 ft. downhole (bottom of well)

"Well logging string became stuck in a 6 3/4" wellbore over the weekend. Attempts to 'fish' for the sources was unsuccessful with the fishing tool becoming stuck in the wellbore above the well logging tool string. The tool string contains three sealed sources: an 18 curie Am-241/Be; a 2 curie Cs-137; and a 0.8 microcurie Cs137. The sources were declared abandoned late on October 19, 2004. The Licensee is preparing to seal the well with red dyed cement and placement of a deflection device in the wellbore. The tool string is sitting at the bottom of the well at 9,150 feet downhole. Source manufacturers and serial numbers are currently unavailable."

Texas Incident No. I-8175

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Power Reactor Event Number: 41142
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TIMOTHY PAGE
HQ OPS Officer: ARLON COSTA
Notification Date: 10/22/2004
Notification Time: 11:00 [ET]
Event Date: 10/08/2004
Event Time: 18:31 [EDT]
Last Update Date: 10/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RONALD BELLAMY (R1)
ANNE BOLAND (R2)
JULIO LARA (R3)
BOB DENNIG (NRR)
VERN HODGE (NRR)
RODGER LANKSBURY (R3)
JACK WHITTEN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

PART 21 REPORT: AUXILIARY RELAYS FAILURE

"In accordance with 10CFR21.21(d)(3), initial notification of a reportable defect is being made by James A. Fitzpatrick (JAF).

"The failure of two General Electric (GE) IRMA auxiliary relays in a short period of time were identified in the corrective action system as a potential common mode failure. Initial troubleshooting revealed that both relay coils indicated open. There was no evidence of any obvious cause for the coils to open circuit (e.g. discoloration, smell, physical damage). Both relays are normally de-energized relays located in a mild environment in the relay room (controlled humidity, no vibration at the panels, no local heat source that could cause accelerated aging). Both relays were installed in 1988 along with 21 other relays. A total of 33 relays were purchased from GE with the same lot/date code.

"An extent of condition review was conducted. By checking the continuity of related relay coils, two other coil failures were detected. A failure analysis of the relays was performed. The failure mode was determined to be an open in the coil due to corrosion of the coil wire. This open in the coil will prevent the relay from changing state as the relay is energized. An independent laboratory concluded that the coil insulation was damaged and that the under lying wire was damaged during coil manufacture. The damage allowed the copper wire to corrode over the years to the point of failure.

"These HMA relays were installed in multiple Emergency Core Cooling Systems (ECCS) and other systems. Each component was evaluated to determine the specific impact on the respective system. The systems affected included: Residual Heat Removal (RHR, the Low Pressure Coolant Injection (LPCI) mode of operation), Emergency Diesel Generators (EDGs), Automatic Depressurization System (ADS), Reactor Core Isolation Cooling (RCIC), Core Spray (CS), and High Pressure Coolant Injection (LPCI).

"JAFs evaluation concluded that a substantial safety hazard existed in that there was a potential for a major deficiency/major degradation of essential safety-related equipment, specifically for the RHR (LPCI mode of operation) and HPCI systems.

"No other safety functions would have been lost for the other identified systems.

"Component and Supplier:
GE HMA Type auxiliary relays
GE Part No. 12HMA124A2
GE Dwg No. DA137C6164P001
Date Code 14VC; 8836
Serial #s: D88542-0001D R02 through D88542-0033D R02

"All were purchased as safety-related from GE under JAF PO # 88-5628

"All installed safety-related relays from this lot were replaced during the recent refueling outage."

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 41143
Rep Org: MASSACHUSETTS RADIATION CONTROL
Licensee: LAHEY CLINIC FOUNDATION
Region: 1
City: BURLINGTON State: MA
County:
License #: 44-0015
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/22/2004
Notification Time: 15:26 [ET]
Event Date: 08/31/2004
Event Time: [EDT]
Last Update Date: 10/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT OF MEDICAL MISADMINISTRATION

"Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%."

"The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory."

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Power Reactor Event Number: 41144
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GLENN HORNE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/23/2004
Notification Time: 21:43 [ET]
Event Date: 10/23/2004
Event Time: 20:23 [EDT]
Last Update Date: 10/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANNE BOLAND (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
2 N N 0 Hot Standby 0 Hot Standby

Event Text

OFFSITE NOTIFICATION TO SOUTH CAROLINA OSHA

A Catawba employee suffered an apparent heart attack while at work and was transported offsite to a local hospital at 1745 EDT on 10/23/04. The employee subsequently passed away at the hospital. No contamination was involved; the employee was working in the Unit supervisor's office.

The licensee is required to make an offsite notification to South Carolina OSHA within 8 hours. The licensee also notified state and local authorities for the states of SC and NC as well as the NRC resident inspector.

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