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Event Notification Report for January 28, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/27/2005 - 01/28/2005

** EVENT NUMBERS **


41351 41361 41362

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General Information or Other Event Number: 41351
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 392-03
Agreement: Y
Docket:
NRC Notified By: ED STROUD (via fax)
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/24/2005
Notification Time: 09:27 [ET]
Event Date: 01/20/2005
Event Time: 10:00 [MST]
Last Update Date: 01/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
LINDA GERSEY (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A PHARMACY SPILL OF SAMARIUM-153

The following information was submitted by the licensee to the State of Colorado in an email dated 1/21/05 at 1137 hours:

"On 1-20-05 at approximately 10:00 Cardinal Health, location 48 (Colorado Springs, CO, License number 392-03) had a Sm-153 spill. Approximately 72 mCi of Sm-153 was spilled on the floor next to the main drawing station in the Lab. Our pharmacist was transferring a vial from the Berlex lead vial shield to our tungsten vial shield when the vial got away from him hitting the floor and breaking. The Pharmacist immediately notified the RSO and they started the decontamination process to minimize the risk of cross contamination into other areas of the lab. The area was segregated and the decontamination process was started. Radiacwash was used to decontaminate the area and all contaminated wipes, shoes, and associated materials were bag[ged] and placed with the Sm-153 waste. After initial decontamination was completed the area was surveyed and readings of 200 Mr/hr were obtained at the surface of the floor. Subsequent rounds of decontamination provided a reading of 50 Mr/hr. After we covered the area with padding and lead the exposure readings went down to 0.2 Mr/hr. Wipes were conducted of areas outside of the lead shielding on the floor and were found to be at background levels. We had a brief staff meeting of the pharmacists to access and evaluate the situation and to go over the proper procedures for transfer and dispensing of Sm-153 so that this incident would not be repeated. The corporate office was notified.

"The material will be allowed to decay for several days, at which point a determination of the levels of impurity contamination will be assessed. The floor will be removed, if needed, to reduce the exposure rate to acceptable levels.

"On 01-21-05 the Radiation Management unit of the State of Colorado, Department of Public Health was notified under section 4.52.2.2 (2) of the state regulations. A written response will be forwarded to the state within 30 days."

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Hospital Event Number: 41361
Rep Org: UNIVERSITY OF MINNESOTA
Licensee: UNIVERSITY OF MINNESOTA
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 22-00187-46
Agreement: N
Docket:
NRC Notified By: JERRY STAIGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/27/2005
Notification Time: 13:00 [ET]
Event Date: 01/25/2005
Event Time: 21:30 [CST]
Last Update Date: 01/27/2005
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):
DAVID HILLS (R3)
SANDRA WASTLER (NMSS)

Event Text

MEDICAL EVENT DURING TREATMENT FOR CANCER OF THE CERVIX

A patient undergoing a 31 hour treatment plan for cervical cancer received less than the prescribed dose delivered to the treatment site and a higher than intended dose to other tissue(s)/organ(s), specifically:

Treatment site A: planned 1643 centiGray, delivered 821 centiGray
Treatment site B: planned 465 centiGray, delivered 372 centiGray

Bladder: planned 1147 centiGray, delivered 1448 centiGray
Rectum: planned 1147 centiGray, delivered 2012 centiGray

Treatment was delivered from 1430 hours on 1/24 and 2130 hours on 1/25 using a low dose rate tandem brachytherapy device containing three Cs-137 sources; 14 milligram Ra-equiv, 9.8 milligram Ra-equiv and 9.8 milligram-equiv. There were two additional Cs-137 ovoid sources, each 14.1 milligram Ra-equiv. The tandem device has a rod that was cut 6 cm. short such that when the tandem was positioned in the patient, the three tandem sources were not extended the proper distance inside the tandem device. The ovoid sources were properly positioned.

The referring physician and patient have been informed. The radiation staff oncologist does not believe that this medical event will have any adverse effect on the patient and a new treatment plan is being prepared for the patient.

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Power Reactor Event Number: 41362
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: GUY McCALLUM
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/27/2005
Notification Time: 21:12 [ET]
Event Date: 01/27/2005
Event Time: 18:30 [EST]
Last Update Date: 01/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS DECKER (R2)

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

Event Text

SINGLE FAILURE IDENTIFIED THAT COULD PREVENT RE-ENERGIZING BOTH ES BUSSES


"On January 27, 2005, Crystal River - Unit 3 (CR-3) discovered an installation subject to a single failure that could prevent both Emergency Diesel Generators (EDGS) and both offsite power sources from supplying power to their respective Engineered Safeguards (ES) Busses. This is a condition contrary to 10CFR50.72 (b)(3)(ii)(B).

"The installation involves the 4.16 Kv supply breakers from the offsite power transformer (OPT) and the Back-up Engineered Safeguards Transformer (BEST) which are the two required offsite power sources. From the OPT, one breaker supplies the 'A' ES Bus and a second breaker supplies the 'B' ES Bus. From the BEST, one breaker supplies the 'A' ES Bus and a second breaker supplies the "B" ES Bus. A traditional (non-nuclear) design for such pairs of supply breakers includes current transformers that are connected to each other for each phase and a watt hour meter from those connections to monitor power. These circuits were installed around 1990 to support the coordination of the new 230 Kv breakers to supply the OPT and the coordination with the 230 Kv supply breakers for the new BEST.

"Should a failure of the wire connecting the current transformers or the watthour meter occur such that the ES Bus supply breakers' lockout relays are actuated, all breakers supplying and receiving power via the ES Busses would be opened and locked out. The result is that neither EDG nor the offsite power source would be able to automatically supply power to its respective ES Bus.

"CR-3 is currently disconnecting and isolating the watthour meters and removing the connection between the respective breakers' current transformers."

Licensee entered Tech Spec 3.8.9.1 at 1830 hours based on single failure but considers both ES busses operable.

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

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