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Event Notification Report for January 23, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/20/2006 - 01/23/2006

** EVENT NUMBERS **


42263 42265 42268 42270 42271 42276 42277 42280 42281

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General Information or Other Event Number: 42263
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MARY BIRD PERKINS CANCER CENTER
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-2651-L01
Agreement: Y
Docket:
NRC Notified By: MIKE HENRY
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/17/2006
Notification Time: 15:30 [ET]
Event Date: 11/22/2005
Event Time: [CST]
Last Update Date: 01/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"The patient was planned to receive an HDR brachytherapy dose of 750 cGy in a single fraction to a distance of 1.0 cm beyond the active dwell positions in the right lung. A catheter was inserted in the right bronchus on November 22, 2005 for the treatment. The catheter was marked at the entrance of the nostril and taped to the nose and face. The patient was then taken to CT for the treatment planning. The treatment plan was developed and approved. The patient was treated in a linear accelerator vault. Prior to treatment, a dummy wire was placed into the catheter and a megavoltage portal image was taken to confirm placement of the catheter. The radiation oncologist believed that he had verified the catheter placement from the portal image. The catheter was connected to the HDR unit and the treatment was performed. At the conclusion of the treatment, the prescribing physician and nurse entered the treatment room to remove the catheter from the patient. At that time it was discovered that the catheter was not fully inserted into the patient's lung. The mark that was put on the catheter during the planning was 15 cm outside of the nose. Apparently the catheter had become loose from the tape. According to the prescribing physician the dose used for this treatment was not enough to produce any significant sequalae in the upper thorax and neck region. The patient was informed on 11/22/05. External beam therapy will be used for the missing dose to the lung. Some procedures have been modified to prevent this from reoccurring."


LA Event Report ID No: LA050009

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General Information or Other Event Number: 42265
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GWINNETT MEDICAL CENTER
Region: 1
City: LAWRENCEVILLE State: GA
County: GWINNETT
License #: GA677-1
Agreement: Y
Docket:
NRC Notified By: LIZ R. SEALE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/18/2006
Notification Time: 07:34 [ET]
Event Date: 01/10/2006
Event Time: [EST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT

The State provided the following information via fax:

"On January 10, 2006, a patient was to receive an Iodine-131 therapy dose of 150 mCi (2 capsules). Upon review of the dose it was determined that the dose received was only 75 mCi (1 capsule)."

This incident was reported to the GA Radiation Control Program on 1/17/06. GA Incident Summary: GA-2006-03I.

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General Information or Other Event Number: 42268
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH SCIENCE CONSULTANTS
Region: 4
City: SALINAS State: CA
County:
License #: 6775-27
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/18/2006
Notification Time: 15:30 [ET]
Event Date: 01/21/2005
Event Time: [PST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)
BENJAMIN SANDLER (TAS)
MEXICO via fax ()

Event Text

AGREEMENT STATE REPORT OF MISSING MOISTURE DENSITY GAUGE

The State provided the following information via email:

"RSO for Earth Consultants, claims his company has broken up and his Alternate RSO has taken their single moisture density gauge. The gauge is a CPN model 503, source model 131 serial number H300305517. This information was first provided in a letter dated 1/21/05 and he has not been able to locate his former ARSO. RHB Richmond has determined that the former ARSO is probably located in Greenfield, CA. RHB will continue its efforts to locate the former RSO and the gauge. RHB Richmond has spoken to the RSO and suggested that he report the gauge as stolen by his former ARSO to the local authorities and request license termination."

These gauges typically contain 10 milliCi of Cs-137 and 40 milliCi of Am-241.



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.

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General Information or Other Event Number: 42270
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: J. MARION EADDY III
HQ OPS Officer: BILL GOTT
Notification Date: 01/18/2006
Notification Time: 17:38 [ET]
Event Date: 01/14/2006
Event Time: [EST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via fax:

"N.C. Radiation Protection Section was notified on 18 Jan 2006 by the RSO for the Charlotte Mecklenburg Hospital Authority of a misadministration during a manual brachytherapy treatment. The authorized user's written directive called for a temporary implant 'tandem and ovoid' using Cs-137 sources to deliver a total dose of 4883 RAD (approximately 49Gy) over 68 hours, with following source loading in the applicator:

"Right Ovoid: 1 at 14.6 mgRaEq [milligram Radium Equivalent] (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 14.6 mgRaEq

"A medical dosimetrist loaded the tandem and ovoid incorrectly. The actual loading of the applicator was:

"Right Ovoid: 1 at 14.6 mgRaEq (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 24.8 mgRaEq (approximately 86.8 mCi or 3212 MBq)

"This errant loading of applicator resulted in the patient receiving 6474 RAD (approximately 65 Gy) to the treatment area. The delivered dose was 33 percent more than prescribed.

"The Cs-137 sources utilized in the procedure were:

"3M Model 6503 (14.6 mgRaEq)
3M Model 6502 (11.2 mgRaEq)
AEA Technology/QSA Model CDC.T1 (24.8 mgRaEq)

"The licensee is conducting follow-up investigations and will make a report the Radiation Protection Section within 15 days of the discovery of the event. The report will contain root cause analysis and procedures to prevent recurrence.

"N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued."

Event Report ID No.: NC-06-04

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General Information or Other Event Number: 42271
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: COLUMBIA WEST ENGINEERING
Region: 4
City: VANCOUVER State: WA
County:
License #: WN-I0517-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/18/2006
Notification Time: 18:05 [ET]
Event Date: 01/12/2006
Event Time: [PST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT REGARDING A DAMAGED TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via email:

"ABSTRACT: The licensee states the gauge was in use near several construction vehicles [at a work site in Clackamas, Oregon]. The gauge was located behind a nearby pickup truck attached flatbed trailer. The gauge user thought the vehicles were not occupied. A driver in the truck started the vehicle and promptly backed it into the gauge before it could be moved by the operator, resulting in damage to the index rod. No other damage was noted. The licensee says the gauge operator was in proper control of the gauge at the time the truck struck the gauge. Regardless, the licensee will provide training to the operators reminding them of the requirements to maintain proper surveillance and control of gauges while away from the licensed storage locations. An explanation of what occurred in this event was also provided to the operators as lessons learned.

"Notification Reporting Criteria: WAC 246-221-250 Notification of Incidents.

"Isotope and Activity involved: 8 mCi of Cesium 137, and 40 mCi of Americium 241/Beryllium.

"Damaged Troxler 3430, serial number 31153.

"Disposition/recovery: The licensee was able to get the source rod back into the shielded position. They had a count rate survey meter and used it to determine that readings were normal. They called the manufacturer's local representative and the RSO for Troxler in North Carolina. The licensee was instructed on how to package the gauge properly. The gauge was taken back to the licensed and secured storage area where additional gauge packaging was used to secure the damaged index rod. They took a wipe test of the gauge. The results came back normal to allow for a normal means of shipping back to Troxler in North Carolina. Shipping is scheduled for January 19, 2004.

"Leak test? Leak test analysis - less than 0.005 microcuries.

"Release of activity? None found.

"Consultant used? Local Troxler representative and Troxler RSO.

Event Report # WA-05-006.

* * * UPDATE ON 01/20/06 * * *

The correct Washington Event report number is WA-06-006.

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Power Reactor Event Number: 42276
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: JEFF CUFF
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2006
Notification Time: 11:34 [ET]
Event Date: 01/20/2006
Event Time: 11:25 [EST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MONTE PHILLIPS (R3)

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

PRESS RELEASE ISSUED REGARDING AGREEMENT WITH DOJ RELATED TO DAVIS-BESSE REACTOR HEAD ISSUE

"A press release is being made today by the First Energy Nuclear Operating Company that it has entered into a deferred prosecution agreement with the U.S. Attorney's Office related to FENOC's communication with the NRC during the fall of 2001 in connection with the reactor head issue at the DBNPS. FENOC has agreed to pay a penalty of $28 million."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 42277
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BOB HATFIELD
HQ OPS Officer: BILL GOTT
Notification Date: 01/20/2006
Notification Time: 12:49 [ET]
Event Date: 01/20/2006
Event Time: 08:56 [EST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHARLES R. OGLE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

RPS ACTUATION

"On 1/20/2006 at 0730 hrs, a Unit 2 control room annunciator was received indicating high conductivity/sodium in the main condenser. The Chemistry Dept. confirmed the sodium level was high indicating saltwater intrusion from a tube leak in the 2B2 Condenser Waterbox. Per the Secondary Chemistry Off-Normal Procedure, a rapid downpower to less than 5% power was initiated to remove the affected waterbox from service. It was decided to go ahead and remove Unit 2 from service rather than remain critical at a low power level. The downpower was planned to decrease power to approximately 25%, perform a manual transfer of plant electrics to the auxiliary transformers, and then manually trip the reactor in accordance with plant procedures. All systems worked as planned during the downpower and the reactor was manually tripped at approximately 25% power at 08:56 hrs. Standard Post Trip Actions and the Reactor Trip Recovery Procedure were carried out without incident.

"All control rods fully inserted and no Steam Generator (S/G) Safety Valves lifted. Feedwater to the S/G was supplied by the Main Feedwater pumps during the shutdown and later transferred to the Auxiliary Feedwater pumps. All safe shutdown equipment operated as expected. The plant is stable in Mode 3, Hot Standby conditions, with decay heat removal being accomplished by steaming through the Atmospheric Dump Valves. The Main Feedwater pumps remain available if needed.

"Unit 1 was not affected by this event."


The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42280
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHUCK BAREFIELD
HQ OPS Officer: PETE SNYDER
Notification Date: 01/20/2006
Notification Time: 17:07 [ET]
Event Date: 01/20/2006
Event Time: 10:17 [CST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHARLES R. OGLE (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 Y 100 Power Operation 100 Power Operation

Event Text

PUBLIC PROMPT NOTIFICATION SYSTEMS SIRENS DISCOVERED INOPERABLE

"The Public Prompt Notification System sirens were inoperable from 10:17 CST until 11:36 CST on 01/20/06. [They were inoperable for] a period of one hour and 19 minutes. The siren system was returned to operation when the antennae for operating the sirens was changed. The Tone Alert Radio System was operational during this entire time period and remains operable. The cause of the failure is not clearly understood at this time. The appropriate test equipment is being sent to the site and a complete troubleshooting plan with a test plan will be started on Monday 01/23/06. Until that time a contingency plan is in place that has personnel on call that will report to the three siren sites if an emergency is declared. They will be in communications with the local authorities to activate the sirens locally in accordance with an approved plant procedure. While performing the troubleshooting and maintenance on the siren system we will have staff standing by at the sirens that will be able to activate the sirens in accordance with an approved plant procedure."

The licensee will notify the NRC Resident Inspector.

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Hospital Event Number: 42281
Rep Org: MERCY HOSPITAL - SCRANTON, PA
Licensee: MERCY HOSPITAL - SCRANTON, PA
Region: 1
City: SCRANTON State: PA
County:
License #: 37-01374-03
Agreement: N
Docket:
NRC Notified By: SAMUEL PAYNE
HQ OPS Officer: PETE SNYDER
Notification Date: 01/20/2006
Notification Time: 17:46 [ET]
Event Date: 01/20/2006
Event Time: 15:00 [EST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

LOST IODINE SEEDS

After an implantation procedure using Iodine 125 seeds was performed at 1500 at Mercy Hospital of Scranton, PA the staff became aware that there were potentially 2 seeds missing. The total activity of the 2 seeds is estimated to be 1.26 millicuries.

The hospital ordered 88 seeds for this operation. 68 seeds were implanted in the patient. The number of implanted seeds was verified using an x-ray. After the operation the hospital counted 18 remaining seeds for return shipment to the seed provider thus, 2 seeds were unaccounted for. The hospital performed surveys of the operating room and was unable to locate any other seeds. At the time of the report the operating room was quarantined for further investigation.

The hospital contacted the health services company that sterilized the seeds to determine if fewer seeds were provided but Anazao Heath was unable to provide an exact count of the seeds. On Monday 1/23/06 the Radiation Safety Officer plans to contact the seed provider, Amersham Health to determine an exact count of seeds shipped.

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.

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