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Event Notification Report for December 12, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/11/2006 - 12/12/2006

** EVENT NUMBERS **


43003 43008 43035 43036 43039 43042

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General Information or Other Event Number: 43003
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: SEAGATE TECHNOLOGY
Region: 3
City: BLOOMINGTON State: MN
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: CRAIG VERKE
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/21/2006
Notification Time: 14:23 [ET]
Event Date: 11/06/2006
Event Time: [CST]
Last Update Date: 12/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE MARIE STONE (R3)
GREG MORELL (NMSS)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT INVOLVING LOST/UNACCOUNTED FOR STATIC ELIMINATORS

The State of Minnesota received the following notification from Seagate Technology via letter dated November 6, 2006:

"Subject: Loss of Anti-static Nuclear Ionizing Devices [General License Material]

"The following anti-static nuclear ionizing devices described below were due for return to the vendor, but could not be found after an extensive search including a written communication requesting assistance from associated work areas across our site.

"The devices are:

"NRD brand Model P-2063-1200, Nuclear Ionizer Fan Element, 31.5 millicuries of Polonium-210 per device

"Serial Numbers A2ER777 thru A2ER785 [nine total], manufactured 9/22/2005."

* * * UPDATE ON 12/11/2006 AT 1013 FROM CRAIG VERKE TO MARK ABRAMOVITZ * * *

The sources were found on 12/7/2006 in a locked storage cabinet. The sources will be returned to the distributor.

Notified the R3DO (Lara), NMSS (Morell), Sandler [ILTAB]

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: 43008
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON HARBORVIEW GAMMA KNIFE
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M0219-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2006
Notification Time: 18:06 [ET]
Event Date: 11/16/2006
Event Time: [PST]
Last Update Date: 12/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE - WASHINGTON - GAMMA KNIFE OVEREXPOSURE

The Washington State Department of Health (DOH) received a preliminary telephone report, November 22, from University of Washington, Harborview Gamma Knife, that a dose of 28 Grays had been administered to a patient. The exposure exceeded the prescribed exposure of 18 Grays by 10 Grays. The cause, thus far, is unknown. DOH is to receive a written report within 15 days.

The dose was administered by a Leksell Gamma System Model 24001 Type C gamma knife with 7,236 Curies of Co-60.

The patient or responsible relative has been notified.

The licensee is required to notify DOH within 24 hours. The notification is apparently several days late.

Washington State report number: #WA-06-066


* * * UPDATE PROVIDED VIA EMAIL FROM SCROGGS TO ROTTON AT 1955 EST ON 12/11/06 * * *

The State provided the following update information via email:

"The cause was stated by the licensee to be human error. The prescribing physician, apparently in a hurry to leave for the day, had prescribed 18 Gy. The physician then entered the Rx value into the computer treatment plan rather than having the medical physicist do it as is the usual procedure. The physician erroneously entered 28 Gy.

"The licensee stated the tumor undergoing treatment turned out to be larger than expected consequently the 28 Gy administered remains therapeutic with likely no ill-effects expected as a result of this incident.

"The treatment plan has been modified so that a similar event is less likely to occur. The progress of the patient is being closely watched by the licensee. DOH is expecting receipt of a written report from the licensee this week."

Notified the R4DO (Smith) and NMSS EO (Janosko).

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 43035
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: JASON KOZAL
Notification Date: 12/06/2006
Notification Time: 16:16 [ET]
Event Date: 11/29/2006
Event Time: [PST]
Last Update Date: 12/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
GARY JANOSKO (NMSS)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST CANCER THERAPY SEEDS

The State provided the following information via email:

"Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006)

"Location of Event: Seattle, Washington (main campus operating room)

"ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention.

"Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries).

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected.

"Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known.

"Disposition/recovery: To be determined.

"Leak test? Original, by Manufacturer, within past six months.

"Release of activity? The seeds were apparently released to the waste water drain. No contamination was found.

"Consequences: None so far, none expected."

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: 43036
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: APPLIED GEOTECHNICAL ENGINEERING CONSULTANTS
Region: 4
City: SANDY State: UT
County:
License #: UT 1800298
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: JOE O'HARA
Notification Date: 12/06/2006
Notification Time: 18:04 [ET]
Event Date: 12/06/2006
Event Time: [MST]
Last Update Date: 12/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
GARY JANOSKO (NMSS)

Event Text

AGREEMENT STATE REPORT - LICENSEE LOST CUSTODY OF TROXLER GAUGE DURING TRANSPORT

The State of Utah reported that a member of the general public recovered a Troxler moisture density gauge on a street located near St. George, Utah. Apparently, the licensee was transporting the gauge through this area when it fell off the vehicle. The licensee was not aware that the gauge was no longer in their custody and continued traveling down the road. A member of the general public, a cable company employee, noticed the gauge and its transportation container lying in the street. The individual recovered the gauge, placed it back in the transport container, and contacted the licensee via the phone number on the package. The licensee arrived and took custody of the gauge from the member of the general public. The licensee reported that the source remained in the safe, shielded position. The licensee reported that the gauge was not damaged and is located in their St George, Utah office. The State is expecting additional details regarding the serial number, isotope, or activity of the gauge.

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Hospital Event Number: 43039
Rep Org: KENNEDY MEMORIAL HOSPITAL
Licensee: KENNEDY MEMORIAL HOSPITAL
Region: 1
City: TURNERSVILLE State: NJ
County:
License #: 29-15459-01
Agreement: N
Docket:
NRC Notified By: LESTER TRIPP
HQ OPS Officer: JASON KOZAL
Notification Date: 12/08/2006
Notification Time: 15:49 [ET]
Event Date: 12/08/2006
Event Time: [EST]
Last Update Date: 12/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MARVIN SYKES (R1)
GARY JANOSKO (NMSS)

Event Text

SHIFT OF I-125 SEEDS AFTER IMPLANTATION

On 10/26/06 the licensee implanted a patient with 104 seeds of I-125 (total activity of 42.2 millicuries, manufactured by Bard, Inc.) to treat prostate cancer. The post implant CT performed on 12/08/06 indicated that the distribution of the seeds was inferior to the intended distribution. A percentage of the seeds had shifted approximately 1.5 cm inferior to what was intended. The licensee is still evaluating at this time what percentage of the seeds intended for the prostate were no longer in the prostate . The licensee immediately informed the patient and the prescribing physician. The patient has to this point shown no ill effects from the migration. However, a quantity of the seeds have migrated to the perineum. Due to the unknown quantity of seeds in the perineum the licensee is still investigating the amount of dose received in this area.

The licensee is investigating the cause of the migration. After the cause is determined they will put corrective actions in place to prevent reoccurrence. The licensee has performed multiple implants that were close to 100% successful since this occurrence. The licensee intends to supplement the patients treatment with an external bean in order to achieve the intended dose.

The licensee notified NRC Region 1 (S. Gabriel, P. Lanzisera)

* * * UPDATE TO HUFFMAN FROM TRIPP AT 10:55 EST ON 12/11/06 * * *

Based on discussion with NRC Region 1 (S. Gabriel), the licensee provided the following revision to the initial event report:

"On October 25, 2006, the licensee implanted 104 I-125 seeds into a patient for the treatment of prostate cancer. The total activity of the implanted seeds was 42.4 mCi. A post-implant CT performed on December 8, 2006, indicated that the seed were misplaced approximately 1.5 cm inferior to the intended position. The licensee is still evaluating the details of the post-implant dosimetry.

"Notifications pursuant to 10 CFR 35.3045 were made on December 8, 2006.

"The licensee is still evaluating the cause of the misplacement of the iodine seeds. After the cause(s) has been determined, corrective actions will be put in place.

"The patient will require will require further treatment of the prostate gland. External beam therapy will be used to supplement the dose to prostate."

R1DO (Conte) and NMSS EO (Morell) notified.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 43042
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE HACKLEMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/11/2006
Notification Time: 00:31 [ET]
Event Date: 12/10/2006
Event Time: 16:08 [PST]
Last Update Date: 12/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
LINDA SMITH (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 5 Startup 0 Hot Standby

Event Text

RAPID SHUTDOWN AND MANUAL REACTOR TRIP DUE TO HIGH REACTOR COOLANT PUMP STATOR TEMPERATURE

"On December 10, 2006, at 1608 PST, operators manually tripped the reactor while it was subcritical. This is an 8 hour notification per 10 CFR 50.72(b)(3)(iv)(A) for actuation of the reactor protection system while subcritical. On December 10, 2006, with Unit 2 operating in Mode 1 at 100% power, operators initiated an unplanned reactor shutdown due to indications of increasing stator temperature on reactor coolant pump 2-2. In accordance with plant procedures, when the reactor coolant pump stator temperature reached 300 degrees Fahrenheit, operators manually tripped the reactor and tripped the coolant pump 2-2. The reactor was subcritical at the time of the reactor trip but all rods had not been fully inserted.

"All control rods fully inserted in response to the reactor trip and all systems functioned as required. The auxiliary feedwater system was already in service as part of the shutdown. The grid is stable and with the exception of RCP 2-2, all major equipment including the 3 emergency diesel generators remain operable. Unit 2 electrical loads are being supplied by the normal startup power. The other 3 RCPs are maintaining forced circulation of the reactor coolant system. Investigations into the high RCP stator temperature are ongoing, the unit will remain in Mode 3 pending the results of these investigations. An estimated restart date is not known at this time. The NRC Resident Inspector has been informed and was onsite at the time of the trip. Unit 1 is unaffected and remains in Mode 1."

The licensee stated that a press release related to this event is likely.

* * * UPDATE TO HUFFMAN DURING PLANT STATUS ON 12/11/06 AT 0419 EST * * *

Licensee believes the cause of the high RCP stator temperature was due to a failed RTD.

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