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Event Notification Report for May 23, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/22/2008 - 05/23/2008

** EVENT NUMBERS **


44219 44234 44235

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Hospital Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 05/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."


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: 44234
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MARIA GHARAKHANIAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2008
Notification Time: 14:35 [ET]
Event Date: 05/22/2008
Event Time: 14:20 [EDT]
Last Update Date: 05/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MEL GRAY (R1)

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

Event Text

REACTOR TRIP DUE TO LIGHTNING STRIKE ON MAIN TRANSFORMER

Lightning struck the main transformer for Millstone Unit 2 and caused actuation of the reactor protection system. The reactor had an uncomplicated trip. Reactor shutdown and all control rods fully inserted. No primary or secondary relief valves lifted. Plant is stable in Hot Standby at NOP and NOT. Level is being maintained with normal feedwater and AFW is available if required. Decay heat is being removed via steam bypass valves.

The licensee notified the NRC Resident Inspector.

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Other Nuclear Material Event Number: 44235
Rep Org: U.S. AIRFORCE
Licensee: U.S. AIRFORCE
Region: 1
City: WARNER ROBINS State: GA
County:
License #: 37-30062-01
Agreement: Y
Docket:
NRC Notified By: DAVID COLLINS
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/22/2008
Notification Time: 15:07 [ET]
Event Date: 03/11/2008
Event Time: [EDT]
Last Update Date: 05/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID PROULX (R4)
PATRICE BUBAR (FSME)
ILTAB (via email) ()

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

Event Text

LOST LASER RECEIVER/TRANSMITTERS CONTAINING AM-241

"Two Laser receiver/transmitters were picked from stock for delivery to the Robins AFB Maintenance program. The two items were picked up from location and manifested for local delivery on 21 February 2008. The items were reported missing on customer complaint by the Avionics Repair shop on 11 March 2008. The item was originally marked as missing in the Automated Tracking System on 27 March 2008. Recent extensive searches have not discovered the missing items.

"Based on preliminary investigation, the items were manifested for delivery, but the local delivery truck did not show on the day it was ordered. The material remained in the Radioactive Material Shipping area for a couple of days. A hand-receipt transfer document was located but it did not have the driver's signature of receipt. Additionally, the transition of new personnel delayed the reporting of the loss to the DDC Radiation Safety Office.

"DDC Radiation Safety Office will work closely with the local Radiation Protection Officer to provide training to emphasis the requirements for timely reporting of incidents involving radioactive material."

INCIDENT NO: DDWG-2008-01

Item NSN: 1270-01-365-9471 containing two 8 microCuries Am-241 sources [16 microCuries total].


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Thursday, March 29, 2012