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Event Notification Report for June 18, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/17/2008 - 06/18/2008

** EVENT NUMBERS **


44219 44290 44298 44299 44301 44302

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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: 06/12/2008
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."

* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *

"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.

"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).

R1DO (Henderson), R3D(Pelke), and FSME (Chang) 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.


* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *

"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

"VHA provided an initial update on June 6, 2008. This update reflects the most current information.

"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

"Patient notification:

"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44290
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [ ] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: BARRY BLEVINS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/12/2008
Notification Time: 05:48 [ET]
Event Date: 06/12/2008
Event Time: 00:40 [EDT]
Last Update Date: 06/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT SUMMERS (R1)

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

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM IDENTIFIED INOPERABLE DURING SURVEILLANCE

"Unit 2 HPCI was declared inoperable during the performance of a scheduled surveillance test. HPCI failed to develop the required discharge pressure to meet its design function." Reactor Core Isolation Cooling (RCIC) is available. The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM DAVE FOSS TO JOHN KNOKE AT 0954 ON 06/17/08 * * *

"The purpose of this notification is to retract a previous report made on 6/12/08 at 0549 hours (EN# 44290). On 6/12/08, the High Pressure Coolant Injection (HPCI) system was declared inoperable as a result of the performance of a routine Surveillance Test (ST). During the ST, the HPCI pump discharge pressure did not achieve the acceptance criteria of greater than or equal to 1258 psig. The highest indicated pressure achieved during the ST was approximately 1230 psig. Therefore, notification of this issue to the NRC on 6/12/08 as a loss of the HPCI safety function was initially made as a result of the belief that the HPCI system was inoperable due to inadequate discharge pressure. HPCI was maintained in an available status as troubleshooting began.

"During subsequent troubleshooting on 6/12/08, it was determined that the Main Control Room HPCI discharge pressure indicator (i.e., the pressure indicator used during the ST) was reading approximately 65 psig low. Therefore, the pressure indicator used during the ST indicated a low value for discharge pressure. Based on this, the actual HPCI discharge pressure during the ST was acceptable. The pressure indicator was recalibrated and the HPCI ST was re-performed successfully. HPCI was declared operable by 1805 hours on 6/12/08.

"Based on the above, there were no unplanned loss of the safety function for the HPCI system. Therefore, the initial ENS notification is being retracted. "

Licensee has notified NRC Resident Inspector. Notified R1DO (Schmidt)

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General Information or Other Event Number: 44298
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: ASTEN JOHNSON, INC
Region: 1
City: CHARLESTON State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES PETERSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/13/2008
Notification Time: 15:13 [ET]
Event Date: 06/13/2008
Event Time: 13:28 [EDT]
Last Update Date: 06/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT SUMMERS (R1)
ANDREW MAUER (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - PORTABLE GAUGE MISSING IN TRANSIT

The following report was received from the State via facsimile:

"The South Carolina Department of Health and Environmental Control was notified at 1:28 p.m. on June 13, 2008 by the licensee that a package containing a radioactive source was lost by Fed-Ex. The sealed source contains 80 mCi of Am-241 and is used in an NDC Systems Model 104 portable gauge. The package was shipped from Macon, GA on June 5th. On June 11th, the licensee received the shipping label, with no package attached, at the licensee's office on Corporate Road in Charleston, SC. The licensee contacted Fed-Ex on the 11th where Fed-Ex then placed a trace on the package which they indicated could take 48 hours. The 48 hour time frame has expired and Fed-Ex has indicated that they cannot find the package but they are continuing their search through various warehouses. Fed-Ex still has the package listed as "in route to its destination". The licensee has also notified the Georgia radiation control program. This event is open pending the results of the licensee's and Department's investigation. Notifications and updates will be made through the NMED system."


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: 44299
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: B J SERVICES
Region: 4
City: DOSSIER CITY State: LA
County:
License #: LA-4130L01A
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/14/2008
Notification Time: 19:19 [ET]
Event Date: 06/14/2008
Event Time: 02:00 [CDT]
Last Update Date: 06/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4)
ANDREW MAUER (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN THERMOMEASURE GAUGE

The State of Louisiana reported the theft of a Thermomeasure Model 5715 1C gauge containing a 100 mCurie CS-137 source (S/N B5633). The gauge was in a truck in a fenced parking area for the licensee (B J Services). The theft was discovered around 0200 CDT on 6/14/08 but the last time the gauge was accounted for was on 6/11/08. The theft has been reported to the police. The State of Louisiana is investigating.

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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3"

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Power Reactor Event Number: 44301
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ANDY DISMUKE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/17/2008
Notification Time: 07:43 [ET]
Event Date: 06/17/2008
Event Time: 05:43 [EDT]
Last Update Date: 06/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (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

TSC HVAC SYSTEM RENDERED NONFUNCTIONAL

"Work Order Number 1050889203 will perform maintenance on 1R24-S026 - 600/208V MCC. The specific work is to remove the LA 600 Breakers in frames 1C & 5C to take measurements for replacement breakers. The removal and measurement of the two breakers will be performed by two work crews simultaneously to minimize out of service time. In order to perform this work activity, the power will be removed from 1R24-S026 which also supplies power to the TSC HVAC rendering it nonfunctional during the performance of this work activity. This work activity is planned to be performed and completed within a 12 hour work shift with 2 hours scheduled for establishing and removing the clearances for a total of 14 hours. During the time this activity is being performed, the TSC air handling unit, TSC condensing unit, TSC filter train, and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered nonfunctional during the performance of this work activity.

"If an emergency declaration is made requiring activation of the TSC during the time this work activity is being performed it will take approximately (3-6) hours to return the equipment back to an operable status dependent on the stage of the work activity at the time the emergency occurs. Plans are to utilize the TSC for any declared emergency during the time these work activities are being performed, as long as radiological conditions allow. Procedure 73EP-EIP-063-0, Technical Support Center Activation, provides instructions to direct TSC management to relocate to the Control Room and TSC support personnel to relocate to the Simulator Building to continue TSC activities if it is necessary to relocate from the primary TSC."

Licensee notified NRC Resident Inspector.

* * * UPDATED AT 1545EDT ON 06/17/08 FROM BARRY COLEMAN TO S. SANDIN * * *

At 1500EDT the MCC was re-energized and the HVAC equipment confirmed operable at 1518EDT on 06/17/08.

The licensee will inform the NRC Resident Inspector. Notified R2DO (Bonser).

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Other Nuclear Material Event Number: 44302
Rep Org: BECKMAN COULTER, INC.
Licensee: BECKMAN COULTER, INC.
Region: 4
City: FULLERTON State: CA
County:
License #: 04-02624-03E
Agreement: Y
Docket:
NRC Notified By: DEBORAH TALBOT
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2008
Notification Time: 12:45 [ET]
Event Date: 06/13/2008
Event Time: [PDT]
Last Update Date: 06/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
THOMAS FARNHOLTZ (R4)
MICHELE BURGESS (FSME)

Event Text

SCINTILLATION COUNTER SEALED SOURCE FOUND LEAKING

A 30 ÁCi (microcurie) Cs-137 sealed source failed a leak test performed on 6/13/08. The leak test results measured 526 cpm with 54 cpm background with no contamination present. The source is used in a Beckman Coulter Scintillation Counter Model LS6500, S/N 7070809 at the Scripps Institute of Oceanography located in La Jolla, CA. The source will be returned to the Corporate Office in Fullerton, CA for disposal.

The licensee also notified the State of California Rad Health Branch of this report.

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Thursday, March 29, 2012