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Event Notification Report for August 14, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/13/2008 - 08/14/2008

** EVENT NUMBERS **


44219 44395 44397 44398 44405 44409 44411

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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: 08/13/2008
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).

* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *

"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.

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

"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.

"We note that the medical center routinely 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 is suspended and an external review is in progress.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.

"Patient notification:

"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."

Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).

* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *

"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).


* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *

A 15-day written report of one of the medical events was submitted to NRC Region III.


Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)

* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).

* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *
Bur
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "

Notified R1DO (Dentel), R3DO (Lara), and FSME (White).

* * * UPDATE ON 7/22/2008 AT 1500 EDT FROM WILLIAMS TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional five patients on July 22, 2008. This brings the total number of medical events to 37 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III."

The licensee will notify NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events.

Notified R1DO (Dentel), R3DO (Riemer), and FSME (Burgess).

* * * UPDATE FROM GARY WILLIAMS TO JOE O'HARA 1145 EDT ON 7/25/08 * * *

"As the result of an ongoing review, medical events were discovered for an additional two patients on July 25, 2008. This brings the total number of medical events to 39 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (W.Cook), R3DO (M.Phillips), and FSME (C.Flannery)

* * * UPDATE AT 0805 ON 08/06/08 FROM THOMAS HUSTON TO JEFF ROTTON * * *

"As the result of an ongoing review, medical events were discovered for an additional four patients on August 05, 2008. This brings the total number of medical events to 43 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (Gray), R3DO (D Hills), and FSME (C. Einberg)

* * * UPDATE AT 1002 EDT ON 8/13/08 FROM HUSTON TO SANDIN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional four patients on August 12, 2008. This brings the total number of medical events to 47 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these four additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Holody), R3DO (Kozak) and FSME (Burgess).

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General Information or Other Event Number: 44395
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GME CONSULTING SERVICES
Region: 4
City: DALLAS State: TX
County:
License #: L-05128
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/08/2008
Notification Time: 09:46 [ET]
Event Date: 08/08/2008
Event Time: 04:00 [CDT]
Last Update Date: 08/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
DUNCAN WHITE (FSME)
ILTAB VIA E-MAIL ()
MEXICO VIA FAX ()

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

Event Text

AGREEEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

"At 0828, the Agency [state] received a call from the Radiation Safety Officer (RSO) for GME Engineering Consulting Incorporated, stating that Troxler model # 3411 moisture/density (M/D) gauge containing a Cesium (Cs) - 137 source and an Americium (Am) - 241 source had been stolen out of one of their trucks parked at their facility. The technician had returned from a job at about 4:00 AM and went into the office to make copies of some of his documents. When he returned to the truck, he found the lock used to secure the M/D gauge in the truck bed had been cut, and the M/D gauge and transport case were both missing. The cable used in association with the lock to secure the gauge was also damaged. The technician reported the event to his RSO, who notified the Agency. Local Law Enforcement has been informed of the event. The RSO stated that he would supply additional information on the event to the Agency via e-mail.

"The Agency received the following update information. The gauge serial # is 9389 containing one 8.3 millicurie Cs-137 source serial # 40-6732, and one 40.0 millicurie Am-241 source serial # 47-5906. The police arrived at the office at about 9:30 AM and obtained fingerprints from the technician's truck and opened a case file. The Dallas police case number is 245096V."

Texas Incident Report # I-8532


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: 44397
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110-18-0013
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/08/2008
Notification Time: 11:29 [ET]
Event Date: 08/07/2008
Event Time: 14:00 [EDT]
Last Update Date: 08/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - UNDEREXPOSURE DURING HDR MEDICAL TREATMENT DUE TO EQUIPMENT MALFUNCTION

The State received notification of a possible medical event due to an equipment malfunction. The licensee was treating a patient for rectal cancer using an HDR Nucleotron Micro Select Model 105.999 Serial 31776. The prescribed treatment consisted of the administration of 29 catheter doses of Iridium-192. During the 12th catheter dose, an equipment malfunction caused a failure of the administered treatment. The failure mode was Code 200 - "No radiation detected." The failure mode caused the unit to stop treatment by not proceeding to the next catheter. Nucleotron immediately contacted. A service technician is expected to arrive on 8/8/08 for repair of the device. Once the HDR unit is repaired, the treatment plan and written directive will be modified and treatment of the patient resumed. Patient and physician have been advised of the treatment interruption and no adverse impact is expected.

The State of Ohio plans to send an inspector to the facility on 8/11/08.

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: 44398
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee:
Region: 3
City: EAU CLAIRE State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/08/2008
Notification Time: 13:38 [ET]
Event Date: 08/05/2008
Event Time: [CDT]
Last Update Date: 08/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
DUNCAN WHITE (FSME)
ILTAB EMAIL ONLY ()

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

Event Text

LOST RADIOACTIVE MATERIAL FOUND IN SCRAP YARD

"Material received at scrap yard on August 5, 2008. Wisconsin DHS verified via phone that material was locked in a secure location from members of the public. On August 7, 2008 DHS investigated the radioactive material, a compacted 55 gallon drum with multiple pieces of scrap inside drum. A mini-spec GR-135DN was used to determine the source of radiation as Ra-226. Radiation exposure and contamination surveys were conducted on the outside of the compacted drum. The maximum exposure observed was 500 uRem/hr. The contamination survey on the drum found no contamination. DHS staff tried to locate the source of radiation inside the drum where the highest radiation levels were located. During the attempt, several pieces of scrap were removed and surveyed and no radiation above background except for one piece that read above background. Material was properly tagged and bagged. The staffs gloved hands were frisked and contamination was present. Individual doffed gloves and re-performed hand frisk and no contamination was found. The staff halted any further handling activities at this time to prevent any possible spread of contamination. The material was properly tagged, bagged and stored at the scrap yard in a locked holding area that is not accessible by members of the public. DHS is exploring options to properly dispose of this radioactive material."

State Event Report: WI080008

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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General Information or Other Event Number: 44405
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: KENNECOTT UTAH COPPER CORPORATION
Region: 4
City: MAGNA State: UT
County:
License #: UT1800289
Agreement: Y
Docket:
NRC Notified By: GWYN E GALLOWAY
HQ OPS Officer: JASON KOZAL
Notification Date: 08/11/2008
Notification Time: 19:19 [ET]
Event Date: 08/06/2008
Event Time: 18:40 [MDT]
Last Update Date: 08/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - BROKEN SHUTTER ON FIXED GAUGE

The state provided the following via facsimile:

"During a shift change for the Euclid drivers, the crusher operator went to the bottom of the crusher and attempted to close the shutter of an Ohmart fixed gauge, [Model SH-F2, serial number 1849CG], containing 1000 mCi of Cs-137, but although the handle turned, the shutter did not close. The operator indicated that there had been no resistance when the shutter handle was turned. One of two screws in the shutter handle was broken and therefore the shutter would not turn when the handle was turned. The last time the shutter was closed was on July 3, 2008. It is unknown at this time when or how the screw was broken. This device will be repaired by an individual specifically licensed by the Utah Division of Radiation Control to perform such service."

Utah report number: UT080002

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Power Reactor Event Number: 44409
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: GARY AHRENS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/13/2008
Notification Time: 16:36 [ET]
Event Date: 08/13/2008
Event Time: 09:31 [CDT]
Last Update Date: 08/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
LAURA KOZAK (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

FITNESS FOR DUTY

A licensed employee had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44411
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILL SAYERS
HQ OPS Officer: PETE SNYDER
Notification Date: 08/13/2008
Notification Time: 17:17 [ET]
Event Date: 08/13/2008
Event Time: 15:49 [EDT]
Last Update Date: 08/13/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RANDY MUSSER (R2)
MIKE WYATT (DOE)
DAVID TIMMONS (USDA)
HARRY DAVIS (HHS)
SNOWDEN (EPA()
MIKE BLANKENSHIP (FEMA)

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

HYDRAULIC OIL SPILLED INTO LAKE WYLIE DISCHARGE CANAL

"Notification to SCDHEC [South Carolina Department of Health and Environmental Controls] and the National Response Center [# 880488] due to a release of approximately 0.5 gallons of hydraulic fluid to Lake Wylie Discharge Canal from a hydraulic line failure on a piece of equipment.

"The hydraulic fluid reached Lake Wylie via yard drain. The fluid reaching Lake Wylie was contained by oil booms in place in the discharge canal."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012