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Event Notification Report for September 4, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/03/2008 - 09/04/2008

** EVENT NUMBERS **


44449 44451 44452 44454 44459 44463

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Hospital Event Number: 44449
Rep Org: UNIVERSITY OF VA MEDICAL CENTER
Licensee: UNIVERSITY OF VA MEDICAL CENTER
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: CATHERINE PERHAM
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/29/2008
Notification Time: 10:47 [ET]
Event Date: 08/28/2008
Event Time: 16:00 [EDT]
Last Update Date: 08/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1)
CHRIS EINBERG (FSME)

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

Event Text

MEDICAL EVENT - PRESCRIBED DOSE DIFFERED GREATER THAN 20%

"Male patient was treated Thursday August 28, 2008 with 'TheraSpheres [TS]' (a Y-90 pure beta-emitting Nordion microsphere product for liver cancer treatment). The procedure began at about 1600 hours. The written directive specified a radiation dose to the right liver lobe of 92 Gy. This required the implantation into the right liver lobe of 1.83 GBq of Y-90 at 4 PM.

"Y-90 operations are guided by a written procedural check-list which is read out aloud in the Operating Room in a step-by-step fashion during every operation. Unfortunately, the [authorized user, (AU)] failed to carry out a step which had been read out aloud to him which required that a blue stopcock in the delivery device be turned toward the delivery device's 'waste vial'. Note: When the blue stopcock is turned toward the 'waste vial' the flow is from the 'source vial' to patient. Otherwise, flow is to the 'waste vial.'

"When [the AU] began the 'source vial' flushing sequence, he saw that flow in the delivery device's transparent tubing was going from the 'source vial' to the 'waste vial' (instead of to the patient). He then turned the blue stopcock to the correct position and continued the flushing sequences. Unfortunately, about 2/3 of the initial activity in the 'source vial' had been diverted to the waste vial during the start of the first flushing sequence. The flushing sequences were repeated several times until no further reduction was observed in the delivery device dose-rate indicators (normally, flushing ceases when the two dose-rate meters indicate 0.0 Mr/h). As per procedure, the 'waste vial,' together with contaminated tubing, stopcocks, catheters and gloves were placed in a plexiglass-shielded waste 'mayo' jar and its dose-rate measured at a distance of 30 cm between jar and meter. Note: The Y-90 activity in the waste jar is determined by a ratio calculation involving the dose-rate measured with the source vial within the plexiglass shield located at 30 cm from the survey meter. (Most beta particles are absorbed in the mayo jar and plexiglass shield. Survey meter measures X-rays produced by the ~1 MeV particles, and not the beta particles).

"From the waste container measurements it appears that 0.68 GBq were implanted into the patient's [right (RT)] liver, with 0.12 GBq going to the patient's lungs. The calculated dose to the RT liver is 34.3 Gy and to the lungs it is 13.2 Gy. The dose delivered to the target is low by about 63%. This, then, is a medical event requiring notifications.

"Note: There was no leakage from the delivery device, its tubes, catheters, stopcocks, therefore, there was no contamination to be cleaned up. All other procedural steps were completed as required by our procedures. The OR and the personnel exiting it were checked for contamination and none was found.

"This scenario, of an accidental diversion of activity to the delivery device's waste vial, has occurred at other institutions. This was RSO's motivation, many months ago, to change the print color of this procedural step from black to red, and to alert the AU to this possibility. This event was due to a simple mistake that may be resolved when a newer version of a TS delivery device is introduced by Nordion in the near future."


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: 44451
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BIRMINGHAM ENGINEERING AND CONSTRUCTION CONSULTANTS
Region: 1
City: BIRMINGHAM State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES McNEES
HQ OPS Officer: PETE SNYDER
Notification Date: 08/29/2008
Notification Time: 12:43 [ET]
Event Date: 08/28/2008
Event Time: 16:10 [CDT]
Last Update Date: 09/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
CHRIS EINBERG (FSME)
ILTAB (E-MAIL) ()

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

"On the afternoon of August 28, 2008 at approximately 4:10 pm, the [Alabama Department of Public Health (ADPH)] received a call [from the] RSO for Birmingham Engineering and Construction Company (BECC). [The RSO] advised [ADPH] that one of his technicians had lost a Troxler model 3440 (serial number 17775) containing Cs-137 and Am-241/Be radioactive sources somewhere in the Birmingham area.

"As described by [the RSO], the technician placed the gauge on the back of his pickup without properly securing it in the transport container. After completing his paperwork, he then proceeded to drive back to the office forgetting that the device had not been properly secured. Upon return to the office, the technician realized the mistake. Information made available to the writer indicates that the gauge was discovered missing at approximately 2:00 pm. At that time, [the RSO] was notified and personnel from BECC immediately conducted a search of the job site and route taken by the technician. The route started from the job site at the Grants Mill Road exit on I-459 traveling southbound to I-65 northbound to Lakeshore Drive where the licensee's office is located. The tailgate to the truck was not closed, the device was not in the transport container but the gauge shutter was closed and locked. [The RSO] further indicated that he had called the State Troopers and they indicated that no gauge had been reported found. [The RSO] indicated that he had not yet called city police.

"The writer then contacted [ADPH] and advised them of the incident. Through conversations, it was determined that BECC needed to contact the police and put out a press release, Also, it was determined that the local EMA Director needed to be advised of the incident. [ADPH] committed to calling the RSO back and relaying this information, [an ADPH representative] also indicated that he would notify the Jefferson County Director.

"The writer had no additional conversation with licensee personnel."

* * * UPDATE FROM STATE OF ALABAMA (VIA E-MAIL) TO KLCO ON 9/02/08 AT 1027 EDT * * *

"On Friday 29 August 2008 Alabama reported that a Troxler Model 3440 device had been lost from a pickup truck the afternoon before in Birmingham, Alabama.

"On Sunday afternoon 31 August 2008 an individual reported to the Irondale, Alabama (part of greater Birmingham) Police Dept that they had found the device and wished to claim the reward. The device is now in the possession of the licensee, BECC, Inc. It was apparently undamaged save for a few scratches. The licensee did a leak test on the device and is awaiting results from lab.

"The State of Alabama is awaiting the licensee's 30 day report and corrective actions. A decision on enforcement actions will be made after review of the licensee's response."

Notified R1DO (Dwyer), FSME EO (Burgess) and ILTAB (via e-mail)

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: 44452
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: PORT LAVACA State: TX
County:
License #: L00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 08/29/2008
Notification Time: 15:18 [ET]
Event Date: 08/29/2008
Event Time: [CDT]
Last Update Date: 08/29/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
CHRIS EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - LEVEL GAUGE SHUTTER MALFUNCTION

"On 8/29/08, Incident Investigation Program received a letter from the licensee stating that on June 23, 2008 while conducting their routine surveillance, a Ohmart/VEGA level gauge used on their vent stack for level detection failed the inspection when the shutter mechanism failed to close fully. An inspection of the gauge found that a bolt on the operating handle had sheared and the shutter would not close. The gauge contains one 200 millicurie Cesium (Cs) - 137 source serial # M-7089. The licensee has contacted the manufacturer and is working with them to schedule the repair of the gauge. Surveys conducted by the licensee has determined that dose rates in the area of the gauge are normal and do not pose a risk of exposures to their workers. The source has been labeled 'Do Not Operate - Contact Site RSO'."

This event is also identified as Texas event number I-8546.

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Power Reactor Event Number: 44454
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: JERRY GRUBB
HQ OPS Officer: VINCE KLCO
Notification Date: 09/01/2008
Notification Time: 00:16 [ET]
Event Date: 08/31/2008
Event Time: 23:00 [CDT]
Last Update Date: 09/04/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
VIVIAN CAMPBELL (R4)
BRIAN McDERMOTT (IRD)
MIKE CHEOK (NRR)
ERIC LEEDS (NRR)
ELMO COLLINS (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO HURRICANE WARNING ONSITE

Site declared a notification of unusual event under HU6/ EAL 7. The site is predicted to experience hurricane force winds from Gustav. As a conservative measure, the plant shutdown was completed at 2232 CDT.

The licensee has notified the NRC Resident Inspector, state and local emergency management agencies.

Notified DHS (Hill) and FEMA (Blankenship).

* * * UPDATE AT 0126 ON 9/4/2008 FROM JERRY GRUBB TO MARK ABRAMOVITZ * * *

The site has exited the Notification of Unusual Event (NUE) at 0021 CDT because 1) grid stability has been restored, 2) HU6/EAL 7 is no longer applicable (Hurricane Gustav is no longer affecting the site), and 3) the NUE for leakage greater than 25 gpm (SU7/EAL 2) is no longer applicable (entered at 0726 on 9/1/2008 and terminated at 0729 on 9/1/2008). The reactor is in mode-4 (Hot Shutdown).

Notified the R4DO (Jones), NRR (Blount), IRD (Gott), DHS (Dub), and FEMA (Casto).

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Other Nuclear Material Event Number: 44459
Rep Org: HUNTINGTON TESTING SERVICES
Licensee: HUNTINGTON TESTING SERVICES
Region: 1
City: HUNTINGTON State: WV
County:
License #: 47-23076-01
Agreement: N
Docket:
NRC Notified By: DONALD ADKINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/03/2008
Notification Time: 11:26 [ET]
Event Date: 08/20/2008
Event Time: 21:00 [EDT]
Last Update Date: 09/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES DWYER (R1)
MICHELE BURGESS (FSME)
RICHARD SKOKOWSKI (R3)

Event Text

SAFETY EQUIPMENT FAILURE

On August 20, 2008, radiographers from Huntington Testing Services were performing radiography on a tank at the Clifty Creek Power Plant, located in Madison, Indiana, when a magnetic base fell and crimped the camera guide tube. At the time the damage to the guide tube occurred, the source was in the collimator. The crimped tube would not allow the radiographer to retract the source back into the shielded position. The radiographer immediately established a boundary and covered the source with lead shot bags, then contacted the Radiation Safety Officer (RSO).

When the RSO arrived at the location, he was able to repair the guide tube enough to enable the source to be retracted into the shielded position. The camera was then transported back to the Louisville, Ky office of Huntington Testing Services. The guide tube has been replaced and the camera is available for service.

The licensee is investigating the incident to determine corrective actions. There were no overexposures as a result of this incident.

The camera was temporarily transferred from Huntington Testing Services' Kentucky license to their NRC license (issued in West Virginia) since Kentucky and Indiana do not have reciprocity.

The camera is a QSA Global 880 Sigma, serial number S1453 with a 85.3 Curie Ir-192 current source strength. Source strength at manufacture date was 103.9 Curies. The source serial number is 48578B.

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Power Reactor Event Number: 44463
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RICKY GIVINS
HQ OPS Officer: PETE SNYDER
Notification Date: 09/04/2008
Notification Time: 05:04 [ET]
Event Date: 09/03/2008
Event Time: 23:43 [CDT]
Last Update Date: 09/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
REBECCA NEASE (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

Event Text

FAILURE OF DAMPERS TO AUTO CLOSE

"Due to RPS A Circuit Protector surveillance testing, a transfer of 'A' Reactor Protection System from alternate power supply back to the 1A RPS MG-set was required. An expected group 6 containment isolation signal was received during the power transfer. Upon review of plant status to ensure systems responded as expected, it was determined that reactor ventilation zone exhaust dampers 1-DMP-64-42 and 1-DMP-64-43 (Inboard and Outboard Reactor Zone Exhaust Dampers) failed to auto-close. Isolation of these dampers is a required safety function.

"The dampers were administratively closed and deactivated in accordance with plant technical specification 3.6.4.2 action B. At the time of this report the cause for failure to auto close has not been determined."

The licensee notified the NRC Resident Inspector.

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