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Event Notification Report for December 3, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/02/2008 - 12/03/2008

** EVENT NUMBERS **


44524 44687 44691 44692 44693

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44524
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER WASHINGTON DC
Region: 1
City: WASHINGTON State: DC
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/26/2008
Notification Time: 18:15 [ET]
Event Date: 09/26/2008
Event Time: [EDT]
Last Update Date: 12/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)

Event Text

MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE

"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.

"As the result of these ongoing reviews, possible medical events were discovered on September 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC.

"These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)

"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients will be reviewed by medical experts.

"A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"The US Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: VA Medical Center, 50 Irving Street NW, Washington DC 20422.

"The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."

* * * UPDATE AT 1030 EST ON 12/02/08 FROM THOMAS HUSTON TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"We are making this notification to retract medical events reported earlier under Event No. 44524. During a reactive inspection, the VA Medical Center in Washington, DC, provided the VHA National Health Physics Program with revised dose information indicating D90 doses were greater than 80% of the prescribed dose for all three patient treatments.

"We will notify our NRC Project Manager (Cassandra Frazier, Region III) of this retraction."

Notified R3DO (Kunowski) and FSME (Burgess).

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: 44687
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: ENGINEERING CONSTRUCTION SERVICES
Region: 1
City: HANOVER State: MD
County:
License #: 03-09201
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/28/2008
Notification Time: 14:56 [ET]
Event Date: 11/28/2008
Event Time: 10:15 [EST]
Last Update Date: 11/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - MARYLAND - DAMAGED TROXLER NUCLEAR DENSITY GAUGE

A representative for the state of Maryland Radiological Health Program reported that a Troxler nuclear density gauge was damaged when run over by construction equipment. The gauge, a Troxler 3430 (8 mCi Cs-137 and 40 mCi Am-241/Be; S/N 39041) was left unattended and was inadvertently run over by a large roller. The licensee secured the scene of the incident and contacted the state of Maryland. The state inspector found that the gauge had been extensively damaged with the source rod exposed. The state called in a Radiological Service Organization (RSO) contractor to assist in the source rod recovery. The source was successfully retrieved and placed into a shielded container and taken to the RSO's facility for ultimate disposal. There was no indication of breach of the sources or contamination as a result of this event. The state plans to follow-up with the licensee regarding failure to maintaining control over the Troxler while in use.

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Power Reactor Event Number: 44691
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: ROBERT J. TOMONTO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2008
Notification Time: 16:04 [ET]
Event Date: 12/02/2008
Event Time: 15:15 [EST]
Last Update Date: 12/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT HAAG (R2)

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

Event Text

FITNESS FOR DUTY

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

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44692
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: TIM GAFFNEY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2008
Notification Time: 19:36 [ET]
Event Date: 12/02/2008
Event Time: 16:20 [MST]
Last Update Date: 12/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID PROULX (R4)

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 N 0 Cold Shutdown 0 Cold Shutdown
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF ONE (1) EMERGENCY SIREN

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On December 2, 2008, at approximately 1620 Mountain Standard Time (MST), the Palo Verde Emergency Planning Department discovered that public warning system siren No. 17 was not responding, and therefore, is out of service. The loss of siren No. 17 could potentially impact a population of approximately 1106 people in the 5-mile emergency planning zone (EPZ).

"Since the loss of siren No. 17 could impair Arizona Public Service Company's ability to inform greater than 5% of the population within the EPZ, this notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii). If an event occurs while siren No. 17 is out of service, the Palo Verde Emergency Plan has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area. The MCSO is prepared to implement this contingency should it become necessary.

"Troubleshooting to determine the cause of the failure will start tomorrow morning (December 3, 2008).

"The NRC Resident Inspector has been notified of siren No. 17 being out of service and this ENS call."

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Power Reactor Event Number: 44693
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: BRIAN JOHNSON
HQ OPS Officer: PETE SNYDER
Notification Date: 12/02/2008
Notification Time: 20:03 [ET]
Event Date: 12/02/2008
Event Time: 16:45 [CST]
Last Update Date: 12/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MICHAEL KUNOWSKI (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

INADVERTENT ACUATION OF EMERGENCY SIRENS

"At approximately 1645 CST, on December 2, 2008, personnel from the City of Red Wing inadvertently activated the sirens from the backup unit for the City of Red Wing. Twenty-six (26) of the 117 sirens in the 10 mile Emergency Planning Zone (EPZ) were activated for approximately two minutes. No press release is planned."

The licensee notified the NRC Resident Inspector.

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