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Event Notification Report for February 10, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/09/2009 - 02/10/2009

** EVENT NUMBERS **


44826 44829 44841 44842

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General Information or Other Event Number: 44826
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SWEDISH HOSPITAL
Region: 4
City: ENGLEWOOD State: CO
County:
License #: 251-02
Agreement: Y
Docket:
NRC Notified By: MARK DATER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/03/2009
Notification Time: 10:45 [ET]
Event Date: 01/28/2009
Event Time: 15:45 [MST]
Last Update Date: 02/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
ANGELA McINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT LEAVES RADIATION THERAPY TREATMENT WITHOUT RECEIVING REQUIRED INSTRUCTIONS

Received from the state by facsimile:

The patient left the hospital without receiving the required radiation therapy instruction. "The patient and her husband were adamant about leaving without waiting any longer. This was an unreasonable patient's husband driving this situation and we [Swedish Hospital] see no need to change our release criteria or procedures because of aberrant behavior of a family member. The patient had this procedure twice before [September 2005 and April 2006]. The implant in 2005 delivered 0.99 GBq. At the time the exposure reading at one meter was 0.25 mR/hr. This most recent procedure delivered less activity, and I would anticipate an even smaller exposure risk at one meter."

Source: Y-90 SIR Spheres at approximately 0.9 GBq

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General Information or Other Event Number: 44829
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TOLEDO EDISON COMPANY
Region: 3
City: OREGON State: OH
County:
License #: 31201490021
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/05/2009
Notification Time: 09:26 [ET]
Event Date: 02/01/2009
Event Time: [EST]
Last Update Date: 02/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK RING (R3)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED GAUGE DEVICE

The following report was received from the State via E-mail:

"Licensee reported a stuck shutter on a fixed gauge, which was discovered during the leak test and shutter check maintenance activity. Licensee stated that shutter had been difficult to move on past checks, but had neglected to have unit serviced. Licensee has contacted service provider to repair shutter mechanism. Device normally operates in continuous mode, so no additional actions are required at this time.

"Ohio will leave this report open pending receipt of final written report from licensee, due in 30 days.

"Note: Licensee stated that they were making this report as a result of awareness of requirements found in Ohio Information Notice 2008-02 regarding fixed gauge stuck shutters and reporting requirements."

This was an Ohmart Corporation model number SH-1 fixed gauge device. There is 0.005 Ci Cs-137 in this device.

The Ohio State reference number for this report is OH 2009-003.

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Power Reactor Event Number: 44841
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW NORRIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/09/2009
Notification Time: 04:31 [ET]
Event Date: 02/09/2009
Event Time: 04:15 [EST]
Last Update Date: 02/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN RUDISAIL (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 OOS DUE TO PLANNED HVAC MAINTENANCE

"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance being performed on the TSC HVAC. Alternate facilities are available to provide emergency functions and actions are proceeding to return the TSC to FUNCTIONAL status with high priority. A 10CFR50.54(q) evaluation has been performed for this planned maintenance activity and has determined that this work may be performed without prior NRC approval.

"The NRC Resident Inspector has been notified."

The licensee stated that the planned maintenance on the TSC HVAC and return to service of the TSC should be completed within 12 hours.

* * * UPDATE PROVIDED AT 1446 EST ON 02/09/09 FROM HANS BISHOP TO JEFF ROTTON * * *

TSC HVAC maintenance is complete and the TSC was restored to service at 1441 EST. The licensee will notify the NRC Resident Inspector.

Notified R2DO (Rudisail).

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Hospital Event Number: 44842
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 1
City: WEST PALM BEACH State: FL
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: TOM HUSTON
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/09/2009
Notification Time: 17:50 [ET]
Event Date: 02/09/2009
Event Time: 16:00 [EST]
Last Update Date: 02/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
SONIA BURGESS (R3)
JOHN ROGGE (R1)
MARK SHAFFER (FSME)

Event Text

REMOVABLE SURFACE CONTAMINATION ABOVE LIMITS

"Two packages containing radioactive material were received with removable surface contamination on the outside of the packages greater than the limit cited in 10 CFR 71.87(i).

"The two packages were received at approximately 4:00 p.m. EDT, February 9, 2009, by the VA Medical Center in West Palm Beach, FL. The two packages contained Germanium-68 PET/CT calibration sources.

"Wipe tests performed on the two packages indicated the following removable contamination levels: 802 dpm/cm2 on one package and 400 dpm/cm2 on the other, as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. Spectral measurements (gamma energy) of the wipes were consistent with the radionuclide contained in the package.

"The final delivery carrier was notified of the contaminated packages at approximately 5:00 p.m. EDT on February 9, 2009, by the VA Medical Center's Radiation Safety Officer. The shipper [Eckert Ziegler Isotope Products] was also notified (by recorded voice message) of the contaminated packages.

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

"Additional information: Permits are issued under the license to Veterans Health Administration facilities. The permit number for the facility involved in these medical events is VHA Permit No. 09-25328-01."

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Thursday, March 29, 2012