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Event Notification Report for July 6, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/02/2009 - 07/06/2009

** EVENT NUMBERS **


45165 45171 45174 45176 45177 45181 45183

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General Information or Other Event Number: 45165
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ST. JOSEPH
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-1288-01
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/26/2009
Notification Time: 12:11 [ET]
Event Date: 06/25/2009
Event Time: [CDT]
Last Update Date: 06/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING MEDICAL EVENT

The following information was provided by the State of Wisconsin via email:

"On June 26, 2009, the Radiation Safety Officer (RSO) notified DHS of a probable medical event that occurred on June 25, 2009 involving an HDR treatment to the esophagus. The authorized user intended to insert the applicator 2 cm past the distal part of the esophageal tumor. A GI specialist verified the location prior to treatment using a scope. Post treatment location of the applicator was reviewed using an AP lateral film. It was then realized that the applicator went 10 cm too far. The prescribed dose was 500 cGy. Therefore, a dose was given to a organ or tissue other than the intended treatment site that exceeds 0.5 Sv (50 rem) to an organ or tissue, and was 50% or more of the dose expected from the administration defined in the written directive (DHS 157.72(1)(a)(3.). DHS inspectors will investigate June 29, 2009."

Wisconsin Incident Number: WI090005

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: 45171
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ACUREN INSPECTION, INC.
Region: 3
City: DAYTON State: OH
County:
License #: 03320990006
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/29/2009
Notification Time: 11:02 [ET]
Event Date: 06/26/2009
Event Time: 11:30 [EDT]
Last Update Date: 06/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
ANGELA MCINTOSH (FSME)
MONTE PHILLIPS (R3DO)

Event Text

AGREEMENT STATE REPORT - DIFFICULTY RETRIEVING RADIOGRAPHY SOURCE

The following report was received via facsimile:

"Licensee contacted Ohio Department of Health at approx. 3:45 PM on 6/26/09 to report an incident which occurred earlier that day involving the inability to retrieve a radiography source at a job site near Dayton, Ohio. The incident involved a QSA Global Model 880D camera with a 85 Ci Ir-192 source.

"At approximately 11:30 AM and after several unsuccessful attempts to retrieve the source, the radiography crew secured the area around the source and contacted a trained source recovery individual at their Cincinnati office for assistance. This person arrived at the job site at approx. 12:20 PM and assessed the situation.

"The recovery person determined that a flange had fallen on the guide tube during the previous shot, which crushed the guide tube and prevented source retrieval. The shot involved a 90-degree bend on a six-inch pipe and the flange was a scrap piece of material found on site that the crew had used to hold the guide tube in place during the shot. It was further determined that the set-up used by the crew for the shot was not very stable, which contributed to the falling of the flange onto the tube. The recovery person was able to retract the source into the camera at approximately 12:45 PM.

"The licensee determined that there was no exposure to the public or radiography crew as a result of this incident. The radiography crew was reminded to ensure the stability of future shot setups before exposing the source. The guide tube was replaced and work continued."

Ohio report number: OH090006

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Hospital Event Number: 45174
Rep Org: KARMANOS CANCER INSTITUTE
Licensee: KARMANOS CANCER INSTITUTE
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/30/2009
Notification Time: 10:33 [ET]
Event Date: 02/18/2008
Event Time: 12:00 [EDT]
Last Update Date: 06/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DUNCAN WHITE (FSME)
MONTE PHILLIPS (R3DO)

Event Text

MEDICAL EVENT INVOLVING A DOSE THAT IS DIFFERENT THAN PRESCRIBED

"On February 18, 2008, an administrative error medical event occurred at our Leksell Gamma Knife facility which resulted in the total dose delivered differing from the written directive by more than 20%, but which agreed with the therapy that was intended and planned by the radiation oncologist authorized user (AU) and the neurosurgeon. This was discovered during the 2008 annual quality management review that was completed on June 24, 2009.

"On February 18, 2008, a stereotactic radiosurgery treatment plan was developed by the neurosurgeon, AU and authorized medical physicist (AMP) that satisfied the therapy intentions of the AU and neurosurgeon. Two of the three metastatic lesions that were discussed in advance at the neurosurgery tumor board meeting on February 13, 2008 by the neurosurgeon and AU were treated, the third being geometrically out of range of the gamma knife system. Specifically, the lesion locations selected at the tumor board meeting were right cerebellum, right occipital lobe and left temporal/parietal. The left temporal/parietal was out of range. The correct intended dose of 20 Gy to 50% isodose was planned and delivered on February 18. The AU and AMP specified both lesions on the Gamma Knife planning QA form which was signed by the AU, Neurosurgeon and AMP. The AU signed the plan and initialed every page including screenshots of the isodoses superimposed on the MRI images for both lesions. The plan included all of the information required in 10 CFR 35.40 (b)(3). Finally, the time out form was completed by the AU, neurosurgeon and AMP.

"The administrative error medical event is the result of the AU not writing a directive for treatment of the right occipital lesion.

"[The event occurred due to] lack of attention to administrative tasks.

"[The individual who received the administration had] no detrimental effect. Treatment was delivered as planned according to doctor's orders.

"The gamma knife quality management review will be done on the day of treatment prior to delivery by a second physicist using the form/checklist attached. This process is already in effect."

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: 45176
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2009
Notification Time: 17:27 [ET]
Event Date: 06/30/2009
Event Time: 11:30 [EDT]
Last Update Date: 06/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL WORKER OVEREXPOSURE

The following information was received via facsimile:

"A worker was working in a hot cell when a F-18 [radio-isotope] was mistakenly delivered to the hot cell. [The] initial estimated worker dose [was] 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. [The] worker has been taken off Rad work and is being monitored"

A Commonwealth of Massachusetts investigation is pending.

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General Information or Other Event Number: 45177
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: ALLEGHENY RODNEY
Region: 1
City: NEW BEDFORD State: MA
County:
License #: G-0112
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKEROL
HQ OPS Officer: VINCE KLCO
Notification Date: 06/30/2009
Notification Time: 17:52 [ET]
Event Date: 06/30/2009
Event Time: [EDT]
Last Update Date: 06/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - SAFETY FUNCTION FAILURE

The following information was received via facsimile:

"The electronics are not working on a [thickness] gauge on the Z-34 press. The equipment is out of use. The [Integrated Industrial Systems] gauge [is a Model #SS-3A] with a serial number [of] #9834LX; 1000 milliCurie Am-241. A potential cause is the source moved."

The licensed contractor RSI (Radiometric Services and Instruments) was contacted to fix the thickness gauge.

A Commonwealth of Massachusetts investigation is pending.

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Power Reactor Event Number: 45181
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: CHRIS DUNN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/02/2009
Notification Time: 18:40 [ET]
Event Date: 07/02/2009
Event Time: 14:15 [CDT]
Last Update Date: 07/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation

Event Text

HPCS INOPERABLE DUE TO LOGIC CARD FAILURE

"On July 2, 2009, at 0100 hours (CDT), the Main Control Room received an alarm associated with a failure of the Nuclear System Protection System (NSPS) Self Test System (STS). The indicated failure was on a High Pressure Core Spray (HPCS) system logic card. The card was removed and testing of the card, completed at 1415 hours, determined that the failure was on a circuit that would have prevented the automatic initiation capability of HPCS. Since HPCS is an emergency core cooling system and is a single train safety system, this is reportable under 50.72 (b)(3)(v)(D). It is unknown at this time what caused the failure and plans are in progress to repair or replace the card."

The logic card is being sent out for repairs. The HPCS system will remain inoperable until the card is repaired and replaced. There is no estimate at this time as to when the card will be replaced.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 45183
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: DAVID BALFOUR
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/03/2009
Notification Time: 14:32 [ET]
Event Date: 07/03/2009
Event Time: 13:05 [EDT]
Last Update Date: 07/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JAMES TRAPP (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP RESULTING FROM TURBINE TRIP

A reactor trip occurred at 1305 EDT and a Connecticut "echo" event was declared at 1315 EDT. The load dispatcher reported a loss of a 115 kV line at the time of the trip which may have caused and/or contributed to the turbine trip. The turbine trip may have resulted from a loss of B12 MCC (motor control center) which carries stator cooling pumps or a momentary interruption to non-vital instrument panels VR11 and VR21.

The following events occurred:
"1) loss of non-vital power may have caused the turbine trip,
"2) RPS [Reactor Protective System] actuation from turbine trip,
"3) system operator reported brief loss of 115 kV line immediately prior to trip,
"4) Primary PORV [Pilot Operated Relief Valve on the pressurizer] lifted [at its setpoint of 2397psia],
"5) Steam generators reached a high level, and
"6) Main feed pump manually tripped due to high steam generator level and manually started AFW pumps [Auxiliary Feedwater Pumps].
"Note: The 'C' charging pump was inoperable at the time of the event."

All control rods fully inserted on the trip. The plant is in its normal shutdown electrical lineup. Decay heat is being dumped to the main condenser and steam generator level is being maintained with the AFW pumps. There was no effect on Unit-3.

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012