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Event Notification Report for July 24, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/23/2009 - 07/24/2009

** EVENT NUMBERS **


44548 45172 45213 45219 45225

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Hospital Event Number: 44548
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER - CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/07/2008
Notification Time: 19:59 [ET]
Event Date: 10/07/2008
Event Time: [EDT]
Last Update Date: 07/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
MARK DELLIGATTI (FSME)

Event Text

MEDICAL EVENTS DUE TO DOSE RECEIVED LESS THAN 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 iodine-125 seed implant brachytherapy programs.

"As the result of these ongoing reviews, medical events were discovered on October 7, 2008, for 6 patients treated at the VA Medical Center in Cincinnati, Ohio.

"These 6 medical events involved seed distributions in the patients that resulted in D90 doses less than 80% of the prescribed doses. These circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045.

"A 15-day written report on these 6 medical events will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events."

* * * UPDATE AT 1520 EDT ON 07/23/09 FROM ED LEIDHOLDT TO S. SANDIN * * *

"Following the notification of the NRC on October 7, 2008, of the six medical events described in Event Report No. 44548, the NHPP initiated a reactive inspection on October 16, 2008. As a result of this inspection and related clinical reviews, the NHPP is notifying NRC of one additional medical event at the Cincinnati VA Medical Center, for a total of 7 medical events at this facility. This event, also involving prostate brachytherapy with I-125 seeds, was discovered on July 22, 2009. Like the previous six medical events, this additional medical event involves a D90 dose less than 80% of the prescribed dose.

"We note that the D90 doses for all seven events were based upon CT scans performed one day after the implants, when the prostate is subject to edema from the procedure which often causes underestimation of the true D90. Furthermore, the prescribed doses were 160 gray, instead of the more common 145 gray. Thus, most if not all of these patients likely received clinically adequate dose distributions, despite the percent-wise slightly low D90s. Adverse biological effects to these patients are not expected.

"The facility has notified the patient.

"A written report on this additional medical event will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify the NRC Project Manager, Cassandra Frazier, of NRC Region III."

Notified R3DO (Hills) and FSME EO (Villamar).

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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Power Reactor Event Number: 45172
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JULIOUS WHITWORTH
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/29/2009
Notification Time: 12:53 [ET]
Event Date: 06/29/2009
Event Time: 11:34 [EDT]
Last Update Date: 07/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GERALD MCCOY (R2DO)

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

OFFSITE NOTIFICATION DUE TO POSSIBLE RELEASE OF FUEL OIL TO THE ENVIRONMENT

"A notification to the Tennessee Department of Environment and Conservation (Chattanooga Field Office) was made at 1134 [EDT], 29 June 2009, pursuant to a failed pressure test on an underground section of diesel generator fuel oil transfer piping. This section of piping is not required for operability of the emergency diesel generators. The section of piping has been isolated. Efforts are in progress to determine if fuel oil was released to the environment."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1642 EDT ON 07/23/09 FROM CALVIN FIELDS TO S. SANDIN * * *

During work to remediate the above concern, an offsite notification was required as described below:

"A notification to Hamilton County Air Pollution Control Bureau was made on July 23, 2009 at 1505 in accordance with the Site's Annual Asbestos Removal Notification . Work was being performed on buried piping when the pipe wrapping was determined to contain asbestos. Work was stopped and the work area controlled by site work documents."

The licensee informed the NRC Resident Inspector. Notified R2DO (Vias).

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General Information or Other Event Number: 45213
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: PETROCHEM INSPECTION SERVICES
Region: 3
City: OREGON State: OH
County:
License #: 03320990001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/21/2009
Notification Time: 08:57 [ET]
Event Date: 06/19/2009
Event Time: [EDT]
Last Update Date: 07/21/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DIFFICULTY RETRIEIVING RADIOGRAPHY SOURCE

The following report was received via email:

"On 6/19/09 at approximately 11:30 a.m., the licensee was unable to retract an industrial radiography source. [The] cause was due to a magnetic positioning device used during operations which fell onto the guide tube, crimping the tube and preventing the source to be retracted to the fully shielded position. [The] device was a QSA Model 660, S/N B2692, with a 91 Curie Ir-192 source, QSA S/N 53932B. No over exposure to personnel or [the] public was reported. [The] source was retrieved into [the] camera by trained personnel within approximately 1/2 hour. [The] licensee revised procedures and conducted refresher training to help prevent similar accidents in the future. ODH [Ohio Department of Health] conducted [an] inspection of [the] job site on 7/1/09. [The] licensee provided [a] written report within [the] 30-day required timeframe. [The] licensee originally thought that this event required a 30-day notice. [The] licensee has been instructed as to the need for 24-hour notification for these events."

Ohio report number: OH090007

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Power Reactor Event Number: 45219
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOHN OHRENBERGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/21/2009
Notification Time: 17:15 [ET]
Event Date: 07/21/2009
Event Time: 14:05 [EDT]
Last Update Date: 07/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)

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

LOSS OF EMERGENCY RESPONSE CAPABILITY - TSC/OSC IS UNAVAILABLE DUE TO HVAC SYSTEM TROUBLE

"Unavailability of TSC/OSC Heating, Ventilation and Air Conditioning (HVAC) System.

"At 1405 hours on Wednesday, July 21, 2009, the Pilgrim Nuclear Power Station (PNPS) Technical Support Center (TSC) / Operations Support Center (OSC) HVAC system was discovered to be nonfunctional. During initial troubleshooting, the breaker providing power to the supply fan mechanically tripped and will not be reset until troubleshooting certifies the breaker is acceptable for use. This event occurred during scheduled preventative maintenance (PM) of the system.

"Under certain accident conditions, the TSC/OSC may become unavailable due to inability of the filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC/OSC personnel to alternate locations.

"The licensee has notified the NRC Senior Resident Inspector/Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an emergency response facility."

The licensee notified the Commonwealth of Massachusetts Emergency Management Agency.

* * * UPDATE AT 2100 EDT ON 07/23/09 FROM KEN GOODALL TO S. SANDIN * * *

"This is a follow-up courtesy notification to EN #45219. All corrective maintenance activities on the TSC/OSC HVAC system are complete and the TSC/OSC is now functional and available for use.

"The NRC Resident has been notified."

The licensee will inform the Commonwealth of Massachusetts Emergency Management Agency. Notified R1DO (Rogge).

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Other Nuclear Material Event Number: 45225
Rep Org: SUPERIOR WELL SERVICES
Licensee: SUPERIOR WELL SERVICES
Region: 1
City: BUCKHANNON State: WV
County:
License #: 37-30412-01
Agreement: N
Docket:
NRC Notified By: LEW CESSNA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/23/2009
Notification Time: 16:33 [ET]
Event Date: 09/20/2008
Event Time: 14:30 [EDT]
Last Update Date: 07/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN ROGGE (R1DO)
PATRICE BUBAR (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

LOST (THEN RECOVERED) LICENSED NUCLEAR MATERIAL

This is an historical report for an incident submitted in response to an on-site inspection by an NRC Inspector (Lodhi).

"On September 20, 2008 at approximately 2:30pm, while returning from an openhole job north of Buckhannon, the neutron shield and the density shield separated from the radiation compartment of an openhole logging truck near Lost Creek on Interstate 79 [exit 110] southbound. The driver continued driving to the shop. Upon return, he noticed a chain hanging freely from the radiation compartment of his truck. He looked in the compartment and noticed that both transport shields and the pig holder had been separated from the unit. He immediately called his supervisor at approximately 3:00pm, who had stopped at the BP in Lost Creek for a drink on the way to the shop, and told him that the transport shield had been separated from the wireline unit. The driver mentioned hearing something after crossing the bridge on interstate 79 South at Lost Creek. The supervisor, who was ? of a mile away from the bridge, proceeded to the spot and immediately picked up the transport shields and pig holder. The supervisor loaded the transport shields and pig holder into the box of his pick-up truck and secured them with separate chains and padlocks and returned to the facility. Upon returning to the facility with the sources, the supervisor contacted his mechanic to reweld the pig holder to the floor of the openhole wireline unit. The supervisor also contacted the camp EIC to report the incident and notify him that all equipment was resecured. The supervisor then placed both sources into the downhole storage pig until the welding was completed.

"According to witness statements both sources were secured with a padlock in their respective transport shields. The shields were mounted on a pig holder that was tack welded to the floor of the radiation compartment on the right rear of the truck. The radiation compartment door was secured with the T-handle closed and locked and a hasp lock on the rear of the compartment. The transport shields were chained together.

"Root Cause: Failure of the tack welds on the pig holder. The failure of the tack welds that held the pig holder to the truck caused the transport shields and the pig holder to be free in the radiation compartment.

"Secondary Cause # 1: Failure of the T-handle and the hasp lock on the compartment door. The failure of the T-handle and the hasp lock on the radiation compartment door allowed the compartment door to open freely and failed to contain the 150+ lbs of material that was inside of the compartment.

"Secondary Cause # 2: Hitting a pothole on interstate 79 South. When the driver of the openhole wireline unit struck the pothole on interstate 79 south it caused the transport shields and the pig holder to move inside of the radiation compartment. The movement of the equipment and the failure of the door mechanisms allowed the equipment to separate from the openhole wireline unit.

"Corrective Actions: Corrective actions were taken immediately to eliminate the possibility of a reoccurrence.
-Complete weld along the base of the pig holder.
-Chain through both transport shields that is bolted to a structural member of the truck (floor, frame, etc).
-Heavy hasp lock (bolt style) on the exterior of the radiation compartment door.

"Research: Research was conducted to verify that there were no overexposures included calculating the expected dose in the worst case scenario with the transportation shields removed from the wireline unit.
Surface reading: 2.0 mR/hr
TI: 0.4 mR/hr
Time along 79: 30 minutes
Expected dose if a person were sitting on the shield for hour: 1 mR

"A survey meter reading was taken at nine feet from the transport shields in order to estimate the potential for exposure to members of the public who would be traveling southbound on interstate 79.
9 ft Reading: 0.02 mR/hr
Average Speed: 70 miles per hour = 369,600 feet per hour
Possible exposure: 0.02/369,600 = 0.00000005411255411 mR."

The licensee stated that visual inspection revealed no damage to the neutron or density shield and that this was confirmed by leak test analysis.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example, level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging.

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