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Event Notification Report for July 28, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/27/2009 - 07/28/2009

** EVENT NUMBERS **


45221 45222 45229 45230 45231

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General Information or Other Event Number: 45221
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CENTURA HEALTH PENROSE - ST. FRANCIS HEALTH SERVICES
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 197-01
Agreement: Y
Docket:
NRC Notified By: MARK DATER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 07/22/2009
Notification Time: 14:07 [ET]
Event Date: 07/22/2009
Event Time: [MDT]
Last Update Date: 07/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via fax from the State of Colorado.

"A medical licensee notified the [Colorado Department of Health] of a misadministration during a HDR [High Dose Rate Afterloader] procedure. A positioning error resulted in an estimated dose of 700 Rads to the wrong site.

"No other details are available at this time.

"The Department has initiated an investigation of this incident."

The licensee did not provide the State with an event date and time in the initial event report.

* * * UPDATE AT 1321 EDT ON 07/24/09 BY ERIC SIMPSON * * *

The following information was received by the State of Colorado via fax:

"The [State of Colorado Department of Health] received the following information from the medical physicist who reported the misadministration involving a therapy treatment with a High Dose rate Remote Afterloader (HDR) at Penrose St. Francis Hospital in Colorado Springs, Colorado.

-The date of the misadministration was 7/21/09.

-Because of the error, the dose was delivered to the entrance of the vagina, rather than intrauteral.

-The patient's physician and the patient have been informed of the incident.

-The applicator used in this procedure uses a collet to hold a 3 mm source tube in place. There may have been a problem with the collet, which allowed the source tube to move.

-The licensee instituted corrective actions, which include additional training for all staff involved in HDR therapy treatments, and an additional check of the applicator prior to start of treatment.

"A full report from the medical physicist is expected within the next 7 days.

"No other details are available at this time.

"The Department has initiated an investigation of this incident."

Notified R4DO (Jones) 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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General Information or Other Event Number: 45222
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS
Region: 3
City: RACINE State: WI
County:
License #: 101-1299-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/22/2009
Notification Time: 16:29 [ET]
Event Date: 07/16/2009
Event Time: [CDT]
Last Update Date: 07/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
PATRICE BUBAR (FSME)

Event Text

AGREEMENT STATE REPORT - MULTIPLE EQUIPMENT ISSUES ASSOCIATED WITH HDR BRACHYTHERAPY UNIT

The following is a summary of information received via fax from the State of Wisconsin. For more details contact the Headquarters Operations Officer.

On July 16, 2009, DHS [Department of Health Services] performed a reciprocity inspection at Wheaton Franciscan Healthcare - All Saints for a source exchange of a 10 Ci, Ir-192 source and routine maintenance of a Nucletron Micro Selectron HDR [High Dose Rate] classic remote afterloader brachytherapy device. During the inspection, three items were identified during testing of the HDR unit: 1) HDR control panel did not operate as designed; 2) the HDR/Linac switch was not wired correctly; and 3) Radiation area monitor was operating sporadically.

On July 16, 2009, DHS informed the licensee that they would not be able to use the HDR unit for patient treatments until all areas of concerns were corrected. The licensee informed DHS that the HDR unit has NOT been used for any patient treatments since the Department authorized the licensee the HDR unit on August 8, 2008.

On July 21, 2009, DHS issued the licensee a Confirmatory Action Letter effective July 17, 2009, that the licensee is not allowed to use the HDR unit for patient treatments until the listed items were corrected

The licensee has committed to address all equipment malfunctions prior to treating patients using the Nucleation HDR unit. DHS plans to conduct an inspection prior to patient treatment.

The State does not anticipate any media attention.

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Power Reactor Event Number: 45229
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: Shawn Miller
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/27/2009
Notification Time: 09:52 [ET]
Event Date: 07/27/2009
Event Time: 07:52 [EDT]
Last Update Date: 07/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY DIMITRIADIS (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

TECHNICAL SUPPORT CENTER REMOVED FROM SERVICE FOR UPGRADES

"On Monday, July 27, 2009, at 0752, Seabrook Station is temporarily relocating its Technical Support Center (TSC) from the permanent location on the 75 foot level of the Control Building (CB) to an alternate location in the Online/Outage Control Center (OCC). This relocation is necessary to allow for installation of new equipment and upgrading of existing equipment in the TSC.

"The site Emergency Response Organization (ERO) has been notified of the modifications and has been instructed on the planned compensatory measure to be implemented during the temporary relocation.

"The NRC Resident Inspector has been notified of the relocation activities.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to loss of the emergency response facility.

"Seabrook Station will provide updates as necessary and will advise the NRC of the restoration of the permanent TSC."

The State of New Hampshire has been notified.

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Power Reactor Event Number: 45230
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JIM KONRAD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/27/2009
Notification Time: 10:39 [ET]
Event Date: 07/27/2009
Event Time: 09:35 [EDT]
Last Update Date: 07/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT DALEY (R3DO)

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

Event Text

TECHNICAL SUPPORT CENTER TEMPORARILY UNAVAILABLE FOR USE

"On July 27, 2009, Fermi 2 is removing the Technical Support Center (TSC) from operation to facilitate maintenance activities for furniture and facility upgrade. During this work the facility will not be available for use. Fermi 2 is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event TSC activation is necessary the Emergency Operations Facility (EOF) will be utilized. Activation and use of the EOF as a back up for the TSC is included in Fermi 2's Radiological Emergency Response Preparedness Plan. The Emergency Call Out System (ECOS) is designed to facilitate contacting TSC personnel to respond directly to the EOF in the event of an emergency. Fermi 2 will notify the NRC upon completion of this work which is expected to be July 31, 2009."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45231
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ADAM MILLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/27/2009
Notification Time: 16:51 [ET]
Event Date: 07/27/2009
Event Time: 10:00 [EDT]
Last Update Date: 07/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY DIMITRIADIS (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

TECHNICAL SUPPORT CENTER (TSC) HVAC FOUND DEGRADED DUE TO WATER INTRUSION

"At about 10:00, on July 27, 2009, the Technical Support Center (TSC) HVAC was found to be degraded. The fan motor was running but there was no air flow and the TSC rooms were not being maintained with a positive pressure. Upon investigation, the fan housing was found partially filled with water, submerging the motor and preventing air flow through the system. Repair of the motor will take more than one day and is being immediately pursued. This affects the ability of the TSC ventilation to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. All other capabilities of the TSC are unaffected by this emergent repair. Existing procedures provide direction to relocate TSC personnel in the event of a TSC habitability concern; however, the backup facility does not have standby electrical power or a filtered ventilation system. Therefore, this condition is considered a major loss of emergency assessment capability and is reportable under 10CFR50.72(b)(3)(xiii)."

The TSC HVAC was last functionally tested satisfactorily on 06/29/09. The licensee believes the water found in the HVAV fan housing may be a result of a clogged drain line.

The licensee will inform the NRC Resident Inspector.

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