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Event Notification Report for August 31, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/28/2009 - 08/31/2009

** EVENT NUMBERS **


45241 45261 45291 45292 45293 45294 45295 45298 45300 45301 45307 45310

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 45241
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HOSPITAL
Region: 1
City: BETHLEHEM State: PA
County:
License #: PA0264
Agreement: Y
Docket:
NRC Notified By: DAVE ALLARD
HQ OPS Officer: VINCE KLCO
Notification Date: 08/03/2009
Notification Time: 20:10 [ET]
Event Date: 07/29/2009
Event Time: [EDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - IMPROPER TREATMENT

The following report was sent from the State of Pennsylvania via facsimile:

"During the patient's treatment, it was determined that the wrong side of the patient's head was being treated [using a gamma knife]. The patient treatment was halted at 47.40 minutes out of the prescribed 55.63 minutes. The prescribed dose was 42.5 Gy to the 50% isodose line. Patient received 34.5 Gy to the 50% isodose.

"PA DEP [The Pennsylvania Department] Bureau of Radiation Protection was notified in writing, dated July 29, 2009. Their suggestion for improvement is while all treatment team members are present during a 'time out' procedure, to have the patient state the side of his/her lesion or treatment and place an imaging marker to designate the treatment side.

"The State [of Pennsylvania] will continue to keep NRC informed of the status of the investigation."

Pennsylvania Report PA090027.

* * * RETRACTION FROM PENNSYLVANIA (ALLARD) TO CROUCH VIA FAX @ 2116 EDT ON 8/28/09 * * *

"Regarding the Lehigh Valley Hospital Medical Event (PA090027) reported to the HOO via fax on 8-3-09, please be advised of our [Pennsylvania Department of Environmental Protection] intent to retract this report.

"Based on our inspection and follow-up with the licensee, it was determined that, although the initial written directive was prepared in error, all radiation treatments received by the patient were, in fact, delivered in accordance with a written directive. However, the licensee has taken corrective actions to avoid a similar event occurring in the future."

Notified R1DO (White) and FSME EO (Suber).


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: 45261
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES
Region: 4
City: TYLER State: TX
County:
License #: L00446
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/13/2009
Notification Time: 18:08 [ET]
Event Date: 08/12/2009
Event Time: 18:00 [CDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
ANDREW MAUER (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE DURING TRANSPORTATION

"On August 13, 2009, at 1630 the Agency [Texas Department of Health] received a call from the licensee's Radiation Safety Officer (RSO) stating that they had shipped a 2.5 curie Cesium 137 source via common carrier to Tyler, Texas from Van Buren, Arkansas. Some time after receiving the source in Tyler, Texas, the licensee discovered that the source had been shipped in a container designed to carry Americium. The licensee recreated the event and determined that the dose rate in the cab of the transport truck was 25 millirem per hour. The trip was estimated to take six hours to complete, so the dose to the driver was calculated to be 150 millirem for the trip. The licensee is attempting to identify the driver and will determine additional dose rates required for shipping during their investigation. A survey was conducted by the licensee prior to the package leaving Arkansas and the individual who performed the survey stated that he did not see any unusual dose rates from the package. The RSO stated that they will provide a copy of the survey and additional information as it is gathered. This Agency [Texas Department of Health] will perform an onsite investigation on August 14, 2009, and will provide additional information to the NRC when prudent."

Texas Incident #I-8655

* * * UPDATE PROVIDED BY ART TUCKER TO JASON KOZAL ON 08/28/09 AT 1740 * * *

The following was provided by the State via e-mail:

"The following information was gathered during interviews conducted at Baker Hughes Oilfield Operations DBA Baker Atlas in Tyler, Texas, on August 21, 2009."

"The Corporate Radiation Safety Officer (CRSO) was asked to describe the events that had occurred on July 12, 2008. He provided pictures which confirmed that the driver had left the facility in Van Buren, Arkansas, at 1545 on July 12, 2009. A picture of the truck arriving in Tyler, Texas, at 21:35 on July 12, 2009, was also provided. The CRSO stated that the driver was not in or around the truck other than for driving. He was not in the area of the source during the time it was loaded on the truck. No video or pictures were available of a survey being performed on the truck. A dose rate survey was provided, but no contamination survey information could be provided. The dose rate survey indicated a reading of 15 microsieverts/hour (uSv/hr) at the back of the truck and 5 uSv/hr and 2 uSv/hr on the sides of the truck. The dose rate inside the cab of the truck is difficult to read, but was stated to be 2 uSv/hr. The CRSO stated that the dose rates were actually in units of millirem/hour (mr/hr) and not uSv/hr as stated on the survey. The CRSO provided a survey done during the investigation that showed the dose rate at the back of the truck to be 15 mr/hr, but the dose rates on the sides of the truck, 3 feet from the container were 170 mr/hr and 140 mr/hr. The 170 mr/hr was recorded on the side of the truck were the Cesium (Cs) 137 source was located. The dose rate inside the cab was recorded as between 24 and 28 mr/hr. The CRSO stated that the vehicle used to take dose readings in the cab actually had a shorter distance from the source to the driver than the actual truck used. The CRSO used 25 mr/hr as the dose rate to assign a dose to the driver. This gave him a dose of 150 millirem for the drive.

"The CRSO was asked if the individual who shipped the packages had ever performed a radioactive shipment before. He said probably not. The CRSO was asked if the Site RSO (SRSO) had reviewed the shipment before it left Arkansas. He stated the individual who had shipped the package was the SRSO. He stated that the old SRSO had left the facility a few weeks prior to this event. The CRSO stated that to his knowledge, the SRSO had not received any training on performing shipments involving radioactive material. I asked if the CRSO had talked with the new SRSO prior to this shipment. The CRSO stated that he was not aware that this individual was the SRSO until this event occurred. He stated that the source that was shipped did not fit into the first container that the SRSO tried to use. He looked around till he found a cask it would fit into and assumed it was the correct one."

"The CRSO was asked why the lack of labels on the shipping container did not raise a flag for the SRSO. He stated that they where in a hurry to get the package out. I asked why the truck did not have placards. He stated that the SRSO knew that it should have been placarded, but he said that the transport company stated that they would place the placards on the truck. I asked why the shipment did not have a contamination survey. The CRSO could not provide an answer.

"The source was removed from the container and placed in the storage location shortly after it arrived in Tyler, Texas. No surveys were performed on arrival in Tyler, Texas.

"The CRSO stated that the error was discovered on August 12, 2009, when the source was being packaged to send to a field site. The person preparing the source for shipment could not find a holder they would normally use, so they decided to use the container that was used when it was shipped from Arkansas. The transport container now had the appropriate labels. The source was placed in the transport container in an area monitored by an area radiation monitor. The area radiation monitor continued to alarm even after the source was fully inserted into the transportation container. This was the first indication the licensee had that there was a problem with the transport container.

"The CRSO was asked if anyone else was on the loading dock while the source was being prepared for shipment. He stated that there was not.

"The CRSO stated that he believed the transport container used borated paraffin or poly as it was designed for a five curie Americium/Beryllium source. He stated that he would send us the transport container certification.

"The CRSO stated that conversations with the driver indicated that the driver was not concerned with his radiation exposure. The driver was offered medical assistance, but refused it."

Notified R4DO (Miller), and FSME EO (Suber).

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General Information or Other Event Number: 45291
Rep Org: LOUISIANA DEQ
Licensee: GE HEALTHCARE
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-5470-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2009
Notification Time: 10:57 [ET]
Event Date: 07/09/2009
Event Time: [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING RADIOPHARMACEUTICALS

The following report was received from the State of Louisiana via facsimile:

"On July 9, 2009, a facility reported a mislabeled unit dose from GE Healthcare nuclear pharmacy. Three 20 mCi unit doses of Tc-99m MDP (bone scans) were ordered by Ochsner [a medical facility]. Two patients were injected. After viewing the images, it was determined that the unit doses were mislabeled. An investigation of GE Healthcare was performed. A preliminary cause was determined to be a mix up of MDP cold vial with DTPA [renal scans] as they closely resemble each other with the same vial configuration and same color label. Contributing factors leading to the incident were Tc-99m/Mo-99 shortage, late arrival of generators, increased number of kits to prepare as a result of the shortage, and pharmacist working alone. Corrective actions involved reviewing procedures and discontinuing manual changes of inventory dispensed on prescription labels."

Louisiana incident number: LA090017

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: 45292
Rep Org: LOUISIANA DEQ
Licensee: CAMERON VALVE AND MEASUREMENTS
Region: 4
City: VILLE PLATTE State: LA
County:
License #: LA-7095-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2009
Notification Time: 10:56 [ET]
Event Date: 07/28/2009
Event Time: [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT OF RADIOGRAPHY CAMERA

The following is a summary of a fax received from the state of Louisiana:

At approximately 10:30 p.m. on the night of July 28, 2009, a radiographer failed to connect the source tube to the camera before he cranked out the source. The cable stop that is attached to the worm cable did not work properly. After dismantling the crankout assembly, the source was hand retrieved and placed back into the camera using the worm cable. A survey was taken to verify that the source was stored safely. The total time of retrieval was approximately 2 minutes.

No personnel were overexposed during this event.

Louisiana Report #: LA090016

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Hospital Event Number: 45293
Rep Org: HEARTS CLINICS NORTHWEST
Licensee: HEARTS CLINICS NORTHWEST
Region: 4
City: COUR D'ALENE State: ID
County:
License #: 46-27704-01
Agreement: N
Docket:
NRC Notified By: WAYNE WHITNEY
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2009
Notification Time: 12:53 [ET]
Event Date: 08/24/2009
Event Time: 16:00 [MDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - ACTUAL DOSE LESS THAN SCHEDULED DOSE

Two patients were scheduled for treatment using Tc-99m. One patient was scheduled to receive a dosage of 8 mCi and the other patient a 25 mCi dose of a different Tc-99m chemical make-up. However, the wrong patient was given the 8 mCi (versus the 25 mCi). Both the patient and physician were notified of the wrong dosage. The critical organ of concern is the upper intestine and the exposure is calculated to be 1.44 Rem which is below the administrative limit.

There is no expected medical effects to the patient.

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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Hospital Event Number: 45294
Rep Org: ALLEGIANCE HEALTH
Licensee: ALLEGIANCE HEALTH
Region: 3
City: JACKSON State: MI
County: JACKSON
License #: 21-00258-06
Agreement: N
Docket:
NRC Notified By: ANAS ORFALI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2009
Notification Time: 14:50 [ET]
Event Date: 08/24/2009
Event Time: 13:47 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

MEDICAL EVENT - D90 DOSE LESS THAN PRESCRIBED DOSE

On April 16, 2009, a patient received a permanent prostate implant of I-125 seeds. On August 24, 2009, post-implant dosimetry analysis, performed multiple times using multiple modalities, determined the D90 dose was 76.3% of prescribed dose. The prescribed dose was 145 Gy using 0.679u/seed and 54 seeds.

The referring physician and patient have been notified.

The licensee is conducting an investigation and will be determining corrective actions.

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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Hospital Event Number: 45295
Rep Org: ALLEGIANCE HEALTH
Licensee: ALLEGIANCE HEALTH
Region: 3
City: JACKSON State: MI
County: JACKSON
License #: 21-00258-06
Agreement: N
Docket:
NRC Notified By: ANAS ORFALI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2009
Notification Time: 14:50 [ET]
Event Date: 08/24/2009
Event Time: 13:47 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

POTENTIAL MEDICAL EVENT - D90 DOSE LESS THAN PRESCRIBED DOSE

On April 16, 2009, a patient received a permanent prostate implant of I-125 seeds. On August 24, 2009, post-implant dosimetry analysis, performed multiple times using multiple modalities, determined the D90 dose was 46.8% of prescribed dose. The prescribed dose was 145 Gy using 0.577 u/seed and 57 seeds.

The referring physician and patient have been notified. The physician will be conducting a corrective implant.

The licensee is conducting an investigation and will be determining corrective actions.

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: 45298
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: PCS PHOSPHATE-WHITE SPRINGS
Region: 1
City: WHITE SPRINGS State: FL
County:
License #: 2702-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2009
Notification Time: 15:42 [ET]
Event Date: 08/25/2009
Event Time: [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
GREG SUBER (FSME)
ILTAB VIA EMAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

FLORIDA AGREEMENT STATE REPORT - X-RAY FLUORESCENCE ANALYZER REPORTED STOLEN

The following information was received from the State of Florida via e-mail:

"Licensee reports that a handheld x-ray fluorescence (XRF) analyzer [containing 30 mCi of Am-241] was stolen. The device was last seen when used on 7/5/09. The device was placed in the office of user and was noted missing when it was looked for on 8/11/09 to use for a job. On 8/24/09, after searching through the company office, the licensee determined that it was missing/stolen. The licensee reports that [the device] is password locked. Licensee is considering offering a reward. Licensee will submit a written report. Florida is investigating."

Florida incident number: FL09-063

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Power Reactor Event Number: 45300
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN COVINGTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/26/2009
Notification Time: 09:20 [ET]
Event Date: 08/26/2009
Event Time: 09:00 [EDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MALCOLM WIDMANN (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

LOSS OF RESPONSE CAPABILITY DUE TO MAINTENANCE RENDERING TSC NON-FUNCTIONAL

"The TSC Air Handling Unit will be taken OOS to repair one of the two compressors. In order to perform this corrective maintenance, the TSC HVAC will be removed from service for [approximately] 1 hour to disconnect the compressor to be repaired and in doing so will render the TSC HVAC inoperable which renders the TSC as non-functional. The TSC HVAC will be restarted to return the TSC to an operable and functional status. The work to repair or replace the compressor is planned to be completed within (1-3 days). After the work is completed, the system will be taken out of service again to reconnect the compressor ([approximately] 1 hr) and return the TSC HVAC to service."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM J.W. COVINGTON TO V. KLCO AT 1045 ON 8/28/2009 * * *

Maintenance was completed and the TSC was restored to operable status.

The licensee notified the NRC Resident Inspector.

Notified the R2DO(Widmann).

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General Information or Other Event Number: 45301
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: KAISER PERMANENTE
Region: 1
City: JONESBORO State: GA
County: CLAYTON
License #: GA1276-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/26/2009
Notification Time: 16:00 [ET]
Event Date: 08/22/2009
Event Time: 07:30 [EDT]
Last Update Date: 08/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
LANCE ENGLISH (ILTA)
GREG SUBER (FSME)

Event Text

AGREEMENT STATE REPORT - EXTERIOR ACCESS DOOR TO RADIOLOGY LAB FOUND OPEN

While responding to an audible alarm, the Clayton County Police Department found an exterior door open to the Radiology Lab at the Kaiser Permanente Nuclear Medicine Clinic located in Jonesboro, Georgia. The Clayton County Police Department notified the Federal Bureau of Investigations and the Georgia Information Sharing and Analysis Center. The Georgia Information Sharing and Analysis Center then contacted the Georgia Radioactive Materials Program.

The licensee is authorized to possess diagnostic imaging isotopes. At this time, no information is available whether radiological material is missing, or if the open door was the cause of the alarm. The investigation is ongoing.

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Power Reactor Event Number: 45307
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: PETE SNYDER
Notification Date: 08/28/2009
Notification Time: 01:13 [ET]
Event Date: 08/27/2009
Event Time: 23:10 [EDT]
Last Update Date: 08/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JOHN WHITE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

NON-CONSERVATIVE TECHNICAL SPECIFICATION SETPOINTS DISCOVERED

"Non-conservative Tech Spec setpoints were discovered that affected Steam Leak Detection for Unit 1 and Unit 2 [High Pressure Coolant Injection] HPCI room high differential temperatures. During a steam leak detection system design basis leak, the present temperature setpoint would not isolate the HPCI steam supply piping.

"A calculation has been performed by engineering which demonstrates that, with both room coolers secured, a design basis steam leak will result in the room ventilation differential temperature exceeding the present Tech Spec setpoints. At this time, the room unit coolers have been secured and HPCI and the associated steam leak detection system remain operable. Calculations are in-progress by engineering for changes to the high differential temperature steam leak detection setpoint."

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 45310
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: Konrad Kulesza
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/29/2009
Notification Time: 16:39 [ET]
Event Date: 08/29/2009
Event Time: 06:15 [PDT]
Last Update Date: 08/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MALCOLM WIDMANN (R2DO)
RAYMOND LORSON (NMSS)

Event Text

NUCLEAR CRITICALITY DETECTION SYSTEM INOPERABLE

"On 08/29/2009 at 0615 PDT, during a scheduled testing of the Nuclear Criticality Detection [NCD] System, it was discovered that in one of the nine locations, two of three NCD units were non-functional. The two NCD units were non-functional apparently due to miswiring. This is still under investigation.

"All movement of SNM [Special Nuclear Material] on site was suspended during the testing of the Nuclear Criticality Detection System.

"This occurrence is reportable to the NRC in accordance with 10CFR70.50.b(2)(i). This is a 24 hour reporting requirement with a follow up 30 day written report.

"Safety Significance of Event:

"The safety significance is very low. Accidental nuclear criticality is highly unlikely. Only two of three NCD units in one of nine locations through out the plant were nonfunctional. The one deficient unit had one functional NCD that would have produced a trouble alarm if actuated. The remaining eight Criticality Detector systems were fully functional and covered the areas where SNM is processed."

The licensee will be notifying their NRC Region II Inspector.

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