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Event Notification Report for December 24, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/23/2009 - 12/24/2009

** EVENT NUMBERS **


45237 45579 45581 45582 45587 45588

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 45237
Rep Org: MUNSON MEDICAL CENTER
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: DENNIS SZMANIA
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/30/2009
Notification Time: 15:15 [ET]
Event Date: 07/30/2009
Event Time: 09:00 [EDT]
Last Update Date: 12/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT DALEY (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

POTENTIAL MEDICAL EVENT INVOLVING NOVOSTE BETA-CATH STRONTIUM BRACHYTHERAPY SYSTEM

The licensee reported that a patient was undergoing brachytherapy treatment of the heart. During the procedure, it was determined that the source was not in the proper position. The sources were retracted and the procedure reattempted. During the reattempt, it was determined that the sources were not going into the proper position. However, the licensee was not able to retract the sources into the Novoste device. The physician removed the catheter and device as an assembly and placed in a safe box. The licensee does not know the failure mode with any degree of certainty and is sending the device to the manufacturer for evaluation. The cardiologist believes it may have been a kink in the catheter. The patient was notified of the event, and the licensee discussed the issue with NRC Region 3(G. Warren).

The device is a Novoste Beta-Cath, Device number: 86865, and source number: ZB551.

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.

* * * RETRACTION FROM DENNIS SZMANIA TO VINCE KLCO ON 12/23/2009 @ 1056 EST* * *

The licensee is retracting the event because the source never entered the patient's body and the exposure to the patient was negligible.

Notified the R3DO(Kunowski) and FSME (Villamar).

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General Information or Other Event Number: 45579
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: COOKEVILLE REGIONAL MEDICAL CENTER
Region: 1
City: COOKEVILLE State: TN
County:
License #: R-71026-D10
Agreement: Y
Docket:
NRC Notified By: DEBRA SHULTS
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/17/2009
Notification Time: 10:59 [ET]
Event Date: 12/15/2009
Event Time: [EST]
Last Update Date: 12/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD BARKLEY (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION OF RADIOACTIVE MEDICAL TREATMENT

The following report was received via facsimile:

"[Tennessee Division of Radiological Health] TN DRH was notified on 12/15/09, by the medical physicist at Cookeville Regional Medical Center, of a possible therapeutic misadministration that occurred the morning of 12/15. A patient was being treated with three sealed sources of cesium-137 (total activity of 70 mg Ra-equivalent) contained in a vaginal applicator. The patient was elderly and heavily sedated. The applicator was inserted and after twenty minutes of treatment, the nurse came into the room to check on the patient and noticed the applicator outside the treatment area. The applicator was removed and placed in a lead pig. The patient may have received a maximum dose of 76 Rem to the thigh area. A written report will be submitted by the licensee."

Tennessee Report Number: TN-09-155

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: 45581
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: MISTRAS GROUP INC.
Region: 4
City: KENT State: WA
County:
License #: WN-IR011-1
Agreement: Y
Docket:
NRC Notified By: KELEE ATTEBERY
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2009
Notification Time: 11:36 [ET]
Event Date: 12/15/2009
Event Time: [PST]
Last Update Date: 12/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following report was received via email:

"The department received a notification from a radiography company [on 12/16/09] located in Kent, Washington, about an event while performing radiographic operations in a fabrication shop in Sedro Wooley, Washington. A 2 inch pipe fell onto the source guide tube and the radiography crew was unable to retract their source past the damage. The crew called the company's Radiation Safety Officer who sent an assistant to the site with lead blankets. The assistant was able to normally retract the source through the damaged area and into the shielded safe storage position of the radiographic exposure device. The dose to the assistant RSO was reported as 480 mRem. No other individuals were reported to have received an elevated dose. A full report from the company's RSO will be made after they perform a reenactment of the incident."

WA Incident Number: WA-09-093
Source material: 80 Ci, Ir-192

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General Information or Other Event Number: 45582
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MARS PETCARE US, INC
Region: 3
City: COLUMBUS State: OH
County:
License #: 00006GL0138
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/18/2009
Notification Time: 13:47 [ET]
Event Date: 11/26/2009
Event Time: [EST]
Last Update Date: 12/18/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
GLENDA VILLAMAR (FSME)
CNCNS - CANADA (FAX)

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

Event Text

AGREEMENT STATE - LOST LEVEL INDICATOR

The following was received via email:

"General licensee (GL) reported to BRP (Bureau of Radiation Protection) on 12/18/09 that a generally licensed device was unaccounted for. The device has been identified as an Industrial Dynamics FilTech FT-50 [fixed gauge] level indicator, serial number 113216, containing 100 mCi of Am-241.

"The licensee last reported that the device was in their possession with the annual GL registration to BRP on 10/11/02. The device was not listed on the next GL registration submitted by the licensee on 11/26/03. During an internal audit by the licensee it was determined that a report of disposition of the device had not been submitted to BRP. The device had been installed in a process line which was decommissioned and dismantled in June 2003. As the licensee investigated the matter they determined that they could not account for the current location of the device. The manufacturer had no record of receipt of the device and the licensee could not locate the device anywhere within their facility.

Additional investigation and information is being requested by BRP. "

Ohio Report #: OH090012

Source Model #: 06110

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 45587
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVID SCHUMACHER
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/23/2009
Notification Time: 12:21 [ET]
Event Date: 12/23/2009
Event Time: 06:56 [CST]
Last Update Date: 12/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

WINTER STORM POWER OUTAGES CAUSE ALERT SIREN INOPERABILITY

"On December 23, 2009, at 0656 hours, 40% of the alert sirens in the Quad Cities Station Emergency Planning Zone were determined to be inoperable for greater than 60 minutes. This is considered a major loss of the Quad Cities offsite notification capability. The alert sirens were disabled due to power outages caused by a winter storm. Efforts are underway at the time of this notification to restore the sirens.

"This report is being made due to the reduction in public notification capabilities in accordance with 10CFR50.72(b)(3)(xiii). As of 1100 hours, all but 6 EPZ sirens (12%) have been restored.

"A follow-up notification will be provided when the sirens have been restored."

* * * UPDATE FROM DEWEERTE TO TEAL AT 1707 ON 12/23/2009 * * *

"Repairs to the emergency sirens were completed as of 1456 CST hours. All sirens are restored."

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Power Reactor Event Number: 45588
Facility: VOGTLE
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILL DUNN
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/23/2009
Notification Time: 17:18 [ET]
Event Date: 12/23/2009
Event Time: 15:25 [EST]
Last Update Date: 12/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARK FRANKE (R2DO)

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

Event Text

MANUAL RPS ACTUATION DUE TO LOSS OF INSTRUMENT AIR

"At 1525 EST, Vogtle Unit 2 was manually tripped from 100% power due to a loss of instrument air to the turbine building.

"System operators were releasing a tagout and restoring one of two instrument air dryers that had been isolated for maintenance. Instrument air low pressure alarms were received in the control room and secondary side valves were responding to the loss of instrument air. Control room operators responded according to procedures. Main feed pump 'B' tripped on a loss of suction pressure and operators manually tripped the reactor.

"The reactor was manually tripped in anticipation of a loss of feed water to the steam generators. All systems responded as required. AFW [Auxiliary Feed Water] actuated as required for loss of feed water. All control rods fully inserted on the reactor trip. Instrument air has been restored to the turbine building and steam dumps are controlling RCS temperatures.

"Cause of the loss of instrument air is being investigated.

"[The NRC] Senior Resident [Inspector] was notified."

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