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Event Notification Report for January 5, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/04/2010 - 01/05/2010

** EVENT NUMBERS **


45595 45599 45605

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General Information or Other Event Number: 45595
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: LAKE NORMAN REGIONAL MEDICAL CENTER
Region: 1
City: MOORESVILLE State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDY CROWE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/29/2009
Notification Time: 17:09 [ET]
Event Date: 11/19/2009
Event Time: [EST]
Last Update Date: 12/29/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - BRAYCHYTHERAPY DOSE DIFFERED FROM THE PRESCRIBED DOSE BY MORE THAN 20%

The following was received via facsimile:

"During a prostrate brachytherapy procedure using a Mick applicator and I-125 sources, 41 of 41 sources were implanted into the patient's perineal soft tissue, inferior to the prostrate [resulting in:] 1. Dose was greater than 5 rem effective dose equivalent, and/or 50 rem to an organ or tissue and 2. the total dose delivered differs from the prescribed dose by 20% or more.

"Explain the effect, if any, on the individual who received the administration: Possible perineal soft tissue fibrosis. The patient is currently without symptoms six weeks following the implant.

"Additional notes:

"Licensee's evaluation of why the event occurred: Visualization of the prostrate was difficult on ultrasound due to poor image quality, leading to needle placement inferior to the prostrate.

"What actions, if any, have been taken or are planned to prevent recurrence: Discontinuation of the procedure if the locations of the needles are not known to relative certainty.

"The patient and the referring physician were notified [of this event].

"No follow-up is required."

NC Incident Report Number: 09-63

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: 45599
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: GEORGIA PACIFIC CONSUMER DIVISION
Region: 4
City: CAMAS State: WA
County:
License #: WN-I0228-1
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/30/2009
Notification Time: 19:02 [ET]
Event Date: 12/30/2009
Event Time: [PST]
Last Update Date: 12/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE - STUCK SHUTTER ON FIXED DENSITY METER

The following was received via email:

"A fixed gauge licensee operating a paper mill in Camas, Washington, reported that the shutter mechanism of an Ohmart Vega fixed gauge, Model Number SH-F1B-0, containing a 100 mCi sealed source of Cesium 137 failed to close during a routine six-month shutter check.

"The Radiation Safety Officer reported the gauge is mounted on a vertical section of six-inch piping and is still functioning correctly as a density meter. The device is not part of any lockout or confined space entry permit and there is currently no safety hazard potential for exposure to radiation associated with the failure of the shutter mechanism.

"The environment where the gauge is mounted is susceptible to messy process conditions which allows water and lime-mud to accumulate on the fixed gauge. This appears to have contributed to the failure of the shutter mechanism. The manufacturer's representative was called by the licensee and has scheduled a visit to the facility to make corrective repairs."

Report #: WA090097

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Power Reactor Event Number: 45605
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RON STOPKA
HQ OPS Officer: PETE SNYDER
Notification Date: 01/04/2010
Notification Time: 13:38 [ET]
Event Date: 01/04/2010
Event Time: 09:30 [CST]
Last Update Date: 01/04/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT DALEY (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

POSSESION OF ALCOHOLIC BEVERAGE IN PROTECTED AREA

"At approximately 0930 on January 4, 2010 a gift package was brought into the protected area that contained a bottle of an alcoholic beverage. The individual that brought the package into the protected area was unaware that a bottle of an alcoholic beverage was in the gift package. The gift package was delivered to the intended individual. As the individual was reviewing the contents of the package, the bottle of alcoholic beverage was identified as part of the package. Security was immediately contacted and took possession of the bottle. The bottle was still sealed with the original seal. The gift package was always attended while inside the protected area. A fitness for duty evaluation of the personnel involved was conducted with no concerns identified."

The individual was a non-licensed licensee supervisor.

The licensee notified the NRC Resident Inspector.

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