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Event Notification Report for January 19, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/15/2010 - 01/19/2010

** EVENT NUMBERS **


45622 45626 45632 45633 45634

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General Information or Other Event Number: 45622
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PRESBYTERIAN HEALTHCARE SYSTEM
Region: 4
City: DALLAS State: TX
County:
License #: 04288
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 01/11/2010
Notification Time: 15:37 [ET]
Event Date: 12/03/2008
Event Time: [CST]
Last Update Date: 01/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING A GAMMA KNIFE

"On December 2, 2008 Austin Headquarters IIP [Incident Investigation Program], was notified of a medical event with a Leksell Gamma Knife resulting in a dose of approximately 15 Gray (1,500 rad) to the wrong cranial nerve. The incident involved the use of a medical gamma stereotactic radio surgical device known as a gamma knife (GK). Essentially the wrong nerve was designated for treatment for a trigeminal procedure that typically calls for a 80 Gray dose within a 4 mm sphere. Treatment of trigeminal neuralgia can account for as many as 20% of the workload on GK facilities with a standard protocol of 80 Gray to the base of the 5th intracranial nerve yet in this case the 7th cranial nerve was mistakenly targeted. Fortunately, for a reason not clear, the authorized neurosurgeon instructed the Licensed Medical Physicist (LMP) to pause the treatment 9 minutes into a 45 minute regime. He then consulted again with the neuroradiologist on the case and they both determined that the slice used in the treatment plan was the 7th not the intended 5th cranial nerve some one centimeter [away]. The physicians on the case do not expect any untoward effect upon the patient who was notified of the mishap and actually resumed successful treatment on the same day. It was the conclusion of the clinical staff who participated on the case that the root cause was a misidentification of the anatomical target site as listed on the Written Directive (WD). The 15 day report by the RSO stated that he has implemented specific measures as corrective actions to prevent recurrence. These include: 1) a change in the written procedures to include a verification of the target site by the neuroradiologist for each case and 2) a modified WD to document the new procedural change to ensure that the correct treatment site is targeted and treated in each procedure.

"The department will conduct a review of at least 20% of past cases to ensure that this error had not occurred before however the clinicians were of the opinion that such a dose to the wrong site would have pronounced and readily observable clinical manifestations.

"On December 17, 2008 the Agency [State of Texas] received a fax from [the] licensee Radiation Safety Officer detailing the medical event. He noted that the Written Directive was complete and signed by all appropriate parties. The exposure to the 7th cranial never was precisely 9.17 minutes resulting in a dose to other tissue of 14.95Gy and to the 5th trigeminal nerve (targeted site) a negligible dose of 10-20 cGy while 80 Gy was intended. Therefore the patient had treatment continued on the correct anatomical site with apparent success. The authorized physicians attest that the misadministration will have no untoward effects upon the patient. For corrective action it will be documented that the neuroradiologist has provided precise information on the MRI slice of the 5th cranial nerve for Trigeminal Neuralgia treatments.

"This event was reported to the Nuclear Material Events Database (NMED) (090019) instead of to the Headquarters Operations Officer as required. This file is closed in NMED."

Texas Incident No. I-8585

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: 45626
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: IESCO, LLC
Region: 4
City: EL SEGUNDO State: CA
County:
License #: 6571-19
Agreement: Y
Docket:
NRC Notified By: ANDREW TAYLOR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/12/2010
Notification Time: 16:10 [ET]
Event Date: 01/09/2010
Event Time: [PST]
Last Update Date: 01/12/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
ROBERT LEWIS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECTED

"On Saturday, January 9, 2010, the Radiation Safety Officer (RSO) of IESCO, LLC, contacted the California Office of Emergency Services to report that a Selenium 75 (27.5 Curies) industrial radiography source disconnected from the drive cable during radiography operations at the Chevron, El Segundo Refinery. During the first exposure, the source disconnected from the drive cable. This was discovered during the radiographer's confirmatory survey, as required after the source is cranked back in the shielded position. It was discovered that the source was disconnected near the collimator and when the drive cable was retracted, the source would slide back a couple of inches and the pigtail would be caught at a bend in the guide tube, allowing the source to be partially removed from the collimator. The radiographer placed lead shielding over the exposed source to minimize radiation exposure. The radiographer then contacted the RSO. Upon arrival at the site, the RSO disconnected the guide tube from the exposure device and then assessed the situation. He placed more lead shielding on the camera until the dose rate at 6 feet was at 20 Mr/hr. He returned the drive cable to the guide tube, reinserted the drive cable into the guide tube and removed the guide tube from the collimator. The RSO was then able to connect the drive cable to the pigtail and crank it back into the exposure device. The RSO stated that the reading taken from the Direct Reading Pocket Dosimeter (DRPD) of the radiographer was 9 Mr and the DRPD of the RSO was 25 Mr.

"After inspecting the equipment and interviewing the radiographer and assistant, the RSO concluded that the source disconnect occurred due to dirt on the shutter of the drive cable preventing the cover on the pigtail from closing, preventing a secure connection. The RSO has scheduled a safety meeting to ensure that the radiographers are aware of the issue and instructed how to avoid another incident. Further investigation will be deferred until the 30 day report has been submitted and reviewed."

California Report No: 5010-010910

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General Information or Other Event Number: 45632
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: JEFF ZELL CONSULTING INC
Region: 1
City: CORAOPOLIS State: PA
County:
License #: 37-28531-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/14/2010
Notification Time: 19:28 [ET]
Event Date: 01/14/2010
Event Time: 14:45 [EST]
Last Update Date: 01/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ROBERT LEWIS (FSME)
ILTAB via email ()
Canada via fax ()

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

Event Text

AGREEMENT STATE - MISSING MOISTURE DENSITY GAUGE

"Zell's former consultant HP (Health Physicist) informed DEP (Department of Environmental Protection) that [a] nuclear gauge was discovered [to be missing] while performing a 6-month inventory on January 13. An unsuccessful search for the missing nuclear density gauge (Humboldt Model 5001 EZ122; Ser. No. 5375) was concluded on January 14. The licensee notes the gauge cannot be accounted for at this time. Gauge contains about 10 milliCuries Cs-137 and 40 milliCuries Am-241 (as an Am/be neutron source)."

PA Event #: PA100001

Notified R1DO (Dimitriadis) and FSME (Lewis).

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

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: 45633
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/18/2010
Notification Time: 23:26 [ET]
Event Date: 01/18/2010
Event Time: [CST]
Last Update Date: 01/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTINE LIPA (R3DO)
CANADA VIA FAX ()
WILLIAM RULAND (NRR)
ROBERT LEWIS (FSME)
This material event contains a "Less than Cat 3" level of radioactive material.

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

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

Event Text

MISSING RADIOACTIVE SOURCES GREATER THAN 10 TIMES THE LIMIT

"In 2009, a radioactive source inventory was conducted by a Prairie Island Radiation Protection Specialist. During the inventory, it was determined that two sources were missing that are greater than 10 times the quantity specified in 10CFR20 Appendix C. These two sources include a 0.07 [micro]Ci U-234 radiation monitor detector and a 0.2 [micro]Ci mixed gamma standard that contains 0.09 [micro]Ci of Am-241 (a 60 ml vial used for HPGe calibration.) The U-234 source is normally stored in the Hot I&C Shop and the mixed gamma standard with Am-241 is normally stored in the Hot Chemistry Lab. The inventory, that concluded on December 18, 2009, listed these sources as lost. Four other sources, that do not exceed 10 times any quantity specified in 10CFR20 Appendix C, were also unaccounted for during this inventory. Radiation Protection is still in the process of locating the missing sources that were identified during this inventory."

The licensee will provide information on the four other sources to the Operations Center on 1/19/2010.

The licensee has informed the NRC Resident Inspector.

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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: 45634
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: GEOFF COOK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/18/2010
Notification Time: 23:43 [ET]
Event Date: 01/18/2010
Event Time: 19:50 [PST]
Last Update Date: 01/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (R4DO)
ROBERT KAHLER (NSIR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY OPERATIONS FACILITY INACCESSIBLE DUE TO ROAD FLOODING

"On January 18, 2010, at about 1950 PST, the access road to the SONGS MESA facilities became flooded after a day of rain. The San Onofre Emergency Operations Facility (EOF) is located at the MESA and because of the flooding, is inaccessible to passenger vehicles. While the EOF itself is operable, in the event of an emergency at San Onofre, SCE [Southern California Edison] would direct EOF emergency responders to the alternate EOF located in Irvine, California. SCE is reporting this occurrence to the NRC in accordance with 10CFR50.72(b)(3)(xiii).

"At the time of this occurrence, Unit 2 was shutdown for a Steam Generator Replacement outage and Unit 3 was operating at about 100% power. SCE will notify the NRC Resident Inspectors about this occurrence and will provide them with a copy of this report."

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