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Event Notification Report for February 1, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/29/2010 - 02/01/2010

** EVENT NUMBERS **


45656 45661 45662 45668

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General Information or Other Event Number: 45656
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HOSPITAL
Region: 1
City: ALLENTOWN State: PA
County:
License #: PA-0232
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/25/2010
Notification Time: 22:01 [ET]
Event Date: 07/17/2008
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT- MEDICAL OVEREXPOSURE EVENT

The following information was received via fax:

"On July 17, 2008 the PA DEP SERO [Pennsylvania Department of Environmental Protection Southeast Regional Office] was notified of a medical event at Lehigh Valley Hospital. Two patients were scheduled for different I-131 therapy doses and the doses got switched. The first patient was prescribed 20 mCi but was administered 75 mCi. The event took place on July 17, 2008. Both the patient and the physician were informed. The patient was given a blocking agent of 130mg SSKI approximately 1 hour after uptake of the I-131. Next day measurements indicated 2 mCi uptake to the thyroid and 10 mCi whole body retention. A procedure modification has been put into place to prevent this from occurring again. Also a Notice of Violation was sent to the hospital."

Event Report ID No: PA080021


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: 45661
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ST. LUKE'S HOSPITAL
Region: 1
City: BETHLEHAM State: PA
County:
License #: PA-0073
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/25/2010
Notification Time: 22:37 [ET]
Event Date: 04/11/2009
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO AN EMBRYO / FETUS

The following excerpted information was received by facsimile:

"Notifications: DEP [PA Department of Environmental Protection] received a letter dated May 1, 2009; Received May 8, 2009 from St. Luke's describing the incident, corrective actions, effects and notification to the patient.

"A patient was administered a therapeutic dose of 134 mCi of I-131 for thyroid carcinoma on April 11, 2008. She had previous negative pregnancy tests on April 6, 2008 and April 10, 2008. Following treatment the patient suspected she was pregnant and returned to the hospital an April 28, 2008. Subsequent testing indicated she became pregnant approximately 4 to 6 days following her treatment. Calculated dose to the fetus was 35 rad, whole body dose. Patient and referring physician both notified. The event occurred because the patient didn't follow the contraceptive plan outlined in the procedure she signed prior to treatment. The hospital staff followed procedure for therapeutic administration of I-131, however corrective actions involve procedure modifications such as over-emphasizing the risks associated with becoming pregnant following administration of radioiodine to prevent further occurrence."

Event Report ID No: PA080016

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General Information or Other Event Number: 45662
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: ABILENE State: TX
County:
License #: 04590
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/26/2010
Notification Time: 14:34 [ET]
Event Date: 01/22/2010
Event Time: [CST]
Last Update Date: 01/26/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT

"On January 26, 2010, [The Texas Department of Health] was notified by the licensee that a source disconnect had occurred on January 22, 2010. A radiographer was cranking a 26 curie iridium (Ir) - 192 source from the camera when he began having difficulty driving the source. He decided to retract the source back into the camera when the source disconnected at the drive cable. The source was driven into the collimator at the end of the guide tube. The radiographer contacted his Radiation Safety Officer (RSO) and informed him of the event. An individual qualified for source retrieval was sent to the location. The source was returned to the camera, and the camera was returned to the licensee's facility. The individual performing the source retrieval received 120 millirem as indicated by his pocket dosimeter. The RSO stated that the failure appeared to be caused by a failure of the connector on the drive cable. The RSO stated that it was a result of normal wear on the device. [The Texas Department of Health] has requested copies of the last three maintenance records for the device. The source serial number is QH2505 manufactured by Spec. The camera serial number is 1203. Additional information will be provided as it is received."

Texas Incident #: I - 8706

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Power Reactor Event Number: 45668
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GARY CASEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/31/2010
Notification Time: 14:34 [ET]
Event Date: 01/31/2010
Event Time: 10:42 [EST]
Last Update Date: 01/31/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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

TEMA NOTIFIED OF A LOSS OF EMERGENCY SIRENS

"At 1100 EST on 1/31/10, the Sequoyah Nuclear Plant Shift Manager was made aware of notifications made to an outside government agency regarding Loss of Offsite Response Capabilities. Specifically, on 1/30/10 at 1826 EST, the Operations Duty Specialist made a Courtesy notification to the Tennessee Emergency Management Agency (TEMA) of 9 offsite sirens which had failed their polling test. This is well below the normal reporting criteria for the Emergency Plan. Subsequently, on 1/31/10 at 1042 EST, TEMA was notified that 4 of the sirens had been repaired, and only 5 sirens are still not responding to the polling test."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1636 EST ON 1/31/2010 FROM MIKE BRUBAKER TO MARK ABRAMOVITZ * * *

"This amendment is being provided to clarify that a loss of offsite notification capabilities did not occur. At 1100 EST on 1/31/10, the Sequoyah Nuclear Plant Shift Manager was made aware of a courtesy notification made by the TVA Operations Duty Specialist to TEMA regarding loss of a small number of sirens due to inclement weather conditions. The courtesy notification was made on 1/30/10 at 1826 to inform TEMA that 9 offsite sirens had failed their polling test. A loss of 9 sirens does not constitute loss of emergency preparedness capability. This amends the original report which was made within 4 hours of the shift manager's notification."

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Widman).

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Thursday, March 29, 2012