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Event Notification Report for March 3, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/02/2010 - 03/03/2010

** EVENT NUMBERS **


45721 45725 45727 45733 45737 45738 45739

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Hospital Event Number: 45721
Rep Org: CHRISTIANA CARE HEALTH SYSTEM
Licensee: CHRISTIANA CARE HEALTH SYSTEM
Region: 1
City: WILMINGTON State: DE
County:
License #: 07-1215302
Agreement: N
Docket:
NRC Notified By: LARRY SIMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/24/2010
Notification Time: 12:56 [ET]
Event Date: 02/23/2010
Event Time: 11:00 [EST]
Last Update Date: 02/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WAYNE SCHMIDT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

POTENTIAL MEDICAL EVENT FROM DOSAGE DELIVERED TO DIFFERENT LOCATION THAN PRESCRIBED

"[The patient] completed her prescribed 5 day, 10fx [High Dose Rate] HDR Brachytherapy to the left breast on January 22, 2010, utilizing a multi-lumen mammosite catheter device. On Feb 22, 2010, in follow-up, the patient complained about skin reddening on the external breast, outside of the mammosite catheter insertion site. The medical physicist involved in the treatment planning process was notified about the unusual finding, who upon investigating the treatment and the plan used to deliver the radiation treatment, found that an incorrect measurement resulted in placement of the radioactive source 10 cm away from the intended position, thereby delivering the prescribed dose to a portion of the unintended area. Majority of the dose was delivered in air, but a significantly high dose was delivered to a small volume of the skin distal to the connector end of the catheter, which could have caused the skin reaction.

"Description of circumstances that led to the event: On Thursday, January 14 at 1130, [the patient] was brought to the HDR suit for CT simulation and the needed measurements. Following the CT scan of the left breast, the physicist went in the room with the source position simulator (a dummy source wire with the exact length of the actual live source cable) to measure the treatment distance for each catheter (distance to the tip of the catheter). A transfer tube was connected to the proximal end of each catheter and dummy cable was fed through the same till it could not go any further. This point is understood as the tip of the closed end catheter. While the dummy cable was being fed, the physicist felt resistance at 115.2 cm, which he recorded as the distance to the tip of the catheter. He then repeated the same measurement for the other three catheters and found that the distance of resistance was the same. All four lumens were measured and the distances were recorded. This multi-lumen mammosite catheter was the first one to be used on a patient and therefore the physicist assumed that this is the correct distance for this device, although other devices similar to this device have different treatment distances. The physicist did not exert extra pressure on the dummy cable fearing the rupture /malfunction of the catheters.

"There were two representatives from the manufacturer present, for proctoring, as this was the first case of the multi-lumen mammosite catheter. The physicist expressed his concern about the unusual treatment distance to one of the representatives, who said that the distance sounded right.

"The measured distances were entered in the plan as the position of the first dwell position of the radiation source for each catheter. The treatment plan was generated and sent to the treatment console for storage and treatment execution that next week. The planning system cannot detect any errors in the treatment distance, as long as the distance is within the length of the closed system.

"The patient returned for her first treatment on the morning of Monday, January 18, and started with treatments, twice a day for five days. There were no warnings or error messages from the treatment console and the treatments were delivered as planned.

"The radiation oncologist reported that the mammosite multi-lumen catheter had no unusual aspects or appearance at either insertion at surgery or at extraction after the last treatment fraction.

"Discovery of the error: Soon after the physician's follow-up meeting with the patient, Monday, February 22, 2010, the physicist was informed about the unusual skin reaction on the patient, on February 22, 2010. The physicist immediately began investigating the treatment records and the treatment plan. He then tried to measure the treatment distance on a sample mammosite multi-lumen device which the manufacturer had provided, as a test device, with the same source position simulator and encountered a similar resistance at the exact same distance. But when exerted more pressure on the source cable, it advanced further and the distance turned out to be 125.2, which was 10 cm longer than the measurement done on the patient. This observation led him to conclude that the patient did not receive the treatment at the intended area, but at 10 cm proximal to the catheter tip, which included some skin and tissue of the external breast medial to the entry point of the device where the skin reaction is. The physicist recalled similar resistance on the dummy source cable on other occasions, which leads to a possible fault with source position simulator assembly. It was also possible that the lumens were kinked at some point inside, where the housing of the lumens was bent (to facilitate wound dressing), thereby causing resistance for the advancing of the dummy source cable.

"A treatment plan was generated that night representing what happened and the following conclusions were made upon review by physics staff that next morning, February 23, 2010, regarding the treatment of the unintended tissue and skin:

"a. An average dose of 1700 cGy was delivered to approximately 100 cc of the unintended breast tissue.

"b. About 7.5 cc of the skin and underlying tissue received a high maximum dose of 6800 cGy (possibly the area of skin reaction)

"c. 35 cc of the intended breast tissue received an average dose of 340 cGy (10% of the total prescribed dose)

"Recommendations:

"1. The physicist should make a list of treatment distances for all standard applicators including partial breast treatment devices and catheters.

"2. Include a therapist or a nurse in the process of all patient measurements and have them double-check the patient measurements.

"3. Acquire a new source position simulator assembly and a set of transfer tubes.

"4. Make a second measurement of the treatment distance on all patient catheters prior to the first treatment."

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: 45725
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS SAN ANTONIO
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 05217
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 02/25/2010
Notification Time: 14:13 [ET]
Event Date: 01/26/2010
Event Time: [CST]
Last Update Date: 02/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL SHALLOW DOSE EQUIVALENT OVEREXPOSURE

"On 1/26/10, the Agency [State of Texas] received a report from the licensee's Radiation Safety Officer stating they had received a report from their dosimetry processor indicating one of their workers had received 230 rem to the badge worn on his left hand. The right hand badge read 1.420 rem for the same period. The RSO stated that the individual involved handled predominantly Fluorine (F)-18. His deep dose equivalent (DDE) for the same period was 439 millirem. The RSO stated that the typical exposure to the hands is between 500 and 1,200 millirem and that the DDE was about 250 millirem per exposure period. The RSO believed the exposure was to his badge only. The RSO stated that on December 23, 2009, the individual was involved in a spill of F-18 and his badge may have become contaminated causing the exposure. The RSO stated that he was waiting on a statement from the individual involved.

"On February 25, 2010, the Agency received a written report of the event from the licensee. A review of the report indicated that the information provided did not appear to substantiate the conclusion made by the licensee that this was a badge only event. The Agency's position is that the actual shallow dose equivalent (SDE) is currently unknown, and may have exceeded the limit. The Agency has begun their investigation. Additional information will be provided as obtained."

Texas Incident Number I-8707

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General Information or Other Event Number: 45727
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 02/25/2010
Notification Time: 18:54 [ET]
Event Date: 01/21/2010
Event Time: [EST]
Last Update Date: 02/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY IMPLANTS OUTSIDE OF THE INTENDED TREATMENT AREA

The following information was received via fax:

"Notifications: The licensee called the PaDEP Southeast Regional Office on the morning of February 25, 2010 to provide a 24-hour verbal notice of a possible Medical Event. The SERO and Central Office discussed the known facts around noon time, and understood the U Penn RSO would be providing more information via email. DEP also provided a verbal notice to NRC Region 1 regarding this possible ME on 2-25-2010.

"On January 21, 2010 a patient was treated by brachytherapy for prostate cancer with sixty five (65) iodine-125 (I-125) seeds. The I-125 seeds were implanted using real time dosimetry under ultrasonic guidance. The written directive called for a therapeutic radiation dose of 145 gray (Gy) [14,500 rad] to the prostate volume, plus 5 millimeters of margin, using interoperative planning. On February 23, 2010, the patient returned for a 30 day post-implant CT. The scan showed that the implanted seeds were "in an appropriate pattern," but outside the intended target. On February 24th the licensee's Radiation Oncology group determined that an additional quality assurance review was warranted, but the RSO should notify PaDEP/BRP [Pennsylvania Department of Environmental Protection/Bureau of Radiation Protection] regarding the case. Based on the information known at this time, PaDEP/BRP believes this ME is reportable under 10CFR35.3045, and may be an Abnormal Occurrence (AO). The state will perform a reactive inspection next week, and coordinate with NRC Region I; because of their ongoing evaluation of pre-April 2008 brachytherapy implants at U Penn, and at the Philadelphia VA hospital.

"Cause of the event: A new ultrasound unit that was used to place the I-125 seeds may have been malfunctioning.

"Actions: There is a reactive inspection scheduled to investigate this apparent ME at U Penn on March 2, 2010. PaDEP/BRP will also ask U Penn to evaluate the need for FDA notification regarding the ultrasound unit."


Event Report ID Number: PA100002

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: 45733
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: ACUREN INSPECTIONS
Region: 4
City: DORCHESTER State: NE
County:
License #: KS RECIPROSIT
Agreement: Y
Docket:
NRC Notified By: HOWARD SHUMAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/27/2010
Notification Time: 13:46 [ET]
Event Date: 02/26/2010
Event Time: 18:40 [CST]
Last Update Date: 02/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LYDIA CHANG (FSME)
RYAN LANTZ (R4DO)

Event Text

AGREEMENT STATE - POTENTIAL OVEREXPOSURE DURING RADIOGRAPHY

A representative of the State of Nebraska has received preliminary information about a radiography incident that may have resulted in overexposures. The incident occurred during radiography of elevated piping at a pumping station. The radiographer and a contactor operating an aerial lift bucket had just completed a radiography shot on some overhead piping. The assistant radiographer was in a different location and had supposedly retracted the source into its safe position. Because the radiographer had his alarming rate meter under his clothing, and because there was significant ambient noise in the work area, the radiographer did not immediately hear that his rate meter was alarming as he and the aerial lift operator approached the radiography camera guide tube to set up for the next shot. When the radiographer heard the alarm, he checked his pocket dosimeter and found it off-scale. The radiographer had the assistant re-perform the source retraction and was subsequently able to confirm that the source was now fully retracted into the camera's safe position.

Based on initial estimates by the radiographer, his worst case exposure could be as high as 7.1 REM. The best case scenario would put his exposure around 200 mREM. The aerial lift operator, who is not a radiation worker, is believed to have exposures less than the radiographer. The radiographer's TLD has been sent for immediate processing by Landauer.

The State should have an inspector at the site on 2/28/10. This report will be updated and more details provided after the State completes its initial inspection.

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Power Reactor Event Number: 45737
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MORGAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/02/2010
Notification Time: 11:30 [ET]
Event Date: 03/02/2010
Event Time: 07:30 [EST]
Last Update Date: 03/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN WHITE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

PRESSURIZER SAFETY NOZZLE WELD DEGRADATION

"A Unit-1 Pressurizer Safety Relief Valve Nozzle to Safe-end Weld, (#4SR-1006-1) was discovered to have an indication not acceptable under ASME Section XI, IWB-3600. The weld is on a 4 inch diameter line to the pressurizer safety relief valve (RV-201). The weld is in our dissimilar metal weld inspection program and was scheduled to be examined this RFO [refueling outage] in accordance with MRP-139 requirements. Initial inspections on 3/1/10 found an indication and the indication was confirmed by a second NDE level 3 examiner. Indication is circumferential, initiated at ID and propagates approximately 1.8 inches circumferentially to about approximately 70% through wall. ASME IWB-3500 allows up to 12.5% through wall for class 1 welds. The defect was found using phased array Ultrasonic Testing (UT). The NDE report is being reviewed and characterized at this time.

"At this time, we believe the most probable cause of the indication is primary water stress corrosion cracking. No active leaks have been identified, the defect is not through wall.

"Unit 1 is in Mode 6. A team has been established and repair options are being investigated."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45738
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MATTHEW FORREST
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/02/2010
Notification Time: 16:40 [ET]
Event Date: 02/25/2010
Event Time: 23:15 [EST]
Last Update Date: 03/02/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
JOHN WHITE (R1DO)
BRIAN HOLIAN (NRR)
WILLIAM GOTT (IRD)

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

Event Text

DISCOVERY OF AN AFTER-THE-FACT UNUSUAL EVENT

"This is a one-hour report for the discovery of a condition that briefly met the emergency action level (EAL) for an Unusual Event but did not warrant declaration of an emergency classification. A detailed review of the conditions that existed at approximately 2315 EST on February 25 during a winter storm determined that the winds reached a speed of approximately 94 miles per hour for approximately four seconds. This wind speed exceeded the EAL value of greater than or equal to 90 miles per hour. However, because the condition cleared within approximately four seconds, a declaration of an Unusual Event would not have been warranted. The information examined during this detailed review was not the wind speed indication displayed in the control room and used by the operators for evaluating Emergency Action Levels. The additional analysis, which was performed following the winter storm, used data obtained by Engineering. The control room indication remained below 90 miles per hour at all times. This event is a one-hour report based on the guidance in NUREG-1022 for a condition that met an emergency plan EAL and the basis for the emergency classification no longer existed at the time of discovery. The [NRC] Resident Inspector has been informed of this notification and good neighbor notifications will be made to [the State of] New Hampshire and Massachusetts."

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Power Reactor Event Number: 45739
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: LANCE LANE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/02/2010
Notification Time: 18:48 [ET]
Event Date: 03/02/2010
Event Time: 14:58 [CST]
Last Update Date: 03/02/2010
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):
CHUCK CAIN (R4DO)

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

Event Text

AUTOMATIC REACTOR TRIP CAUSED BY LOW STEAM GENERATOR WATER LEVEL

"Wolf Creek experienced a reactor trip at 1458 CST. The first out annunciator was Steam Generator Level Lo Lo Reactor Trip.

"The trip was caused by the loss of the 'A' Main Feed Pump. The cause of the loss of the feed pump was due to the loss of 120 VAC non-safety instrument inverter PN09. PN09 supplies the Main Feed Pump Speed Control Circuitry.

"The loss of the PN09 also resulted in the loss of the ability to dump steam to the main condenser. Initial post trip decay heat was being removed with the Steam Generator Atmospheric Relief Valves and Auxiliary Feed Water. The Atmospheric Relief Valves cycled from approximately 1458 CST until approximately 1504 CST. Primary to Secondary leakage is less than 2.68 gallons per day.

"PN09 was re-energized at 1554 CST.

"All systems functioned as designed with the exception of the instrumentation powered by PN09. At the time of the trip the 'A' Emergency Diesel Generator and the 'A' Class IE Air Conditioning Unit were out of service for maintenance.

"The plant is being maintained at normal Mode 3 pressure and temperature."

The reactor trip was uncomplicated and decay heat is currently being removed by steam dumps to the main condensers.

The licensee has notified the NRC Senior Resident Inspector.

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