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Event Notification Report for June 22, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/21/2010 - 06/22/2010

** EVENT NUMBERS **


45964 46009 46015 46033

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 45964
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK JENKINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/29/2010
Notification Time: 21:16 [ET]
Event Date: 05/29/2010
Event Time: 17:30 [CDT]
Last Update Date: 06/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MICHAEL SHANNON (R4DO)

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

CONTAINMENT PURGE ISOLATION SIGNAL CAUSED CONTROL ROOM ISOLATION SYSTEM ACTUATION

"While operating in Mode 1, 100% rated thermal power (RTP), Wolf Creek received a Containment Purge Isolation Signal (CPIS) caused by Containment Purge Exhaust Radiation Monitor GT RE-33 exceeding the high radiation trip setpoint. There was no containment purge in progress at the time of the CPIS so no containment dampers actuated or were required to actuate. Control Room Ventilation Isolation Signal (CRVIS) was also received, as expected, from the actuation of the CPIS. All CRVIS components actuated as required. Review of GT RE-33 identified that the radiation monitor spiked high causing the CPIS then returned to normal values. All other containment radiation monitors are indicating normal values.

"The NRC Resident has been notified of this event by the Licensee."

GT RE-33 is currently removed from service.

* * * UPDATE AT 1630 EDT ON 06/21/10 FROM RICK HUBBARD TO S. SANDIN * * *

"The licensee is retracting this event based on the following:

"The Containment Purge Exhaust Radiation Monitor GT RE-33 failed due to a corrupted database initiated by a Radiation Monitor System (RMS) communication loop problem. The signal was not initiated by actual plant conditions or parameters, so this was an invalid actuation. This actuation did not involve a critical scram. So it is not reportable per 10 CFR 50.72."

The licensee will inform the NRC Resident Inspector. Notified R4DO (Pick).

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General Information or Other Event Number: 46009
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: REDACTED
Region: 1
City: REDACTED State: NY
County: REDACTED
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: VINCE KLCO
Notification Date: 06/15/2010
Notification Time: 10:44 [ET]
Event Date: 05/26/2010
Event Time: [EDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL IMPROPER RADIATION DOSE

The following information was received by facsimile:

"A misadministration involving the implantation of radioactive seeds into the prostate (permanent brachytherapy) was reported to [the New York State Department of Health] office on May 28, 2010. The patient, a 58 year old male diagnosed with prostate cancer, Gleason score of 6, PSA of 3.8, was implanted on May 26, 2010. The prescribed dose was 145 Gy, to be delivered using Iodine-125 seeds, with an activity of approximately 0.36 mCi/seed. The patient was implanted with 112 seeds. A significant number of seeds (22) were placed outside the prostate gland, inferior to the gland (5.4 cm) and in the perineum. According to the medical physicist's calculations, the implanted area of the prostate received a D90 of 140 Gy.

"The initial indication is that the misplacement is a result of misidentification of the prostate by the radiation oncologist who performed the procedure. Ultrasound and C-arm fluoroscopy systems were used to aid with positioning the seeds. It appears that the patient's colon was not properly prepared, which caused poor ultrasound imaging. In addition, a Foley catheter was not inserted into the bladder, which made bladder localization difficult. A post implant confirmatory fluoroscopic image was obtained and the radiation oncologist observed that the sources were outside of the prostate area. On May 28, 2010, a post implant CT scan was performed which confirmed the seed locations and allowed for a calculation of the DVH [Dose-Volume Histogram] to the perineum of 10.0 Gy. The medical record has been requested and will be sent out for an expert review."

New York Event Report ID No: NYDOH-10-01

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: 46015
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF MINNESOTA
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1049-207-27
Agreement: Y
Docket:
NRC Notified By: BRANDON JURAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/16/2010
Notification Time: 15:45 [ET]
Event Date: 06/15/2010
Event Time: 12:15 [CDT]
Last Update Date: 06/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT ADMINISTERED TO WRONG LOCATION

The following report was received via e-mail from the State of Minnesota:

"Event description: The Minnesota Department of Health was notified on June 15, 2010 at 3:40 p.m. [CDT] of a medical event involving a gamma knife treatment at the University of Minnesota Medical Center - Fairview, University Hospital, Minneapolis. The total treatment consisted of 10 exposures, and was scheduled between 11:30 a.m. and 1:30 p.m. on Tuesday, June 15th.

"Five automatic positioning system (APS) shots were completed successfully, and then the treatment called for 5 additional trunnion exposures. The first trunnion exposure called for a setting of 76.3, 86.5, 148.1 in the X, Y, and Z directions, respectively. Instead, the settings of 76.3, 86.5, 76.3 were used. In effect, the X setting was inadvertently used for the Z setting. The error was noticed when the coordinates for the second trunnion exposure were being set up. The Z coordinate value used for the first shot was very different from the Z coordinate for next exposure.

"A new treatment plan was run to determine the dose and the location of the unintended exposure delivery. This plan showed a dose of 3.2 Gy (320 rad) to be delivered to a volume of 0.62 cubic cm at the unintended location. The original plan was re-exported to the GK treatment unit, so the exposure at X, Y, Z setting 76.3, 86.5, 148.1 could be given. Thus, the originally prescribed dose for the treatment region was given. The neurosurgeon and radiation oncologist explained the situation to the patient."

Device Manufacturer: Leksell Gamma System
Model: 24001 Type C

"Source Manufacturer: General Electric Company
Model: 43047

Event Report ID: MN100002


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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Power Reactor Event Number: 46033
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: THOMAS WALLER
HQ OPS Officer: PETE SNYDER
Notification Date: 06/22/2010
Notification Time: 03:26 [ET]
Event Date: 06/22/2010
Event Time: 02:06 [CDT]
Last Update Date: 06/22/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GREG PICK (R4DO)
ELMO COLLINS (R4)
TIM McGINTY (NRR)
ERIC LEEDS (NRR)
WILLIAM GOTT (IRD)
JOHN KNOX (DHS)
ERWIN CASTO (FEMA)

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

RIVER WATER LEVEL ABOVE 899 FEET

River water level exceeded 899 feet above sea level resulting in the licensee declaring a Notice of Unusual Event at 0206 CDT. The plant continues to operate at 100 percent power.

The licensee notified the NRC Resident Inspector.

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