United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2010 > June 23

Event Notification Report for June 23, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/22/2010 - 06/23/2010

** EVENT NUMBERS **


46015 46022 46027 46028 46029 46030 46033 46034 46035

To top of page
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.

To top of page
General Information or Other Event Number: 46022
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: PA-0233
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/17/2010
Notification Time: 13:51 [ET]
Event Date: 06/03/2010
Event Time: [EDT]
Last Update Date: 06/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - HIGH DOSE RATE TREATMENT ADMINISTERED TO AN UNINTENDED AREA

The following report was received via facsimile from the Commonwealth of Pennsylvania:

"The licensee called the PaDEP [Pennsylvania Department of Environmental Protection] Southcentral Regional Office on the morning of June 16, 2010, to provide a 24-hour verbal notice of a medical event. The licensee also notified the patient and attending physician on June 16, 2010. The event involves a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045.

"On June 3, 2010, a patient was undergoing HDR [High Dose Rate] treatment for ovarian cancer. The area to be treated was incorrectly entered into the HDR computer and resulted in the patient receiving a dose to an unintended area. This event was discovered during the second fraction of treatment on June 15, 2010. Cause of the event was human error.

"The Department is awaiting more event details at this time and plans to send regional staff to conduct an inspection on June 21, 2010. Final event details will be communicated in a NMED report."

PA Event No.: PA100012

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.

To top of page
General Information or Other Event Number: 46027
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: WESLEY MEDICAL CENTER
Region: 4
City: WICHITA State: KS
County:
License #: 19-C041-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 10/01/2006
Event Time: [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)

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

Event Text

AGREEMENT STATE REPORT - FOUND BRACHYTHERAPHY SOURCE PREVIOUSLY LOST

The State of Kansas provided the following information via facsimile:

"This event that occurred during the 4th quarter of 2006 at Wesley Medical Center, LLC, was determined during the State of Kansas IMPEP [Integrated Materials Performance Evaluation Program] inspection conducted the week of June 14, 2010, to be reportable under 10CFR2201. An electronic update to the NMED database will follow. Below are details of the event.

"During an inspection by KDHE [Kansas Department of Health and Environment] of Wesley Medical Center 2/14/2007, a review of the 4th quarter Radiation Safety Committee notes revealed that a brachytherapy source was lost for approximately 45 hours. From the inspector's notes: 'Incident where a Cs-137 brachytherapy source was lost for approximately 45 hours before being found in the sheets in the laundry room by the RSO [Radiation Safety Officer]. RSO did not make a determination of exposure to the patient based on conservative and worst case scenarios. Incident was not reported to the State.'

"The RSO notes read: 'We had one recordable event that has been noted in the HNS system. We had one misplaced cesium 137 brachytherapy source. A patient presented for treatment of cervix cancer and we used low-dose Fletcher Suit system where the cesium sources dwell within the patient for 45 hours. The plan was reviewed and the patient was loaded. On the day of removal, one source was missing when the RSO emptied the tandems. Both physicists searched extensively for the source using a Geiger counter. The source was located on the floor in the laundry capture room for women's health. It was determined that the source never reached its destination in the patient, and that it most likely fell into the bed linens during insertion. One environmental service worker spends approximately five minutes per day having an approximate exposure of 1 mRem from that activity. A member of the public would be limited to 100 mRem of exposure per year and the exposure rate would be approximately 1.2 mRem per hour at 3 meters; some of the walls in the room are cinder blocks which provide some shielding. It was suggested that linen be left in the patient's room during their stay to guard against having an incident such as this in the future.'

"The licensee was issued a citation for failure to report this as a lost source.

"Update information provided during the week of June 14, 2010 indicated that the source activity was 37 mCi (15 mg Ra equivalent)."

KS Event No.: KS100006.

To top of page
General Information or Other Event Number: 46028
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: STATE OF KANSAS
Region: 4
City: TOPEKA State: KS
County:
License #: 22-B315-01
Agreement: Y
Docket:
NRC Notified By: DAVID J. WHITFILL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 03/28/2006
Event Time: [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following information was received from the Kansas Department of Health and Environment via facsimile:

"On 3/29/06, Kansas Department of Transportation (KDOT) reported by phone that a portable gauge got hit by a vehicle near SW US 77/50 last night [3/28/06]. The gauge was packed in its shipping container and was ready to load on a truck when the accident happened. The shipping container sustained minor damage. An assessment is being made with details to follow. Follow-up actions will be reviewed in inspection space.

"On 4/7/06, an inspection was conducted of licensee's facility. No items of non-compliance were found. Licensee continues to calibrate and clean their own devices as per their license conditions. If necessary, gauges are sent to the manufacturer for repair.

"On 5/5/06, reports and narratives were received from KDOT personnel involved with the gauge incident. Gauge failed Validator assessment and is being recalibrated. No other damage to the gauge itself was reported.

"Note: This item was determined during the State of Kansas IMPEP [Integrated Material Performance Evaluation] inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR30.50(b)(2)(iii) - The 24 hour report of an event where required equipment is disabled or fails to function as designed when no redundant equipment is available and operable to perform the required safety function."

Kansas Item Number: KS060007

To top of page
General Information or Other Event Number: 46029
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TETRA TECH
Region: 4
City: KANSAS CITY State: KS
County:
License #: 22-C250-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 08/14/2007
Event Time: [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIALLY DAMAGED TROXLER

The State of Kansas provided the following information via facsimile:

"During the course of an inspection performed on 10/31/2007, it was discovered that Tetra-Tech had a gauge damaged in an accident at a temporary jobsite on 8/1/2007. The gauge was leak tested and shipped back to the manufacturer (Troxler) and refurbished and then returned to Tetra-Tech. Tetra-Tech did not notify the State of the damaged gauge and was issued a citation via the Inspection letter dated 11/15/2007. Terra-Tech responded in a letter dated 12/26/2007 and that was accompanied by several pictures of the damaged gauge. Based on the licensee's description and the photos the gauge was only superficially damaged with only a slight dent being visible on one end of the gauge. Had KDHE [Kansas Department of Health and Environment] been notified at the time of the accident on 8/14/2007 and been sent pictures, no response would have been required. The licensee understands, based on their letter, the need to communicate with KOHE regarding future incidents. No further action is required.

"This item was determined during the State of Kansas IMPEP [Integrated Materials Performance Evaluation Program] inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR30.50(b)(2). An electronic update to the NMED database will follow."

KS Event No.: KS070010

To top of page
General Information or Other Event Number: 46030
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: HONEYWELL
Region: 4
City: OLATHE State: KS
County:
License #: GL 506
Agreement: Y
Docket:
NRC Notified By: DAVID J. WHITFILL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 07/27/2006
Event Time: [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING STATIC ELIMINATOR

The following information was received from the Kansas Department of Health and Environment via facsimile:

"On July 27, 2006, Honeywell reported by phone that an internal review showed that a static eliminator device shipped 12/18/03, activity 10 mCi, was missing. As of the report date, the activity of this device would have been 84 microCi (138 day half-life). This would give a gamma exposure of 172 microR/h at 30 cm (11 microR/h at 1 m).

"A search for the device was done, but the device was not found. The root cause was a loss of accountability in that the device was issued to an entire production team or line versus an individual bench within the production line.

"Corrective action included issuing of the devices through the Health, Safety, and Environment (HSE) department rather than a tool crib. Also the devices will only be issued to an individual to improve personal accountability.

"The manufacturer was notified. This event is considered closed.

"Note: This item was determined during the State of Kansas IMPEP [Integrated Material Performance Evaluation] inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR20.2201(a)(1)(ii) - Reporting within 30 days after the occurrence of any lost, stolen or missing material in excess of 10 times the appendix C quantities."

Kansas Item Number: KS060014

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

To top of page
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
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
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.

* * * UPDATE FROM BARTON CROW TO JOE O'HARA AT 1042 ON 6/22/10 * * *

"On 6/22/10 at 0557 Cooper Nuclear Station made a news release concerning the 'Notification of Unusual Event' declared today at 0206 for Missouri River level at 899 feet above sea level.

"This is a 4 hour report per 10CFR50.72(b)(2)(xi) for any event or situation for which a news release has been made that causes heightened public or government concern. State and local agencies were notified by the 'Notification of Unusual Event' declaration.

"At 0900 CDT Missouri River level was at 899.35 feet above sea level.

"The licensee notified the NRC Resident Inspector."

To top of page
Power Reactor Event Number: 46034
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: NORMAN KUZEL
HQ OPS Officer: JOE O'HARA
Notification Date: 06/22/2010
Notification Time: 11:32 [ET]
Event Date: 10/07/2009
Event Time: 10:30 [EDT]
Last Update Date: 06/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMES DWYER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Cold Shutdown

Event Text

HISTORICAL CONDITION PREVIOUSLY REPORTED IN LER 2009-003 SHOULD ALSO HAVE BEEN REPORTED IN ACCORDANCE WITH 10 CFR 50.72 (b)(3)(v)(D)

"On October 7, 2009, two independent diesel generators were rendered inoperable. This was reported in LER 2009-003 as a condition prohibited by plant technical specifications and a common cause that resulted in two independent trains becoming inoperable.

"Upon further review, the condition which existed at Millstone Power Station Unit 2 and reported to the NRC in LER 2009-003, should also have been reported per the requirements of 10CFR50.72(b)(3)(v)(D). A supplement to LER 2009-003 will be submitted.

"The NRC Resident Inspector has been notified."

To top of page
Power Reactor Event Number: 46035
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: CALVIN ACKLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/22/2010
Notification Time: 15:52 [ET]
Event Date: 11/01/2008
Event Time: 04:30 [EDT]
Last Update Date: 06/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMES DWYER (R1DO)

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

Event Text

HISTORICAL CONDITION PREVIOUSLY REPORTED IN LER 2008-005 SHOULD ALSO HAVE BEEN REPORTED IN ACCORDANCE WITH 10 CFR 50.72 (b)(3)(v)(C)

"A required containment penetration was not fully closed during fuel movement from November 1, 2008 until November 3, 2008. This was reported in LER 2008-005 as a condition prohibited by plant technical specifications.

"Upon further review, the condition that existed at Millstone Power Station Unit 3 and reported to the NRC in LER 2008-005, should also have been reported per the requirements of 10 CFR 50.72(b)(3)(v)(C). A supplement to LER 2008-005 will be submitted. The NRC Senior Resident Inspector has been notified."

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