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Event Notification Report for September 8, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/07/2010 - 09/08/2010

** EVENT NUMBERS **


46224 46228 46231 46232 46233

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Hospital Event Number: 46224
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: BRINDA NARAYANA
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/02/2010
Notification Time: 13:30 [ET]
Event Date: 08/30/2010
Event Time: 14:00 [EDT]
Last Update Date: 09/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MISPLACED PALLIATIVE SOURCE IMPLANTS

On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus.

More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants.

The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark.

No long term complications are anticipated.

Both patient and physician have been informed.

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: 46228
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CRYOVAC
Region: 4
City: IOWA PARK State: TX
County:
License #: TX - 01736
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/03/2010
Notification Time: 11:26 [ET]
Event Date: 09/02/2010
Event Time: 10:00 [CDT]
Last Update Date: 09/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

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

"On September 3, 2010, the [State of Texas] was notified by the licensee that on September 2, 2010 the shutter on a NDC Model 103 nuclear gauge failed to fully open during a routine maintenance check. The gauge contains a 150 milliCurie Americium - 241 source. The gauge shutter has been locked closed. The gauge has been removed from the vessel and placed into storage. The dose rate measured at 3 feet from the gauge was 0.4 milliRem per hour. No significant radiation exposure was received by an individual during this event. The manufacturer was contacted and intends to be on site on September 3, 2010 to repair the gauge."

Texas Incident No. I - 8778.

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General Information or Other Event Number: 46231
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 09/03/2010
Notification Time: 15:30 [ET]
Event Date: 09/02/2010
Event Time: [CDT]
Last Update Date: 09/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
BILL VON TILL (FSME)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The State of Texas submitted the following information via e-mail:

"On September 3, 2010, the [State of Texas] received a phone call from the licensee informing them that on September 2, 2010, while conducting routine gauge inspections, the shutter on an Ohmart Vega model SH-F1-A nuclear gauge failed to close. The gauge contains two milliCuries of Cesium (Cs) 137. Open is the normal operating position for the gauge. Radiation surveys in the area of the gauge were measured and were normal. The licensee tried to free the shutter operating mechanism using light oil, but it did not respond. The licensee stated that the gauge is 11 feet off of the ground and there is no access to it without the use of scaffolding and it does not pose a risk of exposure to anyone. The licensee will contact the manufacturer to request repairs on the gauge."

Texas Incident No. I-8779.

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Power Reactor Event Number: 46232
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KENT SLOAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/07/2010
Notification Time: 10:43 [ET]
Event Date: 09/07/2010
Event Time: 10:43 [EDT]
Last Update Date: 09/07/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
WILLIAM COOK (R1DO)

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

PLANT IN-PROCESS COMPUTER OOS FOR MAINTENANCE

"The Beaver Valley Power Station (BVPS) Unit 1 In-Plant Computer (IPC) will be taken out of service for approximately 4 weeks (9/7/10 - 9/30/10) to implement a planned modification. The current IPC is being replaced and a computer outage is required to allow for installation of a new IPC. During this time period the Emergency Response Data System (ERDS) data link to the NRC will not be available at BVPS Unit 1. Other computer based systems not directly associated with the IPC (e.g. Safety Parameter Display System (SPDS), meteorological data) will remain in operation. ERDS parameters will be available to be monitored by control board indications and temporary computer system set up prior to the IPC outage. Compensatory actions have been developed to direct one of the Technical Support Center (TSC) Operations communicators to respond to the control room during a BVPS Unit 1 emergency, should it occur, to facilitate data transfer to the NRC while the ERDS is out of service. Work on replacing the IPC and returning ERDS to service will be ongoing continuously until complete.

"This is an 8-hour reportable event per 10 CFR 50.72(b)(3)(xiii) Major Loss of Assessment Capability. The operation of BVPS Unit 1 and Unit 2 plant systems will not be adversely affected due to this planned action. BVPS Unit 2 ERDS will not be affected by these modifications.

"The NRC Resident Inspector has been notified."

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Other Nuclear Material Event Number: 46233
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: NORTH SLOPE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/07/2010
Notification Time: 11:54 [ET]
Event Date: 09/04/2010
Event Time: [YDT]
Last Update Date: 09/07/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BLAIR SPITZBERG (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

LOCKING MECHANISM MALFUNCTION ON RADIOGRAPHY CAMERA

"On September 4th the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6631).

"At the end of the shift the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated.

"The 2 mR/Hr boundary was reconfirmed and the Radiation Safety Supervisor was notified. A trained radiographer came to the site and removed the locking system and cleaned it. The locking system was successfully reinstalled. The camera has been returned to service.

"Exposure Device: Industrial Nuclear IR-100
Device S/N: 6631
Source S/N: P661
Source Activity: 84 curies
Source Type: Ir192
Source Model # INC Model 32

"There was no exposure to the crew or the general public during this incident."

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Thursday, March 29, 2012