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Event Notification Report for September 16, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/15/2010 - 09/16/2010

** EVENT NUMBERS **


46236 46245 46253 46254

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Hospital Event Number: 46236
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERAN AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS E. HUSTON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 14:00 [ET]
Event Date: 09/08/2010
Event Time: [CDT]
Last Update Date: 09/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL DOSE DIFFERENT THAN PRESCRIBED DOSE

The following information was received by e-mail from a program manager with the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA), National Health Physics Program (NHPP):

" [The VHA is] notifying the NRC of 11 medical events at G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi. These medical events occurred for Iodine-125 permanent prostate seed implant brachytherapy.

"As historical information, 10 medical events were reported to NRC on earlier dates for prostate seed implants at this medical center under NRC Event Report No. 44522.

"Following up on those medical event reports, VHA initiated a comprehensive external review and reanalysis of post-treatment dose parameters for all prostate seed implants performed at the medical center.

"Upon evaluation of updated dose information generated by the external review, medical center staff, working with NHPP, discovered on September 8, 2010, that 11 additional medical events need to be reported.

"10 of the 11 events were based on updated D90 values (considered to be final values) for the planned treatment site being 80% or less than the prescribed dose. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(1)(i).

"1 of the 11 events was based on absorbed dose to a tissue other than the treatment site exceeding the expected dose by 50% or more. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(3).

"As additional information, medical center staff, working with NHPP, has determined that 4 of the 10 previously reported medical events under NRC Event Number 44522 could be retracted because updated D90 values (considered to be final values) from the external review are above 80% of the prescribed dose. If retraction of these 4 events is pursued, NHPP will discuss the dose information with NRC Region III prior to notifying the NRC Operations Center of the retractions.

"NHPP will ensure that the medical center follows NRC requirements for notification of the referring physician and patient for these medical events. The patients involved in the medical events have been tracked by the medical center and the clinical outcomes for the patients have been verified to be consistent with expected clinical outcomes for successful prostate seed implants.

"A 15-day written report of these medical events will be submitted to NRC Region III.

"[The VHA] will notify the NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events.

"In summary, [VHA is] confirming a total of 17 medical events for the medical center. 11 medical events are reported today (10 based on a low dose to treatment site; 1 based on elevated dose to other organs and tissues). 6 medical events were reported previously under NRC Event No. 44522. 4 of the 10 medical events previously reported under NRC Event No. 44522 no longer meet criteria as medical events and might later be retracted.

"Additional Information:

"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.

"VHA permit number of permittee involved in event: Permit No. 23-08786-01."

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: 46245
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: JELD-WEN WOOD FIBER OF OREGON
Region: 4
City: KLAMATH FALLS State: OR
County: KLAMATH
License #:
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/10/2010
Notification Time: 17:29 [ET]
Event Date: 02/22/2010
Event Time: [PDT]
Last Update Date: 09/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE REPORT - BROKEN FIXED GAUGE SHUTTER

The following information was received via facsimile:

"Jeld-Wen Wood Fiber of Oregon located in Klamath Falls possesses 5 fixed gauges at their wood door manufacturing facility.

"In late December 2009, the Radiation Protection Services [RPS] office [State of Oregon] received a phone call from [the Jeld-Wen] Maintenance Manager, who talked to [the] RPS Licensing Manager and stated that he wished to report that there were two gauges at their facility that were having shutter mechanism problems. [The Maintenance Manager] stated he would elaborate on the issue in an email.

"On February 22, 2010, [the Maintenance Manager] emailed [the RPS Licensing Manager] and stated that the gauge with the broken shutter mechanism (Ronan, model SA-8, serial M2119, 20 mCi Cs-137, high level indicator gauge, installed 12-15-88) was operating in the open shutter position and unable to close. [The Maintenance Manager] stated that the licensee had manufactured a 1.5" thick shutter (by approximately 8 inches wide by approximately 1 meter long) that fits between the gauge and the vessel it is attached to. He also stated that this gauge is in a restricted access area that is roped off and the closest area of worker frequency is 20 feet away. [The Maintenance Manager] stated that the other gauge with the 'sticking' shutter (Ronan, model GS-200, serial 3401, 50 mCi Cs-137, digester level indicator, installed 12-15-88) is closable and is also operating. He stated that he would be scheduling a repair for the 50 mCi gauge and would be evaluating whether a replacement will be needed for the 20 mCi gauge.

"On March 15, 2010, [the Maintenance Manager's] email to [the RPS Licensing Manager] was given to [an RPS employee] in radioactive materials licensing. From [the RPS Licensing Manager's] email, another staff member may be working on this incident. [The RPS employee] phoned [the Maintenance Manager] and found that this was an event possibly not entered into the system but he would check with materials inspectors to see if that was the case. [The Maintenance Manager] stated that he was scheduling for repair of the 50 mCi gauge and possibly the 20 mCi gauge but not sure of the latter. [The Maintenance Manager] also stated that he would be submitting an amendment request naming him as Radiation Safety Officer.

"On May 21, 2010, [the RPS employee] requested an update on the repairs/actions by the licensee for the two gauges. No response was received.

"On June 9, 2010, [the Maintenance Manager] phoned [the RPS employee]. He stated that the company did not have the fiscal ability to replace the 20 mCi gauge and asked if the company could continue operating the gauge for approximately 2 more years. [The RPS employee] stated that the SS&D sheet would have to be reviewed as well as an onsite inspection of the gauge.

"On June 23, 2010, [the RPS employee] reviewed the SS&D for the 20 mCi device. For a 500 mCi Cs-137 source, exposure rates with the shutter open were listed as 43 mR per hr at 2 inches, 4.3 mR per hr at 1 foot, and 0.6 mR per hr at 1 meter. At 4 percent of maximum activity allowed, the 20 mCi source located in a restricted access area using 1 meter distance should give an exposure rate of approximately 300 microR per hr maximum. It was also determined that an inspection would be made of the facility in Klamath Falls in late July [in order] to verify exposure rates around the gauge with the shutter open.

"On July 27, 2010, an inspection of the facility was performed by [another employee of RPS]. [This other RPS employee] determined exposure rates around the 20 mCi gauge to be approximately 100 microR per hr at 1 meter. [This other RPS employee] also noted that the gauge is located at or below the catwalk that accesses that area. The licensee was allowed to continue operation with the shutter. [The other RPS employee] also discovered that the 50 mCi gauge with the sticking shutter was not actually sticking but merely hard to open and close due to residue/resin buildup. The licensee cleaned the residue off and covered the shutter mechanism and gauge with a metal canopy to prevent future buildup. Vendor work on this gauge was not performed as the licensee corrected the issue internally. Management approval for the modified shutter of the 20 mCi gauge will be sought at this time. [The Maintenance Manager] noted also during the inspection that the issues with the two gauges had been known by the licensee for approximately 2 years and was only then being reported because he was to become the new RSO and thought it should be.

"On September 10, 2010, a review of this incident was performed and it was found that the NRC HOO had not been notified. A copy of open NMED events for Oregon was also reviewed and no mention of this incident was found. NRC was notified of the incident at this time. Oregon RPS management has not made a final decision on the 20 mCi gauge with the broken shutter mechanism."

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Power Reactor Event Number: 46253
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: BETH JENKINS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/15/2010
Notification Time: 12:03 [ET]
Event Date: 09/15/2010
Event Time: 03:13 [CDT]
Last Update Date: 09/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

HPCI DECLARED INOPERABLE DURING SURVEILLANCE TESTING

"In preparation for quarterly valve testing, the High Pressure Coolant Injection system was declared inoperable and the technical specification required actions were implemented. The system was available for on-line risk. During the testing, the inboard steam isolation valve was stroked closed and reopened and operated properly. The valve was reclosed to continue with valve testing. When an attempt was made to reopen the inboard isolation valve, the valve failed to indicate full open.

"The system remained inoperable due to the valve malfunction. Therefore, the condition is being reported in accordance with 10 CFR 50.72 (b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"Maintenance activities are currently in progress to restore the system to the operable status."

The licensee entered a 14-day Limiting Condition of Operation per Technical Specification 3.5.1.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46254
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: NATHAN SEID
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/15/2010
Notification Time: 21:00 [ET]
Event Date: 09/15/2010
Event Time: 17:40 [CDT]
Last Update Date: 09/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JEFF CLARK (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

BOTH CONTAINMENT HYDROGEN ANALYZERS OUT OF SERVICE DUE TO FAILED SURVEILLANCES

"At 1740 CDT, VA-81A, Hydrogen Analyzer Panel, was declared not functional due to failing surveillance test OP-ST-VA-0006, Containment Hydrogen Monitor Monthly Check. VA-81B, Hydrogen Analyzer Panel, was previously not functional due to performance of surveillance test IC-ST-VA-0033, 18 Month Channel Calibration of Containment Hydrogen Analyzer, VA-81B.

"This results in no Hydrogen Analyzers being available to monitor containment, which prevents being able to assess for potential loss of containment barrier for Emergency Action Level purposes via the containment hydrogen greater than 3% method.

"USAR [Updated Safety Analysis Report] section 9.10.2.5 allows for both Hydrogen Analyzers to be out of service for up to 72 hours. "

The licensee informed the NRC Resident Inspector.

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