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Event Notification Report for October 14, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/13/2010 - 10/14/2010

** EVENT NUMBERS **


46319 46320 46322 46326 46330

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Hospital Event Number: 46319
Rep Org: COMMUNITY HOSPITAL
Licensee: COMMUNITY HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 130600901
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/08/2010
Notification Time: 09:57 [ET]
Event Date: 10/06/2010
Event Time: [EDT]
Last Update Date: 10/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVE PASSEHL (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

DELIVERED DOSE POTENTIALLY DIFFERENT THAN THE PRESCRIBED DOSE

During a brachytherapy treatment, the patient breast received an incorrect entry of the catheter position from a treatment planning system. Because of this, the prescribed dose was 340 centi-Gray at 1 centimeter from the tumor cavity while the actual dose received was 680 centi-Gray at 1 centimeter from the tumor cavity.

The physician notified the patient of the potential dose difference. Based on physician review, it was determined that there was no affect on the patient.

The reason for the potential dose difference was due to a missed change of a program default in the software program of the radiation treatment planning system. A new check step has been added to the Community Hospital procedure in order to correct the issue.

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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Hospital Event Number: 46320
Rep Org: LIBERTY HOSPITAL
Licensee: LIBERTY HOSPITAL
Region: 3
City: LIBERTY State: MO
County: CLAY
License #: 241617801
Agreement: N
Docket:
NRC Notified By: SCOTT COZAD
HQ OPS Officer: VINCE KLCO
Notification Date: 10/07/2010
Notification Time: 11:32 [ET]
Event Date: 10/06/2010
Event Time: 09:00 [CDT]
Last Update Date: 10/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVE PASSEHL (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

DELIVERED DOSE POTENTIALLY DIFFERENT THAN THE PRESCRIBED DOSE

During a brachytherapy, a patient was prescribed a dose of 125 Gray to the prostrate. The delivered dose resulted in about 11 percent of the prescribed dose. The physician notified the patient and his guardian and also determined there was no radiation impact on the patient.

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: 46322
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: SOR TESTING LABS
Region: 1
City: Carteret State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES MCCULLOUGH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/08/2010
Notification Time: 19:45 [ET]
Event Date: 10/08/2010
Event Time: 15:00 [EDT]
Last Update Date: 10/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGE TO TROXLER PORTABLE DENSITY GAUGE

A Troxler portable density gauge was run over by a front end loader, at a construction site, causing damage and bending the source rod. The source rod is retracted but the shutter door is open. The density gage was returned to its storage container. Survey of the device and area indicates that no leakage occurred. The unit will be returned the licensee location for storage in a locked area for the weekend. The density gauge will be sent out for repair next week.

The density gauge is a Model 3430 Troxler with a nominal 8 mCi Cs-137 gamma source and a 40 mCi Am-241:Be neutron source.

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General Information or Other Event Number: 46326
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: IESCO, INC.
Region: 4
City: WILMINGTON State: CA
County:
License #: 6571-19
Agreement: Y
Docket:
NRC Notified By: STEVEN E. FRYSINGER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/11/2010
Notification Time: 21:15 [ET]
Event Date: 10/10/2010
Event Time: 11:45 [PDT]
Last Update Date: 10/11/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
PAUL MICHALAK (FSME)
MICHAEL SHANNON (R4DO)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - DAMAGE TO RADIOGRAPHY CAMERA GUIDE TUBE

The following information was received from the state via email.

"On October 10, 2010, at approximately 11:45 P.M., an IESCO radiography team was performing radiography operations at the Conoco Phillips Refinery in Wilmington, CA. The team was exposing a small pipe when a 6 inch pipe spool fell approximately 2 feet from a work bench to the ground where the source guide tube was lying while the source was extended during an exposure. The flange end struck the guide tube and it crimped the tube, preventing the source from being retracted after the exposure time had elapsed. The RSO was contacted at approximately 1150 and he responded to the scene. While waiting for the RSO to arrive, the radiographer sent the assistant away from the area and proceeded to adjust the boundary around the scene to where the dose rate at the boundary was 2 mr/hour (actual dose rate) or less and to maintain constant surveillance of the boundaries so that no one could enter the area where the incident had occurred.

"When the RSO arrived, he had both the radiographer and assistant stay out of the area of the incident and he proceeded to retrieve the source. He proceeded to straighten the guide tube and then placed 20 lb. lead shot bags on the source (the collimator had fallen off when the pipe spool struck the guide tube) to shield the source. The RSO then proceeded to cut open the source guide tube with tin snips. He then flattened the guide tube with lead sheets to expose the drive cable at the area where the guide tube was crimped to allow the source to be retracted back to the exposure device. While he was cutting the guide tube, the RSO placed his survey meter between himself and the source to monitor his exposure, along with two direct reading pocket dosimeters (DRPD) place at his chest (on had a 0-200 Mr range and the other had a 0-500 Mr range). He stated that his hands and chest were both approximately the same distance from the source during this phase of the recovery. While cutting the guide tube, the RSO periodically went to the crank to attempt to retrieve the source and then returned to cut more of the guide tube until the source was able to cranked without any resistance. After enough of the guide tube was removed to allow source to bypass the crimp, the RSO then went to retract the source. After the source had been retrieved, the exposure device was surveyed to ensure that the source was in the shielded position and then the exposure device was locked. The whole retrieval operation took approximately 30-45 minutes.

"The estimated dose to the RSO during this incident was 110 millirem on both DRPD's, which is equivalent to being exposed by a radiation field of 200 mR/hr for 33 minutes. The radiographer was discovered to have a DRPD that was off scale and thus was told to stay out of the area of the incident and his dosimeter was sent to Mirion Technology (formerly Global Dosimetry) for emergency processing. The radiographers assistant's dose was estimated at 10 millirem as read by his DRPD. An estimate of the radiographer's dose will need to be reported to determine if an over exposure has occurred. Since all reporting of the incident was timely and the procedures were followed for this incident and for the off-scale DRPD, there is no evidence that a violation has occurred and the licensee will not be cited at this time. Any future actions will be determined after a review of the 30 day report which will be provided by the licensee as required under 10 CFR 34.101(a)."

The radiography camera is a QSA Global A424-9 with Ir-192 35.6 Ci source.

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Power Reactor Event Number: 46330
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRANDON SHULTZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/13/2010
Notification Time: 09:50 [ET]
Event Date: 10/14/2010
Event Time: 01:00 [EDT]
Last Update Date: 10/13/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER EMERGENCY VENTILATION SYSTEM SCHEDULED MAINTENANCE

"This ENS is being issued in advance of a planned activity.

"On 10/14/10 at 0100 hours Limerick Generating Station will apply a clearance to inspect and repair fire suppression equipment associated with the onsite Technical Support Center (TSC) Emergency Ventilation System and perform corrective maintenance associated with the MD-1 (outside air) damper. While the clearance is applied, the TSC Emergency Ventilation system will not be available to be restored within the time period required to staff and activate the TSC Emergency Response Organization (ERO). This work is expected to be completed 10/14/10. If an emergency is declared requiring TSC ERO activation, the TSC will be staffed and activated using emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of TSC staff becomes necessary, the Station Emergency Director will relocate the staff to an alternate TSC location in accordance with applicable procedures.

"This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility because of the planned unavailability of the TSC Emergency Ventilation system. The NRC Resident Inspector has been informed."

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Thursday, March 29, 2012