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Event Notification Report for January 11, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/10/2011 - 01/11/2011

** EVENT NUMBERS **


46522 46527 46530 46531 46532

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Agreement State Event Number: 46522
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: MEDICAL CENTER AT BOWLING GREEN
Region: 1
City: BOWLING GREEN State: KY
County:
License #: 202-124-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/05/2011
Notification Time: 16:51 [ET]
Event Date: 07/13/2010
Event Time: [CST]
Last Update Date: 01/05/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1DO)
JIM LUEHMAN (FSME)

Event Text

KENTUCKY AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was obtained from the State of Kentucky via email:

"The event timetable began on 12 July 2010 when the Medical Physicist entered the pre-treatment information into the facilities brachytherapy software package (VariSeed«, Varian Inc). The information included patient demographics, treatment date and radioisotope information; in this case I-125 encased in titanium for a treatment date of 13 July 2010. The medical procedure was carried out successfully and 97 seeds were implanted. This number of seeds is within the expected limit of what is normally encountered during these procedures and thus did not stand out as a triggering event for a double check.

"During a routine post-procedure review, conducted on 14 July 2010, the medical physicist identified a potential issue and began the chain of notification as required by the radiation safety office; medical, administrative and safety.

"The discrepancy arose from the identification of source activity, as indicated on the written directive versus the information printed on the post-procedure information sheet. The information had inadvertently been entered into the pre-procedure planning software in units of milliCurie while the units of measure were identified as units of 'U' [Air-Kerma], leading to a discrepancy in the delivered dose of approximately +27%. The specific information in this case indicated the strength was 0.410 U (0.323 mCi) while in reality the actual source strength was 0.521 U (0.410 mCi).

"The facility conducted a root-cause analysis that indicated two areas of concern for a root cause. The initial identified area of concern is the ability to enter information into an automated system in either of two separate units; 'U' or milliCurie. This was followed closely by the lack of a documented double verify means; which although always important to any therapeutic intervention, would have negated the incident in this case. Since the software does not allow for the exclusion of one unit in favor of the other, the root-cause is the failure to have in place a procedure that included the documented double-verification of the dose strength used in the calculations.

"In order to negate the recurrence of this type of error, the oncology physics section has implemented the following procedure. The therapeutic seeds will be ordered and received as is currently performed. The medical physicist will enter the information into the software package using the vendor supplied source strength of the implantable seeds; using the 'U' [Air-Kerma] value only. The Air-Kerma value has been chosen as the unit of preference because this is rapidly becoming the professional unit of choice by the medical physics community and is the default unit of the VariSeed« software package. Once in the operating room a time-out will be conducted between the medical physicist and the medical dosimetrist. The dosimetrist will observe the software settings while the medical physicist reads aloud the information contained in the 'Seed Count and Strength Verification' form including the seed strength; in 'U' [Air-Kerma], and procedure date. Both persons will then sign the form. The remainder of the process will remain unchanged.

"The patient was contacted by the radiation oncologist the morning of 15 July 2010 and returned for immediate CT imaging of the pelvis on 16 July 2010. The error was explained to the patient, as well as the urologist who assisted in the procedure, and additional monitoring of the prostate, rectum and urethra are to be conducted to better determine a dose distribution. At this point a general dose estimate is that the patient received 3,800 Rem greater than was intended. Although this estimate may be decreased or otherwise adjusted based on the serial monitoring to be conducted over the six months post-procedure.

"The procedure has been implemented and the physics section, including the radiation oncologist, have been in-serviced as of 26 July 2010."

The State of Kentucky received the above notification from the licensee on July 28, 2010. According to the State of Kentucky, the licensee did not originally report this event (via telephone on July 15, 2010) as a medical event therefore the State did not report the event to the NRC Operations Center. During an interoffice review, the State determined that a miscommunication had occurred and they should have reported this event to the NRC.

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: 46527
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: CRAIG NEUSER
HQ OPS Officer: PETE SNYDER
Notification Date: 01/10/2011
Notification Time: 11:51 [ET]
Event Date: 01/10/2011
Event Time: 09:21 [CST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

UNAVAILABILITY OF TSC AND EOF FUNCTIONS DUE TO SCHEDULED MAINTENANCE

"At 0921 CST on Monday January 10, 2011, the Kewaunee Power Station (KPS) disabled electrical power to the KPS Technical Support Center (TSC) to perform motor control center maintenance. The major TSC components that were disabled include plant process control system (PPCS) workstations, primary lighting, and ventilation. In the Emergency Operations Facility (EOF), PPCS workstations have been disabled. Additionally, the dose projection program (MIDAS) does not have the capability to automatically populate with plant data. The safety parameter display system (SPDS) and emergency response data system (ERDS) remain operational. This activity has been evaluated in accordance with 10 CFR 50.54(q) to ensure that KPS will be able to deal with an accident or emergency should one occur. If required, existing procedural guidance will be utilized to relocate TSC personnel to predetermined alternate locations. A copy of emergency procedures and emergency telephone directories are staged in the alternate locations.

"The maintenance is scheduled to be completed by 1400 CST on January 10, 2011.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM GARY AHRENS TO PETE SNYDER AT 1701 EST ON 1/10/11 * * *

At 1545 CST all of the functionality that was removed from service per the above notification was restored to service.

Notified R3DO (Kunowski).

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General Information Event Number: 46530
Rep Org: U.S. ARMY
Licensee: TACOM LCMC / US ARMY NATIONAL GUARD
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/10/2011
Notification Time: 16:22 [ET]
Event Date: 01/04/2011
Event Time: 09:00 [CST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

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

Event Text

TRITIUM VIAL CRACKED DURING MAINTENANCE OF MORTAR SIGHT UNIT

"On 4 January 2011 at 0900 hrs an Army National Guard employee was performing maintenance on a M64A1 sight unit in an attempt to remove the course elevation deflection scale on the sight unit which contained a 1 curie tritium lamp. The assembly is considered a module which is authorized by the licensee for replacement. During the removal of the scale assembly the tritium lamp was damaged. The worker immediately realized what had happened and called the local RSO to handle the incident. The State RSO was notified of the incident who in turn notified the US Army CECOM health physicist. The device was double bagged by the local RSO and placed in a designated LLRW storage area for future disposal. The local RSO performed contamination wipes of the device and surrounding works areas on Jan 4th. The arms room in the CSMS shop was immediately shut down and had limited access by authorized personnel. Wipe test results were received back from the Army lab on 6 Jan that indicated tritium contamination of 60 K dpm on the device itself and a few thousand dpm of the surrounding work bench. The RSO proceeded to decontaminated the affected contaminated areas and rewiped the work area to release it from radiological control. The second contamination survey (after decon) showed tritium contamination significantly reduced. At the time of this report the licensee does not have the final test results. The maintenance person involved in the incident was required by the licensee to have a tritium bioassay taken. Tritium bioassay results were not available at the time of the report. Investigation by the licensee is being conducted as to determine how the device was damaged during maintenance."

The event occurred at the New York Army National Guard, Combined Support maintenance Shop - Arms Room in Rochester New York.

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

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Power Reactor Event Number: 46531
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAULA GERFEN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 19:39 [ET]
Event Date: 01/10/2011
Event Time: 13:21 [PST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BOB HAGAR (R4DO)

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

Event Text

BOTH TRAINS OF AUXILIARY BUILDING VENTILATION BECAME INOPERABLE

"On January 10, 2011, at 1321 PST, Diablo Canyon Power Plant, Unit 2, entered Technical Specification Limiting Condition of Operation (TS LCO) 3.0.3, when both trains of Auxiliary Building Ventilation System (ABVS) became inoperable following closure of damper M-4 and the ensuing loss of both exhaust fans E-1 and E-2. TS LCO 3.0.3 was exited on January 10, 2011, at 1342 following a status reset and selection of fan E-2. This provided a ventilation flowpath and use of both exhaust fans in the Safeguards mode. Both trains of Auxiliary Building Ventilation are operable. This 8-hour non-emergency report is made pursuant to 10 CFR 50.72(b)(3)(v)(D)."

The unit is not in a TS LCO. All 3 unit EDG's are operable and offisite power is in the normal lineup.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46532
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: THOMAS DITCHFIELD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 21:47 [ET]
Event Date: 01/10/2011
Event Time: 12:00 [CST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

FITNESS FOR DUTY - CONTRACTOR CUSTODIAN FOUND WITH ALCOHOL INSIDE THE PROTECTED AREA

Alcohol was found in the possession of a contractor inside the protected area. The individuals access to the plant has been terminated. Contact the Headquarters Operations Officer for additional information.

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