Event Notification Report for January 12, 2011

UNPLANNED IODINE-131 DOSE TO AN EMBRYO

The following event description is from an email message:
"On 12 Jan 2011, a Nuclear Medicine patient received a dose of I-131 of 100 milliCuries for a thyroid ablation. She received a pregnancy test just before the dose was administered and the result was negative. Two weeks after the dose she made an ER visit complaining about nausea and vomiting; she was then administered a serum pregnancy test. The result indicated she was roughly two weeks pregnant. On 27 Jan the doctor notified the Navy that the patient became pregnant very close to the therapy time.

"On 28 Jan a dose calculation estimated the dose to the embryo to be 213 mGy (21.3 rads). On 31 January the Naval Radiation Safety Committee was notified that the patient was possibly pregnant prior to the therapy.

"Pregnancy test performed immediately prior to therapy was negative. Patient was not trying to get pregnant prior, but did have unprotected intercourse in the few days before therapy. She denies intercourse in the week after therapy. Standard precautions were given to the patient during a visit several weeks prior to the therapy and included the following: 1). She could not be treated if she was pregnant, and 2). A pregnancy test would be performed immediately prior to therapy.

"At a dose estimate of 213 mGy, there is a slight increased risk of failure to implant, but if the fetus survives, the outcome is expected to be good. This was discussed at length with the patient. The patient and the doctor communicated on 26 Jan after the patient discovered she was pregnant. Further follow up included a phone call the next day and a counseling visit 4 days later, after dose estimate calculations were completed. "

AGREEMENT STATE REPORT - THEFT OF A NUCLEAR DENSITY GAUGE

The following information was received by e-mail:

"The licensee's RSO [Radiation Safety Officer] contacted DRH [Mississippi Division of Radiological Health] to report the theft of their Troxler Model 3440 (S/N 26434) nuclear gauge that was secured in the back of their stolen white Ford F-150 pick-up truck parked in the licensee's fenced lot. The truck and gauge were estimated to have been stolen between 1500 [CST] and 1530 [CST]. The gauge was stored in the yellow plastic transport case with Radioactive Yellow II labels attached.

"The licensee was instructed by DRH to send in a written report describing the incidents leading up to the event that occurred on January 12, 2011, and any corrective actions or follow up performed. Once the gauge is located, DRH will survey and retrieve the gauge. DRH will notify NRC Operations. Event is under investigation and enforcement action may be required by DRH.

"Jackson City Police was notified by the licensee. Mississippi State Department of Health (MSDH) notified Mississippi Emergency Management and Mississippi Homeland Security. MSDH issued a press release January 13, 2011. DRH will notify NRC Operations."

Gauge Isotopes: Cs-137(9 mCi) and Am/Be-241 (40 mCi).

Mississippi Event Number: MS-11-001

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

LOSS OF UNIT 2 ESSENTIAL SERVICE 480V BUS

"On January 12, 2011, at 1020 hours, Unit 2 480V Essential Service Bus 29 was inadvertently deenergized. The cause of the bus trip was inadvertent contact with a bus feed breaker by a station employee during unrelated work activities. Normal power to Bus 29 was restored at 1026 hours. While Bus 29 was deenergized Division II core and containment cooling systems were unavailable and inoperable.

"The plant responded normally to the loss of Bus 29 with the exception of Bus 28/29-5 which should have automatically transferred from Bus 29 to the reserve feed from Bus 28. This condition renders both divisions of the Low Pressure Cooling Injection (LPCI) mode of the Residual Heat Removal (RHR) system inoperable. Technical Specifications 3.5.1.E has been entered, requiring restoration of LPCI in 72 hours.

"Bus 28/29-5 was manually energized from Bus 28 at 1213 hours; however, LPCI remains inoperable pending investigation and restoration of Bus 28/29-5 auto-transfer function.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function."

LPCI mode of the RHR system is inoperable because the auto-transfer function for Bus 28/29-5 provides a back-up power supply to the LPCI injection motor operated valves from Bus 28.

A swing diesel test was in progress during this bus loss, however the diesel was not loaded and had no impact on the bus failure. The diesel was subsequently secured.

The licensee notified the NRC Resident Inspector.