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Event Notification Report for February 3, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/02/2011 - 02/03/2011

** EVENT NUMBERS **


46528 46574 46577 46581 46584 46585 46588

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Agreement State Event Number: 46528
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: SAINT NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGEN State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 14:29 [ET]
Event Date: 01/10/2011
Event Time: [CST]
Last Update Date: 02/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - NUMEROUS MEDICAL EVENTS FROM PROSTATE BRACHYTHERAPY

The following was received from the state via fax;

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a comprehensive review of all prostate brachytherapy cases to determine whether any medical events had occurred. On January 10, 2011, the licensee's Radiation Safely Officer reported the identification of five medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. The licensee is identifying a medical event of any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only. [D90 is a recognized value in the regulatory guidelines and means a dose of 90% to the prostate. Anything outside of the D90 value is considered to be a medical event.] The licensee performed a comprehensive review of all 44 prostate implants performed since August 2003. The licensee's five medical events include one overdose to the prostate and four underdoses to the prostate. All were patients who received seed implants only. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1)(e).

"Overdoses (medical event criteria used: D90>195 Gy): 11/13/2008: 199.15 Gy

"Underdoses (medical event criteria used: D90<135 Gy):
2/9/2007: 100.20 Gy;
11/12/2007: 127.34 Gy;
6/16/2008: 130.12 Gy; and
7/13/2010: 116.16 Gy"


* * * UPDATE FROM CHRIS TIMMERMAN TO JOHN KNOKE AT 1212 EST ON 2/1/11 * * *

"This is an update to Event Notification 46528. The licensee recently performed post-implant dosimetry on seven prostate brachytherapy patients whose post-implant dosimetry had never been performed. Evaluation of these seven implants prompted the licensee to report two additional medical events. The medical events involved permanent implants of l-125 for prostate brachytherapy where the total dose delivered to the prostate differs from the prescribed dose by 20% or more. The licensee is in the process of notifying the affected patients and referring physicians.

"Underdoses (medical event criteria used: D90<135 Gy):
8/22/2005: 102.89 Gy; and
5/8/2006: 126.24 Gy;

"DHS will send a special inspection team to determine the root cause(s) of these medical events."

WI Event Report ID No.: WI 110001 Update

Notified FSME(Angela McIntire) and R3DO (Richard Skokowski)


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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Agreement State Event Number: 46574
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSON CLINIC, LTD
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/27/2011
Notification Time: 15:43 [ET]
Event Date: 01/26/2011
Event Time: [CST]
Last Update Date: 01/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MEDICAL UNDERDOSE

The following report was received via fax:

"On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS [Wisconsin Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients.

"Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%.
"Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%.
"Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%.

"DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report."

Wisconsin Report Number: WI110003

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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Agreement State Event Number: 46577
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County: SUFFOLK
License #: RCN01762
Agreement: Y
Docket:
NRC Notified By: ANTHONY CARPENITO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/31/2011
Notification Time: 13:59 [ET]
Event Date: 01/13/2011
Event Time: [EST]
Last Update Date: 01/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL DOSE EXCEEDING ANNUAL OCCUPATIONAL DOSE LIMIT FOR ADULTS

The following was received via email:

"On 1/13/11, the licensee reported to the Agency [Massachusetts Radiation Control Program] a potential dose exceeding the adult occupational total effective dose equivalent limit of 5 rem. The situation causing this event occurred during late December 2010, when a number of emergency repairs within a cyclotron were conducted over several days. The potential for overexposure was suspected on 1/5/11. A dosimeter exposure readings report of the [Optically Stimulated Luminescence OSL) was received by the licensee from the dosimeter service, after quick read, on 1/13/11. Affected individual's annual TEDE reported at 5457 mrem. Exposure (1596 mrem) obtained by official [OSL) dosimeters worn during cyclotron repair operations differed significantly from exposure (620 mrem) obtained by electronic dosimeter worn simultaneously during cyclotron repair operations. Electronic dosimeters are used by individuals for real-time readings during the repair operations. The licensee removed affected individual from any potentially high exposure operations.

"Investigation ongoing. Intermediate and draft reports have been received. Awaiting final written report by licensee.

"The Agency considers this event to still be OPEN."

Massachusetts Event # 01-9454.

Notified R1DO (Dwyer) and FSME (McIntosh).

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Power Reactor Event Number: 46581
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID BONVILLIAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/01/2011
Notification Time: 17:51 [ET]
Event Date: 02/01/2011
Event Time: 14:30 [CST]
Last Update Date: 02/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (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

SEVERE WEATHER CONDITIONS

"At 1430 on 2-1-2011, due to worsening road conditions from heavy snowfall, a determination was made that there is a loss of plant access for some individuals and some impairment of evacuation routes. This meets the criteria for an immediate notification (8 Hour) per 10 CFR 50.72 (b)(3)(xiii). There is no impact on plant operation, all T/S [Technical Specification] required minimum staffing requirements are satisfied. The weather is predicted to be hazardous until the evening of 2/2/2011. The Missouri Department of Transportation reported they have a plow truck running from Callaway Plant to Jefferson City, MO. They also reported visibility is extremely poor due to blowing snow. The Missouri State Emergency Management Agency duty officer has been notified of the degraded Callaway ERO [Emergency Response Organization] response time and evacuation route issues.

"The NRC Resident Inspector was notified of this event by the licensee."

Two shifts of personnel will be on site throughout this event. Diesel fuel, food, and water are above required minimums.

* * * UPDATE FROM DAVID BONVILLIAN TO JOHN KNOKE AT 1821 EST ON 02/02/11 * * *

"As of 1600 [CST] on 2/2/2011, road conditions have significantly improved. Primary evacuation routes have been reported to be passable. There is reasonable assurance of normal ERO response time. NRC Resident Inspector has been informed of the intent of this change and will be notified of this communication."

Notified R4DO (Howell).

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Power Reactor Event Number: 46584
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CURTIS LYCKE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/02/2011
Notification Time: 08:52 [ET]
Event Date: 02/02/2011
Event Time: 05:33 [EST]
Last Update Date: 02/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GEORGE HOPPER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOSS OF RCS COOLANT FLOW IN ONE LOOP

"Unit 2 Reactor automatically tripped at 0533 EST. This was due to loss of coolant flow in the 'C' RCS Loop. The first indication of the reactor trip was the annunciator for 'Loss of Coolant Flow > P8.' The 'C' RCP is running with motor current indicating normal. 'C' LOOP RCS flow is approximately 25% on all three channels with 'A' & 'B' RCS LOOP FLOW approximately 104%. All three auxiliary feedwater [AFW] pumps automatically initiated as designed on low-low steam generator level following the trip. Currently, RCS temperature is being maintained stable at no load temperature. All systems responded as expected with the exception of the Intermediate Range Neutron Indication. N36 indication was undercompensated and Source Range indication did not automatically energize, but was subsequently manually energized.

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) for 4-hour notification of RPS Activation and 10 CFR 50.72(b)(3)(iv)(A) for 8-hour notification of actuation of AFW. Plant responded as expected. The NRC Resident Inspector has been notified of this event and is on site.

"There were no radiation releases due this event, nor were there any personnel injuries or contamination events."

This was an uncomplicated reactor trip and all control rods fully inserted. The plant is in a normal electrical alignment. AFW has been secured and the steam generators are being feed from main feedwater. Decay heat is being released through the main condenser steam dumps. Estimated time for repair and re-start is not known.

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Power Reactor Event Number: 46585
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JAMES FORMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/02/2011
Notification Time: 10:08 [ET]
Event Date: 02/02/2011
Event Time: 07:00 [CST]
Last Update Date: 02/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
LINDA HOWELL (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation

Event Text

PARTIAL LOSS OF EMERGENCY SIRENS DUE TO SEVERE WINTER STORM

"February 2, 2011, at approximately 0600 hours (CST), a Severe Winter Ice Storm was experienced causing a loss of 11 of 40 emergency sirens (approximately 28 percent) for Clinton Power Station. At 0700 hours (CST), since the sirens were not restored to operation within one hour, this event was determined to be a major loss of emergency assessment capability. Currently, 29 of 40 sirens are operational and no estimated return to service has been provided for the remaining sirens.

"DeWitt County, Illinois Emergency Management Agency, and the NRC Resident Inspector have been informed of this information."

Unit operation is not affected by the storm. No additional contingency actions have been planned. No press release is planned.

Also notified R4DO (Howell) due to weather issue at Region 3.

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Power Reactor Event Number: 46588
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RON GIBBS
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/02/2011
Notification Time: 17:14 [ET]
Event Date: 02/02/2011
Event Time: 08:30 [CST]
Last Update Date: 02/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

PARTIAL LOSS OF PROMPT NOTIFICATION SYSTEM (PNS) EMERGENCY SIRENS DUE TO A LOSS OF POWER

"At approximately 0830 [CST] on 2/2/2011, eleven (11) of thirty-two (32) STP Prompt Notification System (PNS) sirens were not operable due to loss of power. The sirens were subsequently polled at approximately 0909 [CST] and all sirens except 3 were operable. The loss of power was caused by rolling outages due to unusually severe cold weather. ERCOT issued an order requiring load shedding to maintain a steady state system frequency of 59.8 Hertz (Hz) on the grid. The outages were suspended at 1400 hrs but rolling outages could continue through the end of the week potentially affecting the sirens. All 32 sirens were likely affected during the outages for some un-quantified period of time. Continuous polling of the sirens was not performed or advisable since polling depletes the batteries which could affect the operability of the sirens.

"STPNOC [South Texas Project Nuclear Operating Company] has notified Matagorda County Sheriff Department. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of using Local Law Enforcement Personnel for 'Route Alerting' of the affected areas of the Emergency Planning Zone (EPZ). Matagorda County Emergency Management has verified that the Matagorda County Sheriffs Department is on standby for Route Alerting.

"STPNOC is currently transitioning to new sirens. While the new sirens are not currently credited in the STP Emergency Plan, we have received final FEMA approval. All of the new battery-backed sirens were tested and verified to remain operable and capable of notifying the population in the EPZ.

"This notification is being made under 10 CFR 50.72(b)(3)(xiii) due to a significant loss of the offsite Prompt Notification System. It is possible that rolling outages may recommence in the next several days."

The licensee informed the NRC Resident Inspector and the offsite agencies identified above.

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