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Event Notification Report for February 17, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/16/2011 - 02/17/2011

** EVENT NUMBERS **


46609 46618

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Agreement State Event Number: 46609
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: MERCY MEDICAL CENTER
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #: 0339157HDR
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2011
Notification Time: 13:39 [ET]
Event Date: 02/10/2011
Event Time: [CST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
KEITH McCONNELL (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING MAMOSITE BALLOON CATHETER POSSIBLY AFFECTED DOSE

The State of Iowa reported the following via email:

"The licensee reported a potential medical event that had occurred on Thursday, February 10, 2011.

"A patient was under going breast cancer treatment using a Nucletron Corporation Micro Selection High Dose Rate Afterloader (HDR). The HDR contained a 5.2 curie Iridium-192 sealed source. The patient was scheduled to receive a total dose of 3400 cGy in ten (10) fractions of 340 cGy each over a five day period. The licensee performs a CT scan on the patient before each fraction to confirm the positioning of the balloon catheter.

"On the morning of Thursday, February 10, 2011 the patient arrived for the seventh fraction. The licensee's CT scanner was not operable at the time so the Authorized User (AU) (Radiation Oncologist) imaged the patient using ultrasound. The AU noticed at the time that the patient had some drainage from the surgical incision but the results of the ultrasound appeared [to show] that the balloon catheter was correctly placed. The patient then received the seventh fraction. When the patient returned for the eighth fraction in the afternoon of the 10th the licensee's CT scanner was operable. This scan showed that the balloon catheter had completely leaked out all of the fluid. The AU and Medical Physicist made the decision to not perform the eighth fraction due to the possibility that the patient may have received a double dose (680 cGy) during the previous fraction.

"The patient, referring physician and surgeon were then notified. The surgeon removed the leaking balloon catheter and replaced it with a new catheter. The patient completed fraction nine on the morning of Friday, February 11, 2011 and is scheduled for fraction ten and treatment completion in the afternoon of the 11th.

"The AU and Medical Physicist do not believe that this event will result in any adverse complications to the health of the patient. The licensee will continue to investigate this event and provide a written report to IDPH within 15 days of the occurrence."

Iowa Item Number: IA110001

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: 46618
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW WISNIEWSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/16/2011
Notification Time: 15:29 [ET]
Event Date: 02/16/2011
Event Time: 11:25 [EST]
Last Update Date: 02/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARC FERDAS (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

Event Text

STEAM LEAK ON HIGH PRESSURE COOLANT INJECTION SYSTEM

"During system startup of [High Pressure Coolant Injection] HPCI for quarterly surveillance, audible and visual indications of steam leakage were observed. The system was secured and subsequently isolated (with outboard valve de-energized for configuration control). As a result of the steam leakage, a local fire alarm was received in the Control Room. HPCI is currently isolated and will not perform its safety function.

"Operators were dispatched to the Reactor Building fire panel to verify that the fire alarm was due solely to the steam leak. As a precautionary measure, personnel were evacuated from the Reactor Building. Operators entered [Off Normal Procedure] ON 3158, Reactor Building High Area Temperature/Water Level, and verified that room temperatures were decreasing after the steam line was isolated. No EOP-4, Secondary Containment Control, entry conditions were exceeded."

The steam leak was isolated when HPCI was secured. Associated fire alarms were verified to be caused by the steam leak. There was no impact on other plant equipment or personnel safety. The source of the steam leak is suspected to be from a steam trap but this has not been confirmed.

The licensee notified the NRC Resident Inspector and the State of Vermont Department of Public Service Nuclear Engineer.

Notified R1DO (Ferdas)

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