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Event Notification Report for February 18, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/17/2011 - 02/18/2011

** EVENT NUMBERS **


46609 46619 46621 46623

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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: 46619
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DOUG PETERSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/17/2011
Notification Time: 17:12 [ET]
Event Date: 02/17/2011
Event Time: 14:39 [CST]
Last Update Date: 02/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (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

OFFSITE NOITIFICATION DUE TO AN ALARMING EMERGENCY SIREN

"At 1439 [CST], on 2/17/2011, the NextEra Energy Duane Arnold control room was informed that an emergency siren in the Cedar Rapids area was alarming. This information came via the Cedar Rapids Police Department and Linn County Emergency Management Agency who stated that they had been informed that a siren was alarming.

"No emergency condition exists at NextEra Energy Duane Arnold and efforts are currently underway to determine if in fact an emergency siren is alarming."

The licensee notified the NRC Resident Inspector and the local press.

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Power Reactor Event Number: 46621
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: DENNIS MORRIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/17/2011
Notification Time: 19:07 [ET]
Event Date: 02/17/2011
Event Time: 15:11 [PST]
Last Update Date: 02/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VINCENT GADDY (R4DO)
SMITH (DOE)
DEDEAUX (EPA)
TIMMONS (USDA)
FORDE (HHS)
CASTA (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 19 Power Operation 19 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO HYDRAZINE SPILL CONTAINED ONSITE

"On February 17, 2011, at approximately 1200 PST, noted approximately 70 gallons of diluted 35% hydrazine had spilled fully contained in a bermed area from a chemical holding tank inside the Protected Area and subsequently removed to barrels.

"Off-site notifications were made as follows:
"National Response Center at 1536 [PST] [NRC REPORT #967808]
"Cal-EMA at 1530 [PST]
"San Diego Department of Health at 1526 [PST]"

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46623
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MORGAN
HQ OPS Officer: PETE SNYDER
Notification Date: 02/18/2011
Notification Time: 02:31 [ET]
Event Date: 02/18/2011
Event Time: 00:51 [EST]
Last Update Date: 02/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MARC FERDAS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

INACTIVE LEAK IDENTIFIED ON PRESURIZER HEATER WELL

"During a scheduled VT-2 boric acid examination on the Unit 2 Pressurizer lower level heater penetrations a boric acid leak was identified on heater penetration N-3."

The licensee characterized the leak as inactive. The approximate sizes of the round boric acid deposits are 1/32 inch and 1/64 inch. The licensee continues to investigate and plan recovery actions.

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012