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Event Notification Report for March 2, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/01/2011 - 03/02/2011

** EVENT NUMBERS **


46528 46643 46649

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 03/01/2011
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.

* RETRACTION FROM MEGAN SHOBER TO JOHN SHOEMAKER VIA FACSIMLE AT 1355 EST ON 3/1/11 *

"This is a second update to Event Notification 46528. The licensee is retracting an overdose previously reported for a patient who received a permanent prostate implant on November 13, 2008. During a reactive inspection conducted on February 18, 2011, DHS inspectors identified that post-implant dosimetry of prostate brachytherapy implants had not been performed appropriately. Specifically, the licensee's former physics consultant generated post-plans that were not based on the number of I-125 seeds actually implanted in the patients. For the patient in question, the original post-plan was based on an implant of 98 seeds; however, only 76 seeds were actually implanted. The licensee's current physicist generated a new post-plan using the correct number of I-125 seeds and observed a corresponding reduction in dose delivered. The new D90 value for this patient does not meet the licensee's medical event criteria."

WI Event Report ID No.: WI 110002, 2nd Update

Notified FSME(McIntosh) and R3DO (Dickson)

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Agreement State Event Number: 46643
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TRICAN WELL SERVICE
Region: 4
City: SPRINGTOWN State: TX
County:
License #: GLA G02259
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOE O'HARA
Notification Date: 02/25/2011
Notification Time: 19:03 [ET]
Event Date: 02/25/2011
Event Time: 16:15 [CST]
Last Update Date: 02/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
ROBERT LEWIS (FSME)

Event Text

MISSING SHUTTER HANDLE ON BERTHOLD MODEL LB 8010 PORTABLE DENSITY GAUGE

On 2/22/11, Trican Well Service was preparing to use the portable gauge at a well jobsite in De Soto Parish, Louisiana when they discovered the gauge was missing its shutter handle. The crew stopped work, took surveys to ensure the shutter was fully closed, and placed the gauge out of service until a repair can be performed. The device is a Berthold Model LB 8010 serial number 10074 portable density gauge used in well servicing operations. The device contains 20 milliCuries of Cs-137, serial number 014808. The crew does not know when the handle became detached. They searched the jobsite for the handle but were unsuccessful in recovering it. The device is in the custody of the licensee. Berthold has been contacted and plans to repair the gauge on March 1, 2011.

Texas Incident No. I-8825

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Power Reactor Event Number: 46649
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: PHIL SANTINI
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/01/2011
Notification Time: 12:54 [ET]
Event Date: 03/01/2011
Event Time: 11:00 [EST]
Last Update Date: 03/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)

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

EMERGENCY DIESEL GENERATORS START ON A LOSS OF POWER FROM 138 KV CIRCUIT

"At 1100 EST, Indian Point Unit 2 experienced a loss of offsite power from the 138 Kv circuit. All three Emergency Diesel Generators automatically started as required. All other plant systems functioned as required. Restoration of offsite power from the 13.8 Kv offsite circuit is in progress. Investigation into the loss of the 138 Kv circuit is ongoing. Indian Point, Unit 2 continues in Mode 1 at 100 % power."

Indian Point, Unit 2 is in a 72 hour LCO due to a loss of 1 of 2 offsite circuits. Unit 3 was not affected.

The licensee has notified the NRC Resident Inspector and will be notifying the Public Service Commission of the State of New York.

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