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Event Notification Report for May 26, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/25/2011 - 05/26/2011

** EVENT NUMBERS **


46859 46860 46861 46865 46867 46869 46876 46883 46885

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Agreement State Event Number: 46859
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: JOE O'HARA
Notification Date: 05/19/2011
Notification Time: 13:03 [ET]
Event Date: 07/02/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION USING HDR AFTERLOADER

The following was received from the State of New York via fax:

"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee called on 7/2/07 to report an event involving HDR unit. Patient did not get incorrect treatment. In fact patient did not receive any therapeutic dose on this session. Here is what happened.

"A patient was receiving mammosite therapy with the Nucletron HDR unit. During this session, the therapist went into the treatment room, and placed the transfer tube on the patient (across from right superior to left inferior) but did not connect it to the catheter in the patient's breast. Then she went out to get the doctor. Neither of them checked to make sure that the catheter was connected to the transfer tube through the connector. Then they delivered the treatment. Since the mammosite connector (closed end) was attached to the transfer tube tune, there was no interlock. But there was no sensor or interlock to inform them that there was nothing connected to the other end of this connector. So the source proceeded as programmed and stuck out 16 cm from the end of the transfer tube in the connector tube. They saw this only when they went in to disconnect after treatment. According to their calculations, the source was at distance of 38 cm from the patient's left leg. Notice that the transfer tube is part of Nucletron equipment. The connector that connects from the transfer tube to the catheter is part of mammosite (Cytec) equipment. There was no sensor to ensure that this connection was made. It appears that the connector's closed end was sticking out in the air by the patient's leg and the programmed positions for treatment resulted in the source being in the connector in air about 16 cm from the patient's left leg. Physician/RSO admitted over the phone that the treating physician did not check the applicator and connection prior to treatment. The patient received the correct treatment later.

"Policy and procedure reviewed. 'The physician will log into the treatment system to initiate treatment delivery and he will be responsible to ensure that all treatment parameters and connections are satisfied'. A copy of the Cytec and Medwatch correspondence was included with the documentation.

"This case can now be closed."

HDR Brachytherapy event (NYS DOH Internal Tracking No. 553). NY Event Report Number: NY-11-02.

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: 46860
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City:  State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: JOE O'HARA
Notification Date: 05/19/2011
Notification Time: 14:36 [ET]
Event Date: 06/20/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION USING HDR AFTERLOADER

The following was received from the State of New York via fax:

"New York law prohibits the release of any identifiers In cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee telephoned [the State of New York] on 6/20/07, to report misadministration on 6/19/07. Patient was a 73 year old woman receiving the second of her 5 fractions of HDR for cancer of the cervix. It was a ring and tandem setup. 600 cGy prescribed to point A in the cervix. Patient moved about halfway through the treatment and with the applicator about 6 cm inferior to the cervix, the cervix received about 382 cGy while the vagina received about 218 cGy.

"During a conference call between Bureau staff and facility staff including radiation oncologist, physicist, and administrator, it was learned that the patient had had 10 children and muscles were not tight. Prior to the start of the treatment, she complained of discomfort from the foley catheter due to bladder distention and the clamp was loosened a bit. She continued to be uncomfortable and moved during the treatment of 644 seconds. Therapists reassured her and completed the treatment, despite the movement. It was discovered later that the applicator had slid inferior by about 6 cm.

"The radiation oncologist believes that the 218 cGy to the vagina will not impact the patient adversely because there is some disease in that area. The patient and the referring physician have been informed. The physician does not plan to make up for the deficit dose to point A in the cervix. Facility submitted an RCA and to prevent recurrence, they have implemented the following measures. (1) Minimize time between applicator insertion and treatment. (2) Use of stabilizing devices at the time of insertion to minimize applicator movement (3) Use anatomical markings at the time of device insertion to help verify applicator position just prior to and during treatment (4) Expand patient instruction with increased emphasis on need to remain still and (5) Staff education on patient monitoring prior to and during treatment, with applicator position verification added to physics checklist.

"These are sufficient.

"As of 5/13/09, the patient is free of disease and complications.

"This event may be closed."

HDR Brachytherapy misadministration (NYS DOH Internal Tracking No. 548). New York Event Number NY-11-01.

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: 46861
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NONE PROVIDED
Region: 1
City: NONE PROVIDED State: NY
County:
License #: NONE PROVIDED
Agreement: Y
Docket:
NRC Notified By: NONE PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/19/2011
Notification Time: 14:03 [ET]
Event Date: 10/02/2007
Event Time: [EDT]
Last Update Date: 05/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED TWICE THE PRESCRIBED DOSE

The following report was received via fax.

"New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report.

"The licensee reported on 10/3/2007 that on 10/2/2007, a patient received 4 mCi 131 Iodine for a whole body scan instead of the 2 mCi that was ordered. The error was discovered after the radiopharmacy tried to reconcile their orders and shipments and found that a vial with 4 mCi [milliCurie] of 131 Iodine was missing and called the hospital. The nuclear medicine department staff inspected the waste sent from the department to the environmental services section of the hospital and found that the box they had sent did trigger an alarm and had been isolated. On closer inspection, they found one vial containing 2 mCi Iodine 131. An extra vial of Iodine 131 of 4 mCi (meant for another order) had been placed by the nuclear pharmacy in the box and sent along with the 2 vials of 2 mCi each. The technologist retrieved this mCi vial and one 2 mCi vial and gave the 4 mCi iodine capsule to the patient.

"The NM [Nuclear Medicine] technologist had retrieved 2 vials from the box on 10/2/2007. The order was for 2 vials, one for the patient dose and the other the standard. Failures: 1. She failed to verify that the labels on the dose vials matched the labels on the shipping box. 2. She failed to read the label on the vial containing the capsule that she gave to the patient. 3. She failed to assay the patient dose using the dose calibrator. 4. She failed to survey the box before sending it to the environmental services for disposal. All 4 failures are in violation of the licensee's protocol for the use of radioactive materials.

"The authorized user physician believes that the dose of 4 mCi for a whole body scan is still within the range in use at the facility and does not expect any harm to the patient as result of this event. A health physicist was consulted and doses to various organs were estimated and documented. To prevent a recurrence, they have implemented a TlME OUT protocol for administration of RAM [radioactive material], which requires that 2 technologists must agree on the correctness of the activity, assay and document it on both a hard copy log and the computer in the hot lab.

"These steps are adequate.

"This event is closed."

New York Event Number: NY-11-03
New York State DOH Internal Tracking Number 566


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: 46865
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: S&ME INC.
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0922-4
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/20/2011
Notification Time: 11:32 [ET]
Event Date: 05/18/2011
Event Time: [EDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AND SUBSEQUENTLY RECOVERED TROXLER GAUGE

The following information was received from the North Carolina Radiation Protection Section via e-mail:

"On May 18, 2011, an employee of S&ME parked a company truck at his house. The truck had a Troxler 3411B Portable Nuclear Gauge double locked in an aluminum box in the bed of the truck.

"The next morning, he discovered the truck missing. Company management was notified, who in turn notified Local Law Enforcement and the agency [State of North Carolina]. About 15 minutes after the Agency notification. the police determined that the vehicle had been towed. The explanation for the towing of the vehicle was that the vehicle, which was in front of the employees residence, had its wheels on the grass.

"The vehicle was retrieved from the towing company. The gauge was still locked in its storage box and appeared untouched."

"Device/Material Info:

Troxler 3411B S/N 13772
Cs-137 S/N 50-2590 9 mCi
Am-241 S/N 47-9185 44 mCi"

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

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 46867
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHRIST HOSPITAL AND MEDICAL CENTER
Region: 3
City: OAK LAWN State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2011
Notification Time: 16:36 [ET]
Event Date: 05/13/2011
Event Time: [CDT]
Last Update Date: 05/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - EARLY TERMINATION OF RADIATION THERAPY BECAUSE OF POWER SUPPLY VOLTAGE VARIATION

"On Wednesday May 18th, the licensee's radiation safety officer contacted the agency [Illinois Emergency Management Agency] to advise that a medical event had likely occurred the prior Friday. Based on their initial evaluation, 1 of the 10 fractions prescribed for a patient was not delivered as intended such that less than 50% of the expected dose was delivered during a fraction.

"The written directive indicates that the patient was scheduled to undergo 10 treatments to her breast twice a day over a period of 5 days. Each treatment involved 340 centiGy for a total written directive prescription of 3,400 centiGy. During the 6th fraction after completion of treatments in channels 1 and 2, the unit experienced a power supply error. Sensing the power variation, the device automatically withdrew the source and did not complete the treatment for channel 3. Although additional attempts were made to clear the error and continue the treatment, none of the remaining 4 channels could be finished. The licensee had experienced similar problems with the device the previous week which had resulted in a service call on May 10. At that time the power supply was adjusted to ensure operation within specifications. The unit operated normally following the repair until the event on the 13th. The power supply as well as main controller board was subsequently replaced by the manufacturer Saturday morning and the patient returned that afternoon to complete the remaining portion of the 6th fraction. All the remaining fractions were delivered without incident. The fraction which finished the overall treatment was completed Tuesday. There have been no errors or incidents noted since the replacement of the above components.

"The licensee is still investigating this incident with the manufacturer to conduct an engineering evaluation of the power supply failure, however the 'fail safe' design of the system operated as expected. The licensee's initial estimate was that the patient received 133 centiGy of the 340 centiGy intended fractional dose. The patient and the referring physician were advised of the event but since the remaining fractions of the treatment were completed under the revised treatment plan, no adverse affect on the patient is expected and no other additional action is anticipated."

The intended dose for this fraction was 3.4 Gy. The dose received was 1.3 Gy.

Illinois Report Number: 11058

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 DAREN PERRERO TO VINCE KLCO ON 5/24/11 @ 0902 EDT * * *

The following information was received via email:

"On May 23, 2011 the licensee's medical physicist provided information to the agency [Illinois Emergency Management Agency] which demonstrated that the target volume involved in the interrupted fraction received a dose of 217 cGy of the prescribed 340 cGy rather than the conservatively estimated 130 cGy. This dose to the patient treatment volume represents 63% of the prescribed dose and therefore does NOT constitute a medical event as identified in regulations."

Notified R3DO (Cameron) and FSME EO (McIntosh)

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Agreement State Event Number: 46869
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: URSINUS COLLEGE
Region: 1
City: COLLEGEVILLE State: PA
County:
License #: PA-0952
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2011
Notification Time: 23:27 [ET]
Event Date: 05/20/2011
Event Time: 12:00 [EDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
CHRISTIAN EINBERG (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TRITIUM EXIT SIGN

The following report was received via fax:

"On 5/20/2011, the PA DEP [Pennsylvania Department of Environmental Protection] Bureau of Radiation Protection (BRP) was notified by the Safety Manager from Ursinus College, explaining that during their dormitory inspection performed this morning, a tritium exit sign with perhaps 10 to 20 curies of H-3 is missing and presumed stolen."

Pennsylvania Event: PA110011

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Non-Agreement State Event Number: 46876
Rep Org: ECS CAROLINAS, LLP
Licensee: ECS CAROLINAS, LLP
Region: 1
City: CAMP LEJEUNE State: NC
County:
License #: 32-31294-01
Agreement: Y
Docket:
NRC Notified By: HARRY SLATER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/24/2011
Notification Time: 13:24 [ET]
Event Date: 05/24/2011
Event Time: 12:30 [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)
LAURA PEARSON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TROXLER MOISTURE DENSITY GAUGE STOLEN

At approximately 1230 EDT on 5/24/11, a Troxler Moisture Density Gauge, Model #3440, S/N 20641, with 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen from a truck at Camp Lejeune Marine Corps Base. The RSO reported the theft to the Base Safety Officer.

* * * UPDATE FROM HARRY SLATER TO HOWIE CROUCH ON 5/24/11 @ 1431 EDT * * *

The Troxler Moisture Density Gauge was located on the job site off the side of the road in a ditch. There was no damage to the gauge, and the gauge was placed back into service.

* * * UPDATE FROM HARRY SLATER TO CHARLES TEAL ON 5/25/11 @ 0732 EDT * * *

The following was excerpted from an email:

"Initial investigation indicated that the [technician] did not have the gauge locked in the case while not in use. The gauge was also placed out of [the technician's] sight more than 10 feet from him. The case and the locking equipment were in the truck and are in working condition. The gauge did still have the lock trigger in place. The lack of securing the gauge when not in use is in direct violation of the company policies as indicated on the license and on the document signed by [the technician]."

Notified R1DO (Dentel), FSME EO (McIntosh), and ILTAB (Pearson).

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

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Power Reactor Event Number: 46883
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: VINCE KLCO
Notification Date: 05/25/2011
Notification Time: 11:36 [ET]
Event Date: 04/02/2011
Event Time: 12:18 [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
GLENN DENTEL (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

LOSS OF RPS/UPS POWER SUPPLY

"On Saturday, April 2, 2011, Unit 2 refueling outage activities were in progress. The 2A RPS/UPS Static Inverter was out of service and bypassed with loads transferred to the primary alternate power supply. At 1218 hours, a post maintenance test was performed on the secondary alternate power supply. The inverter alternate power manual transfer switch was transferred from the 'primary alternate' to 'secondary alternate' position to support the post maintenance test. Since the transfer switch is 'break before make' the alternate power supply was interrupted momentarily. This deenergized the 2A RPS/UPS power distribution panel loads including the Division IA and IIA RPS relays and Division IA and IIA NSSSS [Nuclear Steam Supply Shutoff System] relays. Primary containment isolation valves (PCIVs) automatically closed on more than one system. The IB and IIB channels were unaffected.

"The portion of the primary containment isolation system that received an actuation signal functioned successfully. All of the affected open isolation valves automatically closed. The isolation was a partial actuation of the isolation actuation instrumentation.

"This 60-day ENS report is being made per 10CFR 50.73(a)(2)(iv)(A) and 10CFR50.73(a)(1) to report invalid automatic actuations of systems listed in paragraph (a)(2)(iv)(B). The listed system that actuated was general containment isolation signals affecting containment isolation valves in more than one system. Primary containment isolation valves (PCIVs) closed on drywell chilled water (DWCW), reactor enclosure cooling water (RECW), primary containment instrument gas (PCIG), and suppression pool cleanup."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46885
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT W. DITTMER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 14:41 [ET]
Event Date: 05/14/2011
Event Time: 14:28 [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

VIOLATION OF LICENSE CONDITION

"On May 16, 2011, at 2013 Eastern Daylight Saving Time (EDT), Watts Bar Nuclear Plant Unit 1 (WBN) entered Technical Specification (TS) Limiting Condition for Operation (LCO) 3.7.5, Condition B, because based on performance of Surveillance Requirement (SR) 3.7.5.2, the Turbine Driven Auxiliary Feedwater system was determined to be inoperable. Failure of the surveillance was caused by loss of the ability to control the turbine driven auxiliary feedwater pump (TDAFWP) manually. This was the first operation of the TDAFWP since the turbine had been rebuilt and had a new governor and servo installed during the WBN refueling outage 10 in May 2011. Misalignment of the servo caused the controller to stick, so that the TDAFWP pump could not be controlled in manual. The servo was replaced and the TDAFWP subsequently passed its required surveillance. LCO 3.7.5 was exited at 1745 on May 19, 2011.

"Although the TDAFWP was not known to be inoperable until performance of the surveillance, TVA has concluded that the inoperability existed from the time that WBN entered Mode 3.

"WBN had entered Mode 3 at 1428 EDT, on May 14, 2011. LCO 3.0.4 prohibits MODE changes when an LCO is not met except under certain conditions that were not applicable to this event. Therefore, TVA considers that WBN entered Mode 3 without the required three operable trains of AFW.

"TVA also determined that the TDAFWP was inoperable for a period of 123 hours and 17 minutes while the plant was in Mode 3, which exceeded the 96 hours allowed for an inoperable train of AFW in LCO 3.7.5. (72 hours to restore, 6 hours to be in MODE 3, and 18 hours to be in MODE 4). It should be noted that actions were taken and completed within the required time from time of discovery of the condition.

"Changing MODEs when LCO 3.7.5 was not met, and exceeding the time allowed for an inoperable train of auxiliary feedwater (AFW) were determined to be reportable as a condition prohibited by Technical Specifications in accordance with 10 CFR 50.73(a)(2)(i)(b).

"Since these conditions are a violation of the requirements contained in Section 2.c of the WBN License (Technical Specifications), this notification is made in accordance with Watts Bar License condition 2.G.

"The NRC Resident [Inspector] has been notified."

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