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Event Notification Report for June 22, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/21/2011 - 06/22/2011

** EVENT NUMBERS **


46962 46963 46968 46976 46977

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Agreement State Event Number: 46962
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2885-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/15/2011
Notification Time: 18:53 [ET]
Event Date: 09/22/2006
Event Time: [EDT]
Last Update Date: 06/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
LARRY CAMPER (FSME)

Event Text

PATIENT RECEIVED RADIATION THERAPY AND LATER DETERMINED TO BE PREGNANT

The following report was received via e-mail:

"Patient had thyroidectomy in 2005 and came into nuclear medicine dept. on Sept. 8, 2006 for consultation for I-131 treatment, the nuclear medicine [NM] resident interviewed her, explained precautions, stated importance of not becoming pregnant. A pregnancy test was performed on September 21, 2006 and the results were negative. The patient was then treated with 95 mCi of I-131 on September 22, 2006.

"After missing one of her Endocrine clinic appointments following the radioactive iodine therapy treatment, on December 22, 2006, the patient went to the Endocrine clinic for a follow up visit. Following that visit, NM was informed by endocrinology that the patient was pregnant. NM contacted OB/GYN and learned that the patient visited her OB/GYN physician and that ultrasound confirmed that the patient was pregnant. The ultrasound revealed that the patient was approximately 8-weeks pregnant, putting the date of conception at approximately September 1-6, so the patient was already 2-3 weeks pregnant at the time of the pregnancy test.

"It was estimated that the fetus received about 25 rad of radiation exposure. Upon discovery of the incident, patient was advised to see a genetic specialist immediately at the Montefiore Medical Park to discuss the radiation exposure to the fetus and possible consequences as a result of the radiation exposure.

"An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health."

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Agreement State Event Number: 46963
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN-KETTERING CANCER CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/15/2011
Notification Time: 18:22 [ET]
Event Date: 10/06/2009
Event Time: [EDT]
Last Update Date: 06/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
LARRY CAMPER (FSME)

Event Text

MEDICAL UNDERDOSE DURING BONE RADIATION THERAPY

The following report was received via e-mail:

"A patient was treated in the nuclear medicine department on October 6, 2009 with Quadramet (Sm-153 EDTMP) for bone pain administered by the user. The Nuclear Pharmacy prepared, assayed and dispensed 43.5 mCi of Quadramet. The dose was prepared with a needle attached to a syringe. After administration, the syringe and additional materials were returned to the Nuclear Pharmacy for re-assay to determine the activity remaining in the administering materials. Reassaying is a standard procedure. The assay revealed that 12.7 mCi of the Sm-153 remained in the syringe cap and the needle itself. The administered dose was determined to be 30.8 mCi, an underdose of approximately 30%.

"[The] attending physician in consultation with the Authorized User agreed not to bring the patient back to add to the dose already administered and to await the result of response. In their opinion, there will be no adverse affect on the patient.

"The Nuclear pharmacy will review whether a needle needs to be present on the dose syringe when dispensed. Nuclear pharmacy will also investigate availability and use of three-way lock to facilitate flushing of the syringe.

"An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health."

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: 46968
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: NEWARK BETH ISRAEL MEDICAL CENTER
Region: 1
City: NEWARK State: NJ
County:
License #: 508028
Agreement: Y
Docket:
NRC Notified By: WILLIAM CSASZAR
HQ OPS Officer: PETE SNYDER
Notification Date: 06/17/2011
Notification Time: 12:40 [ET]
Event Date: 06/17/2011
Event Time: 10:00 [EDT]
Last Update Date: 06/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - NUCLEAR CARDIAC PACEMAKER FOUND

"At approximately 10:00 AM EDT on Friday, June 17, 2011, a resident telephoned the above licensee and reported finding an 8 Curie Pu-238 nuclear cardiac pacemaker (ARCO NU-5 s/n 001). The licensee's medical physicist who interviewed the caller, immediately contacted NJDEP RMP [New Jersey Department of Environmental Protection Radioactive Material Programs). After interviewing the medical physicist, it was learned that the resident, while cleaning and gathering personal belongings of her deceased parent, came across an envelope that contained the pacemaker. The pacemaker was initially implanted in 1973 at the licensee's location (Newark Beth Israel) and removed in 1975 at an unknown location. After the pacemaker was removed, for reasons not yet known, it came back to the residence other patient where it remained until it's discovery on 6/17/11. The medical physicist has arranged to go to the resident's apartment later in the day where he will package the pacemaker for it's return and storage at the licensee's facility. At 12:15 PM the same day, the medical physicist reported that the pacemaker was safely returned to the licensee's facility. The pacemaker was intact with no signs of damage. The licensee will attempt to locate any files/information pertaining to the patient that may still be stored from the 1970's. A full report is expected from the licensee."

NJ Event ID No. NJ-11-17-06

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Non-Agreement State Event Number: 46976
Rep Org: ELI LILLY & COMPANY
Licensee: ELI LILLY & COMPANY
Region: 3
City: INDIANAPOLIS State: IN
County:
License #:
Agreement: N
Docket:
NRC Notified By: STAN HAMPTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/21/2011
Notification Time: 15:47 [ET]
Event Date: 06/21/2011
Event Time: [EDT]
Last Update Date: 06/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
ERIC DUNCAN (R3DO)
JIM LUEHMAN (FSME)
ILTAB via email ()

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

Event Text

TWO TRITIUM EXIT SIGNS DISCOVERED MISSING DURING ROUTINE INVENTORY

Two (2) generally licensed tritium exit signs were discovered missing from their installed location in Building 80 at the Eli Lilly facility in Indianapolis, IN. Each exit sign contained a calculated activity of 19 Curies.

Manufacturer information and serial numbers (S/N) as follows:

Manufacturer - SRBT, Mfg date - April 2010, S/N - C077812
Manufacturer - SRBT, Mfg date - May 2010, S/N - C078813

Both signs were installed on 10/6/2010.

The licensee is conducting an investigation and will determine appropriate corrective actions.

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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Power Reactor Event Number: 46977
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: RICK GARCIA
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/21/2011
Notification Time: 18:40 [ET]
Event Date: 04/23/2011
Event Time: 08:14 [PDT]
Last Update Date: 06/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RICK DEESE (R4DO)

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

Event Text

INVALID PRIMARY CONTAINMENT ISOLATION SYSTEM ACTUATION DUE TO UNRECOGNIZED DESIGN CONFLICT

"This event is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an automatic actuation of general containment isolation signals affecting containment isolation valves in more than one system. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73(a)(2)(iv)(A). This actuation was invalid since it was caused by maintenance activities and not by any actual plant condition warranting containment isolation.

"On April 23, 2011, at 0814 hours, during implementation of a clearance order for ongoing work, Reactor Protection System (RPS) Bus A was transferred from the normal to alternate power supply. The power transfer functions as a break before make, and the momentary loss of power caused an unexpected actuation of the Groups 3 and 4 outboard containment isolation valves. Outboard isolations occurred in the reactor building drain and ventilation systems, and reactor closed cooling systems. Control room emergency ventilation and standby gas treatment systems also started. All systems functioned as designed, excluding those components that were already removed from service. Following the event, the RPS Bus A was re-energized and the plant was restored to normal operating condition for the current configuration per plant procedures.

"The unexpected actuation was due to a latent design conflict between a new design modification and existing equipment that was not discovered until during the implementation phase of the modification. The subsequent investigation cited inadequate review and engagement in the design process by station personnel of the vendor supplied design change modification package as the cause. As part of the implementation of the modification package an interposing relay was introduced into the Nuclear Steam Supply Shutoff System (NSSSS) logic circuit. The work for this modification was performed on the two days prior to this event, April 21st and 22nd. The new design was such that the source of power for the added relay was the same power supply which supplied the alternate logic channel. The resulting condition created a scenario where loss of the RPS-A power supply would complete both halves of the NSSSS outboard trip logic. The design has been revised such that loss of RPS-A or RPS-B power supply will not result in loss of both halves of the NSSSS trip logic circuit. Planned corrective actions will enhance procedures to ensure key design parameters and performance objectives are established early in the design process.

"There were no actual safety consequences associated with this event since all affected equipment responded as designed. The NRC Resident Inspectors have been notified."

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