Event Notification Report for July 12, 2011

MOISTURE DENSITY GAUGE SHUTTER STUCK IN THE CLOSED POSITION

Tennessee Valley Authority Paradise Fossil Plant uses an Ohmart Model SR1-A density gauge with a sealed source containing up to 1,562 milliCuries of Cesium 137. The gauge is used to monitor the density of the limestone slurry at the Unit 2 scrubber. On July 12, 2011 at 1330 (CDT) the shutter on the density gauge was determined to be not operable. It was determined that the shutter failed in the closed position when the operator received a slurry density high alarm.

The shutter failure is in the closed and safe position. The gauge has been entered into the corrective action program and will be repaired by the manufacturer at a later time. There were no personnel exposures, no damages to other equipment, and no additional compensatory actions necessary since the shutter is failed closed/safe position.

The licensee notified the R2DO (Freeman).

INAUDIBLE CRITICALITY WARNING SIREN

"At approximately 1730 on 7/12/2011, a regularly scheduled test of the inside Criticality Warning System (CWS) covering the Fuel Manufacturing Operation (FMO) was conducted. It was discovered that a CWS warning horn in the ChemMet lab was determined to be inaudible. Compensatory measures were immediately implemented. All other horns of the inside CWS in all other areas were functional and clearly audible. The affected area will remain shut down pending an investigation and implementation of additional corrective actions. The event is being reported within 24Àhours pursuant to 10CFR70.50(b)(2) as a safety equipment failure. A CWS warning horn in the ChemMet lab was determined to be inaudible. All other CWS warning horns operating correctly. Investigation results pending. Affected area access was restricted. The faulty CWS horn has been replaced and tested."

The licensee notified Region 2(Coovert) and will notify the state radiation protection agency and New Hanover Emergency Management.

See related Events #47061 and #47066.

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING TREATMENT DOSE ADMINISTERED TO WRONG SITE

The following event report was received from the Pennsylvania Bureau of Radiation Protection:

"The licensee called the PA Department of Environment Protection (PaDEP) Southeast Regional Office at 1050 EDT on July 14, 2011 to provide a 24-hour verbal notice of a Medical Event (ME). A total treatment dose was administered to the wrong site, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(3). This event also meets the criteria for Abnormal Occurrence (AO) reporting.

"On July 12, 2011 a Yttrium-90 (Y-90) SIR-Sphere treatment was performed. The written directive was for treatment of the liver's right lobe, but the total treatment was delivered to the left lobe. The prescribed dose was 31.5 millicurie (mCi) of Y-90.

"There are several open questions regarding root cause, potential health impact on the patient and communications to the patient and their physician. PaDEP/BRP will be performing a reactive inspection, which is scheduled for Monday July 18, 2011. Updates to this NRC report will be made once we investigate the ME at Lehigh Valley Health Network and obtain the follow-up written report from the licensee."

PA report Number: PA110016

* * * UPDATE AT 1500 EDT ON 08/02/11 FROM D. ALLARD TO S. SANDIN VIA FAX * * *

The State of Pennsylvania is retracting this report based on the following:

"After a PaDEP reactive inspection on July 28, 2011 and discussion with the licensee regarding the circumstances of a SirSphere infusion performed on July 12, 2011, it was determined a Medical Event [and Abnormal Occurrence) did not occur.

"The licensee's report concludes that there was no medical event because the authorized user intended to treat a lesion in the right lobe of the liver and that was what happened. The interventional radiologist who performed the procedure elected to use the left hepatic artery because a prior treatment through the right hepatic artery was unsuccessful in treating this lesion. The interventional radiologist and the authorized user discussed this at the time of the treatment and were in full agreement on the procedure.

"Medical Event should be retracted; no further action to be taken at this time."

Notified R1DO (Bellamy) and FSME (McKenney).

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.

AGREEMENT STATE REPORT - PATIENT RECEIVED TREATMENT TO INCORRECT ORGAN

"Approximately four (4) weeks prior to the therapy, patient was scanned for extrahepatic shunting through injection of 99mTc MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.

"On Tuesday July 12, 2011, at 11:00 AM the patient was treated with 0.977 GBq of 90Y TheraSphere per protocol. Interventional Radiologist properly placed catheter. A second interventional Radiologist confirmed the catheter placement.

"On Tuesday July 12, 2011 at 6 PM, post procedure scan identified significant activity in the duodenum. Initial estimate indicates 0.117 GBq had shunted into the duodenum approximately 12% of the administered activity. An initial estimate indicates dose to duodenum is approximately 110 Gy.

"The asymptomatic patient was discharged with follow up contacts for possible intervention as a result of the dose to the duodenum. Patient has been notified. Referring physician has been notified.

"Literature search indicates patient may have developed vascularization post-scan, pretreatment.

"An inspector from the Department [Ohio Bureau of Radiation Protection] will conduct an inspection the week of July 25, 2011."

Ohio Event Report Number: 2011-014

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 MARK LIGHT TO VINCE KLCO ON 7/19/11 AT 1326 EDT * * *

Based on further review by the licensee, the patient's organ in question did not receive the above referenced dose.

Notified the R3DO(Duncan) and FSME (Zelac).