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Event Notification Report for August 26, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/25/2011 - 08/26/2011

** EVENT NUMBERS **


47174 47175 47196 47197 47198

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Agreement State Event Number: 47174
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: CARILLION CLINIC
Region: 1
City: ROANOKE State: VA
County:
License #: 770-051-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 15:42 [ET]
Event Date: 08/07/2011
Event Time: [EDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

VIRGINIA AGREEMENT STATE REPORT - DOSE RECEIVED BY PATIENT GREATER THAN PRESCRIBED

The following information was obtained from the State of Virginia via fax:

"On August 7, 2011, the licensee's RSO received notification of an incident. A patient was treated for bronchial/trachea carcinoma using temporary brachytherapy employing a HDR delivery system. Subsequent to treatment, it was realized that dwell positions were misrepresented on the approved treatment plan. Reconstruction of the applicator position led to the conclusion that dose to organs or tissue other than the treatment site received more than 50 Rem and more than 50% of the expected dose. Licensee notified Virginia Department of Health on August 17, 2011. Referring physician was notified on August 17, 2011. Physician is meeting with patient on August 19, 2011. Licensee indicated organs at risk and health effects to patient are under development."

Virginia Report ID: VA-11-08

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: 47175
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OUR LADY OF BELLEFONTE HOSPITAL
Region: 1
City: ASHLAND State: KY
County:
License #: 202-144-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: PETE SNYDER
Notification Date: 08/19/2011
Notification Time: 15:39 [ET]
Event Date: 07/15/2011
Event Time: 12:15 [CDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - IMPROPER THERAPEUTIC HYPERTHYROID DOSE

Kentucky provided the following information via e-mail:

"On July 15, 2011, an 82 year old male patient was scheduled for a therapeutic dose of I-131, 15 mCi for the treatment of subclinical hyperthyroidism with [the prescribing physician]. The therapeutic dose received from the radiopharmacy was assayed prior to administration and indicated an amount of 19.9 mCi.

"The technologist assaying the dose contacted [the physician] concerning the difference in the amount ordered and the amount received. [The physician] chose to accept the dose and administer it to the patient based on the patient's age and symptomatic subclinical hyperthyroidism and enlarged lobe.

"[The physician] accepted the dose clinically but did not document this on the written directive prior to administration. The change in dose is documented in [the physician's] dictation, completed on July 15, 2011 at 1:44 p.m., acknowledges the change in the dose administered and it is documented that the technologist informed him of the difference in dose and his acceptance and why this amount was acceptable.

"The failure to change the written directive prior to administration was not identified until August 8, 2011 during OLBH's [Our Lady of Bellefonte Hospital] annual audit conducted by a Medical Physicist. [The] RSO and the Director of Radiology contacted the RHB [Radiation Health Branch] on August 9, 2011 for notification of the medical event.

"Contributing Factor: Failure to change the written directive prior to administration of the I-131.

"Corrective Actions by Licensee: A policy and procedure review was conducted. The Quality Management form and Written Directive used with administration of I-131 therapies was reviewed and updated to include an area that requires explanation of any dose that differs from the prescribed dose being administered and the signature of the AU [authorized user] confirming the change in dose prior to administration."

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: 47196
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BEN SCHRUM
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2011
Notification Time: 01:48 [ET]
Event Date: 08/25/2011
Event Time: 01:18 [EDT]
Last Update Date: 08/25/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MALCOLM WIDMANN (R2DO)
VICTOR MCCREE (R2RA)
JACK GROBE (NRR)
JANE MARSHALL (IRD)
JOHN KNOX (DHS)
MIKE BLANKENSHIP (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO AN AFTERSHOCK EARTHQUAKE

On August 25th at 0118 EDT, North Anna Power Station declared an Unusual Event due to seismic activity onsite (EAL HU 1.1). Both units are currently shutdown and electrical power is being supplied from offsite. There were no personnel injuries. There was no radiological release. Site structure and system inspections are in progress. No damage has been identified.

The NRC Resident Inspector and state and local authorities have been notified.

* * * UPDATE FROM JOHN BALTOR TO ERIC SIMPSON AT 1215 EDT ON 8/25/11 * * *

At 1149 EDT another minor tremor was felt at the station. No geological information is available at this time. There is no immediate indication of any equipment damage. Walkdowns are being performed at this time.

North Anna Emergency Management indicated that there was currently no plan to secure from the Notification of Unusual Event until there is sufficient indication that the station will not experience any additional aftershocks to prevent having to re-enter an emergency status once exited.

The current status of North Anna, Unit 1 is Mode 5. Unit 2 is in Mode 3 in preparation for cool down.

The licensee will verify that the NRC Resident Inspector is notified.

Notified IRD (Marshall), NRR (Thorp), and R2DO (Widmann).

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Non-Agreement State Event Number: 47197
Rep Org: INTEGRITY TESTLAB
Licensee: INTEGRITY TESTLAB
Region: 1
City: NEW CASTLE State: DE
County:
License #: 07-30791-01
Agreement: N
Docket:
NRC Notified By: WILLIAM BATTING
HQ OPS Officer: ERIC SIMPSON
Notification Date: 08/25/2011
Notification Time: 11:50 [ET]
Event Date: 08/24/2011
Event Time: 09:17 [EDT]
Last Update Date: 08/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

RAD WORKER DOSIMETRY IN EXCESS OF EXPOSURE LIMITS

"At 0917 EDT on 8/25/11, Integrity Testlab received a facsimile notification from Integrity Testlab's dosimeter processor, Landauer, that an assistant radiographer's July 2011 dosimeter had received/recorded 9.587 R.

"According to the assistant radiographer, his dosimeter had come off his work clothes during radiographic operations on 7/29/11. When he discovered that his film badge was not on his work clothes, he looked for and found the dosimeter near the exposure device. He believes that his dosimeter had 4 or 5 exposures during the time the dosimeter was near the exposure device.

"The exposure time for each exposure was about 40 seconds in length. On 8/2/11, the assistant radiographer informed the RSO what had occurred on 7/29/11. The RSO instructed the assistant to complete a statement on what transpired on that date. The RSO verified the assistant's statement with the radiographer.

"The RSO verbally instructed the assistant how to best secure the dosimeter on the rate alarm meter pouch and to periodically check that all required dosimetry remains on his person during radiographic operations.

"The RSO reviewed all daily pocket dosimeter readings recorded for the month of July. He determined that the assistant had performed radiography for a total of 9 days in July. The RSO also noticed that he had performed radiography with the same radiographer 8 of those 9 days. The radiographer's pocket dosimeter reading recorded 200 mR, while his assistant's daily readings totaled 201 Mr. The RSO contacted Landauer in order to get the radiographer's July recorded dosimeter results and Landauer verbally informed the RSO that the total was 87mR for the month of July for the radiographer.

"After reviewing all documentation, the RSO believes that the assistant's dosimeter was accidently exposed to excessive radiation and that this was not an actual overexposure. Furthermore, the RSO intends to inform all personnel involved in Integrity Testlab's Radiation Safety Program about this event and to instruct the personnel on the importance of securing their dosimetry on their person.

"An 880 Sigma device was involved during this occurrence and it had contained Ir -192, 55.5 Ci."

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Power Reactor Event Number: 47198
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DON TAYLOR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/25/2011
Notification Time: 17:14 [ET]
Event Date: 08/25/2011
Event Time: 16:10 [EDT]
Last Update Date: 08/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MALCOLM WIDMANN (R2DO)

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

Event Text

NOTIFICATION TO OFFSITE AGENCY REGARDING AN ONSITE OIL SPILL

"At 1610 EDT on August 25, 2011 the Virginia Department of Environmental Quality was notified of an oil spill that occurred at 1900 EDT on August 24, 2011. The spill was approximately 150 gallons to the gravel outside the North Anna Unit 2 Turbine Building. The event occurred while purging CO2 from the Unit 2 Main Generator with air. Standing oil from the gravel was pumped to barrels and oil soaks were applied to the remaining oil. Clean up of the gravel areas continued."

The NRC Resident Inspector has been notified in addition to the state and local authorities.

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Thursday, March 29, 2012