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Event Notification Report for September 20, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/19/2011 - 09/20/2011

** EVENT NUMBERS **


47263 47264 47266 47267 47277 47278

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Hospital Event Number: 47263
Rep Org: QUEEN'S MEDICAL CENTER
Licensee: QUEEN'S MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: BRIAN OYADOMARI
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/13/2011
Notification Time: 22:01 [ET]
Event Date: 09/13/2011
Event Time: 10:30 [HST]
Last Update Date: 09/13/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)

Event Text

MEDICAL EVENT INVOLVING THE ADMINISTRATION OF THE WRONG RADIOPHARMACEUTICAL

At approximately 1000 HST a patient scheduled to receive an administration of 5 mCi In-111 for an imaging scan (Octreotide) received instead a 1.55 mCi Sr-89 injection. The Sr-89 dose, originally 4mCi, was expired (89 days) and administered unintentionally due to personnel error. The RSO calculates that the red bone marrow will receive a dose of 63 rem.

The patient was informed and is being monitored for changes in blood chemistry. The attending and prescribing physician will be informed.

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: 47264
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: DELRAY MEDICAL CENTER, INC
Region: 1
City: DELRAY BEACH State: FL
County:
License #: 3519-1
Agreement: Y
Docket:
NRC Notified By: SHAWN ANDERSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/14/2011
Notification Time: 13:07 [ET]
Event Date: 08/12/2011
Event Time: [EDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ANGELA MCINTOSH (FSME)
JIM WHITNEY BY EMAIL (ILTA)

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

Event Text

AGREEMENT STATE REPORT - MISSING CS-137 SOURCE

The following information was received via facsimile:

"[The State of Florida] received a report from licensee of a missing 144.6 microCurie Cs-137 sealed source used as a dose calibrator. Source was first discovered missing by inventory on Aug 12, 2011. Also reported by licensee that the Hot Lab was broken into 2 weeks ago and items were missing from a crash cart. Advised licensee to make a police report. Central Inspection Office assigned to investigate."

Florida Incident Number: FL11-078.


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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Agreement State Event Number: 47266
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/14/2011
Notification Time: 15:03 [ET]
Event Date: 09/09/2011
Event Time: 18:00 [CDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A LESS THAN PRESCRIBED DOSE ADMINISTRATION

The following information was received from the State of Texas via email:

"On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received."

Texas Incident No.: I-8883

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: 47267
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: WELD SPEC INC
Region: 4
City: LUMBERTON State: TX
County:
License #: 05426
Agreement: Y
Docket:
NRC Notified By: WELD SPEC INC
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/14/2011
Notification Time: 15:26 [ET]
Event Date: 09/12/2011
Event Time: [CDT]
Last Update Date: 09/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
ADELAIDE GIANTELLI (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER EXCEEDS FIVE REM TEDE FOR YEAR

The following information was received via E-mail:

"On September 14, 2011, the Agency was notified by the licensee that a radiographer had exceeded 5 REM TEDE for the year. On September 12, 2011, while operating an INC IR102 camera, serial number 4843, containing a 67 Curie Iridium (IR) 192 source, the radiographer failed to fully retract the source into the camera after completing three shots on a weld. This was discovered when the trainee discovered that safety lock was already in the open/unlock position when he was going to unlock the source for the first exposure on the second weld. The radiation survey meter was turned off and no radiation pagers alarmed. Both radiographers noted that their 0-200 mR pocket dosimeters were off scale. They stopped work, fully retracted the source in the camera, and reported the incident to the RSO. Their Landauer badges were sent off for emergency processing and the results were received on September 14, 2011. The trainer received 3.361 Rem deep dose equivalent whole body dose. The trainee received 2.787 Rem. The total exposure for the year of the trainer is at 5.152 Rem and the RSO is still awaiting his August 2011 dose report to add to his total dose for the year. The trainer has been removed from duty. Additional information will be provided as it is received in accordance with SA300."

This event occurred at Total Refinery, Highway 366 and 32nd St., Port Arthur, Texas, 77642.

Texas Incident Number: I-8884.

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Power Reactor Event Number: 47277
Facility: BYRON
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SHANE HARVEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/19/2011
Notification Time: 11:10 [ET]
Event Date: 09/19/2011
Event Time: 10:07 [CDT]
Last Update Date: 09/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (R3DO)

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

Event Text

SPDS AND ERDS UNAVAILABLE DURING REPLACEMENT OF PLANT PROCESS COMPUTER SYSTEM

"At 1007 CDT on September 19, 2011, the Unit 2 Plant Process Computer (PPC) was removed from service for a planned replacement in the current Unit 2 Refueling Outage. The Unit 2 PPC feeds the Safety Parameter Display System (SPDS) used in the Main Control Room (MCR) and the Technical Support Center (TSC). The Unit 2 PPC also feeds the Emergency Response Data System (ERDS). The Unit 1 and Unit 2 PPCs also feed the Plant Parameters Display System (PPDS) used in the MCR, TSC and Emergency Operations Facility (EOF). Meteorological data will remain available. The dose assessment program will remain functional as the Unit 1 PPC will be capable of providing the necessary data through PPDS to run the program. The dose assessment program is not affected by the Unit 2 PPC being out of service. As compensatory measures, a proceduralized backup method to fax or communicate via a phone circuit applicable data to the NRC, TSC, and EOF exists. There is no impact on the Emergency Notification System (ENS) or Health Physics Network (HPN) communication systems.

"The new Unit 2 PPC is scheduled to be functional on September 25, 2011. However, based on the Mode Unit 2 will be in, this will limit the number of points that would provide usable data. The Unit 2 PPC will be tested as Mode changes occur. The Unit 2 PPC is planned to be declared functional by Mode 2. A follow-up ENS call will be made once the Unit 2 PPC is declared functional.

"The loss of SPDS and ERDS is a 'major loss of assessment capability' and is reportable under 10CFR50.72(b)(3)(xiii).

"The NRC Senior Resident Inspector and the State of Illinois (through the Illinois Emergency Management Agency Resident Inspector) have been notified of this ENS call."

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Power Reactor Event Number: 47278
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE NIEMEYER
HQ OPS Officer: JOE O'HARA
Notification Date: 09/19/2011
Notification Time: 11:59 [ET]
Event Date: 09/19/2011
Event Time: 08:00 [CDT]
Last Update Date: 09/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES DRAKE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ACID LEAK ONSITE

"A report has been made to the Texas Commission on Environmental Quality concerning leakage of BULA 7016 (phosphoric acid) from a tank and berm at the Service Water Intake Structure. The berm is cracked, therefore the material is leaking into the soil surface. No chemicals have reached the reservoir."

The NRC Resident Inspector has been notified.

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