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Event Notification Report for November 28, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/25/2011 - 11/28/2011

** EVENT NUMBERS **


47463 47467 47468 47469 47470 47474 47477 47478 47479

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Agreement State Event Number: 47463
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: 00466
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/21/2011
Notification Time: 15:23 [ET]
Event Date: 11/17/2011
Event Time: 07:00 [CST]
Last Update Date: 11/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
BILL VON TILL (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 MICROSPHERES

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

"On November 21, 2011, the Agency [Texas Department of State Health Services] was notified by one of its licensees that it had determined that a therapy event had occurred on November 17, 2011, during an administration of Yttrium-90 microspheres. The patient was prescribed a dose of 135 gray to the target tissue. Surveys of the administration equipment following the procedure indicated readings that were higher than expected if the full dose had injected into the patient. Initial estimates by the licensee are that a dose of 95.8 gray was administered to the target tissue, approximately a 29% variation from the prescribed dose. The licensee will confirm the dose administered and investigate to determine the cause of the event. Information on this event will be updated as it becomes available."

Texas Incident #: I-8904

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: 47467
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: THE MEDICAL CENTER AT BOWLING GREEN
Region: 1
City: BOWLING GREEN State: KY
County:
License #: 202-124-26
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/22/2011
Notification Time: 16:28 [ET]
Event Date: 11/16/2011
Event Time: 07:00 [CST]
Last Update Date: 11/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
JIM LUEHMAN (FSME)

Event Text

KENTUCKY AGREEMENT STATE REPORT - WRONG BRACHYTHERAPY TREATMENT PLAN PERFORMED ON WRONG PATIENT

The following information was obtained from the Commonwealth of Kentucky via email:

"Kentucky RHB [Radiation Health Branch] was notified via e-mail on 11/17/11 at 10:30 a.m. [EST] and via telephone call on 11/17/11 at 10:45 a.m. of a possible medical event occurring on 11/16/11. The medical event involved using the wrong permanent prostate brachytherapy implant treatment plan on the wrong patient. The facility performed back to back procedures on two patients on two consecutive days and the implant procedure used on the second patient was actually developed for the first patient. The RSO reported that immediately after completing the procedure, the mishap was noted by the Radiation Oncologist and a post implant CT and MRI were performed immediately. The Radiation Oncologist who developed the treatment plan and performed the procedure determined the dose delivered to the target organ based on D90 was 90%. According to the RSO, written directives for both patients called for the same number of seeds of the same radionuclide and same activity and both called for the same prescribed dose thus accounting for the oversight on the part of the Radiation Oncologist. These similarities however, allowed for a D90 of 90% despite the wrong treatment plan being used. The State will continue to keep NRC informed of the status of their investigation."

The patient was given 79 seeds with 0.0406 mCi of I-125 per seed (STM 1251). The manufacturer was Bard Brachytherapy Inc.

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: 47468
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: COLUMBIA PRESBYTERIAN MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 93-2878-05
Agreement: Y
Docket:
NRC Notified By: TOBIAS A. LICKERMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/22/2011
Notification Time: 16:53 [ET]
Event Date: 11/14/2011
Event Time: 07:00 [EST]
Last Update Date: 11/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
JIM LUEHMAN (FSME)

Event Text

NEW YORK AGREEMENT STATE REPORT - GAMMAKNIFE THERAPY UNDERDOSE DUE TO MECHANICAL FAILURE OF DEVICE

The following information was obtained from the New York City Office of Radiological Health via email:

"Type of event: Therapy, gammaknife

"Description of event: Patient was being treated by gammaknife Model C-23004 for a meningioma. Halfway through, the treatment was automatically terminated. It was discovered that the latch that fastens the immobilizing frame of the head to the couch failed. Termination of treatment resulted in an underdose of more than 50% below the prescribed dose for that fraction. This was the third of three patients who were being treated at about that time. The first two patients were treated without incident.

"Discovery of Event: Event was discovered when treatment was automatically terminated in the course of treatment.

"Effect on Patient: In the opinion of the responsible physician, there are no expected sequelae for this patient as a result of this event.

"Root Cause of Event: The root cause of this event was mechanical failure. There was not found to be any computer failure involved.

"Actions Taken to Prevent Recurrence of Event: Replacement of latch mechanism.

"Inspection Results: An inspector from the [NYC] Office of Radiological Health conducted an inspection on 11/17/11. The inspector found the circumstances of the event to be as described above.

"Any Issuance of Violations: No formal violation was issued.

"This case is considered closed."

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: 47469
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SONIC SURVEYS, LTD.
Region: 4
City: MONT BELVIEU State: TX
County:
License #: 02622
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/22/2011
Notification Time: 18:03 [ET]
Event Date: 11/18/2011
Event Time: 07:00 [CST]
Last Update Date: 11/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
JIM LUEHMAN (FSME)

Event Text

TEXAS AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE

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

"On November 18, 2011, the Agency [Texas Department of State Health Services] was notified that a licensee had lost, and subsequently abandoned, a logging tool containing a 20 milliCurie cobalt (Co)-60 sealed source at a depth of approximately 5,100 feet down a well in Matagorda County, Texas. The well is a brine solution well that was converted to gas storage; it is a domed salt cavern. There is no rig on the well and the source is at the bottom of the cavern. There is no danger of rupture or exposure. There are no plans to enter the well or cavern in the near future with tubing or wire line. No further action will be taken to retrieve the tool.

"Source information: 20 milliCurie Cobalt-60
"Manufacturer: Eckert and Ziegler
"Model: HEG-060
"SN: CZ3507"

Texas Incident No.: I-8906

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Agreement State Event Number: 47470
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LIGHTING SYSTEMS, INC.
Region: 4
City: BERKELEY State: CA
County:
License #: 5490-1
Agreement: Y
Docket:
NRC Notified By: CURT PRENDERGAST
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/22/2011
Notification Time: 18:20 [ET]
Event Date: 08/15/2011
Event Time: [PST]
Last Update Date: 11/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
JIM LUEHMAN (FSME)
MEXICO (via)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received via telephone:

On or about August 15, 2011, Lighting Systems, Inc. shipped three tritium exit signs to a customer via UPS. Upon delivery, the customer refused receipt of the signs. UPS retained possession of the signs. UPS has not returned the signs to Lighting Systems, Inc. and has been unable to locate the signs.

Each sign contained 7.5 Curies of tritium. Model number: SLX-60. Serial numbers: 11-14985, 11-14986, and 11-14987.


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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Agreement State Event Number: 47474
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UW-MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/23/2011
Notification Time: 16:53 [ET]
Event Date: 11/23/2011
Event Time: [CST]
Last Update Date: 11/23/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3DO)
JIM LUEHMAN (FSME)
ILTAB VIA EMAIL ()

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

Event Text

AGREEMENT STATE REPORT - LOST OR MISSING IODINE-125 PLAQUE SEED

"On November 23, 2011, during a physical inventory of iodine-125 seeds to be returned to the vendor, it was determined that one (1) iodine-125 eye plaque seed was missing. The patient and room surveys were conducted at the time of the eye plaque procedure (late May) to verify no seed had been left in the patient or the room, and that all sources were returned from the procedure to the source storage room. The manufacturer's assay was 2.94 mCi per seed on May 20, 2011. The assay at the time of the procedure was within 3% of the manufacturer's assay. All attempts to identify the time, location, or the passage of disposal did not produce a definite result.

"The Wisconsin Department of Health Services (DHS) followed up with the licensee by phone and will conduct an investigation the first week of December."

Event Report No.: WI110020

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: 47477
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/25/2011
Notification Time: 06:32 [ET]
Event Date: 11/25/2011
Event Time: 05:23 [EST]
Last Update Date: 11/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 58 Power Operation

Event Text

AUX FEEDWATER PUMP START AFTER MAIN FEEDWATER PUMP TRIP

"At 0522 EST on November 25, 2011, operators manually started all Auxiliary Feedwater (AFW) pumps in response to a manual trip of the Unit 1 East Main Feedwater Pump due to bearing failure.

"Operators were responding to increasing vibrations on the East Main Feedwater Pump and reducing turbine load when the East Main Feedwater Pump was manually tripped [at approximately 90% power] due to high vibrations. Operators entered the abnormal operating procedure for Loss of One Main Feedwater Pump, which directs starting all three AFW pumps.

"Plant power was stabilized at approximately 58%.

"The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10CFR50.72(b)(3)(iv)(A) due to the valid actuation of the AFW system in response to equipment failure."

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Power Reactor Event Number: 47478
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RICK ROBBINS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/27/2011
Notification Time: 04:22 [ET]
Event Date: 11/27/2011
Event Time: 02:38 [CST]
Last Update Date: 11/27/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (R3DO)
JANE MARSHALL (IRD)
SHER BAHADUR (NRR)
JENNIFER UHLE (R3)
DAN GATES (DHS)
STEVE HOLLIS (FEMA)
BRUCE BOGER (ET)
CYNTHIA PEDERSON (R3)

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

Event Text

UNUSUAL EVENT DUE TO A LOSS OF OFFSITE POWER DURING SWITCHING OPERATIONS

"At 0238, Point Beach Unit 1, classified an Unusual Event based on CU3.1, loss of power to or from the 1X-04 transformer that results in a loss of all offsite power to both safety-related busses 1A-05 and 1A-06 for greater than 15 minutes and at least one emergency [diesel] generator is supplying power to an emergency bus."

The 1X-04 transformer converts 345 kV to 13.8 kV. Both Emergency Diesel Generators are running supplying the safety-related busses.

The licensee notified State and local agencies and the NRC Resident Inspector.

* * * UPDATE FROM KARL COSSEY TO JOHN KNOKE AT 0843 EST ON 11/27/11 * * *

"Off-site power to Unit 1A-05 and 1A-06 Safeguards Busses has been restored via Unit 2 2X-03 High Voltage Station Transformer and 1X-04 Low Voltage Station Transformer.

"During the transient, all four Emergency Diesel Generators (EDGs) started as expected with G-01 EDG supplying the Unit 1 1A-05 Safeguards Bus and G-03 EDG supplying 1A-06 Safeguards Bus. Off-site power to the Unit 2 Safeguards Buses was not affected. The start of the EDGs is also reportable under 10CFR 50.72 (b)(3)(iv)(A).

"All systems responded as designed during the transient and operators performed in accordance with procedures and their training. Unit 1 is stable in Mode 5 within normal operating bands. Unit 2 remains operating at 100% power. The Unusual Event was terminated at 0700 [CST] on November 27, 2011. A press release is planned."

The licensee has notified State and local agencies and the NRC Resident Inspector. Notified R3DO (Julio Lara), IRD MOC (Jane Marshall), NRR EO (Sher Bahadur), DHS (Rickerson), and FEMA (Hollis).

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Power Reactor Event Number: 47479
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KIRK DUEA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/28/2011
Notification Time: 01:04 [ET]
Event Date: 11/27/2011
Event Time: 16:57 [CST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3DO)

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

Event Text

ROD WORTH MINIMIZER CONTROL SWITCH FOUND OUT OF REQUIRED POSITION

"After transitioning to Mode 2 from Mode 4, while performing the Rod Worth Minimizer (RWM) operability test, it was discovered that the RWM control switch was in the BYPASS position. The RWM enforces predetermined control rod withdrawal and insertion sequences. Complying with these predetermined sequences ensures a Control Rod Drop Accident does not exceed analytical limits. With the control switch in the BYPASS position, the RWM was inoperable and would not have enforced the predetermined control rod withdrawal sequence. The RWM control switch was restored to the OPERATE position and the RWM was verified to be operable.

"This issue is being reported under 50.72(b)(3)(v)(D) as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of the RWM, which is a system needed to mitigate the consequences of the Control Rod Drop Accident."

The licensee will be notifying the NRC Resident Inspector.

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