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Event Notification Report for November 29, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/28/2011 - 11/29/2011

** EVENT NUMBERS **


47467 47468 47474 47479 47481 47482 47483

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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: 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: 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.

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Power Reactor Event Number: 47481
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CHUCK HAIDAR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/28/2011
Notification Time: 12:34 [ET]
Event Date: 11/28/2011
Event Time: 06:00 [PST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

Event Text

OFFSITE NOTIFICATION OF UNPLANNED ACIDIC SOLUTION DISCHARGE

"During the regeneration of the Unit 2 full flow condensate polishing demineralizer (FFCPD) resin, 5 percent sulfuric acid briefly overflowed from the bermed area. The majority of the acid went into the floor drains in the FFCPD area and then to the turbine building sump system.

"An estimated quantity of 2 gallons of sulfuric acid was released into the storm drains that discharged into the circulating water system. The quantity released was well below the reportable quantity. The fire department and environmental/hazmat team were contacted and responded.

"Precautionary notifications were made by SCE to:
- California Emergency Management Agency
- San Diego Dept. of Environmental Health."

The cause of the leak has been corrected and no additional discharge is anticipated. The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 47482
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: MATT JOHNSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/28/2011
Notification Time: 18:40 [ET]
Event Date: 11/28/2011
Event Time: 16:50 [EST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WAYNE SCHMIDT (R1DO)

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

Event Text

OFFSITE NOTIFICATION OF OIL SHEEN IN DISCHARGE CANAL

"At approximately 1650 EST on 11/28/2011 an oil sheen of about 20 ft. in diameter was observed in the Unit 2 discharge canal. The source of the oil is unknown at this time. There is no adverse impact on the plant. All required notifications have been made, including the New York State Dept. of Environmental Conservation, Westchester County Dept. of Health, and the U.S. Coast Guard National Response Center."

The NRC Resident Inspector has been informed.

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Fuel Cycle Facility Event Number: 47483
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: BILLY WALLACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/28/2011
Notification Time: 19:12 [ET]
Event Date: 11/28/2011
Event Time: 09:30 [CST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
SCOTT FREEMAN (R2DO)
THOMAS HILTZ (NMSS)

Event Text

24-HOUR REPORT CONCERNING A LOCALIZED LOSS OF A GEOMETRY CRITICALITY CONTROL CONTINGENCY

"At 0930 CST on 11-28-11, during annual inspection of the C-400/C-409 floor drains and sumps according to procedure CP4-CU-CH6021, a chemical operator identified that an eye wash drain was no longer properly sealed around the concrete base and would not prevent solutions from entering the drain if challenged. NCSA [Nuclear Criticality Safety Assessment] CHM-001 requires specific drains to be sealed to prevent the accumulation of fissile material in the unsafe geometry drain system. In violation of NCSA CHM-001, the poured concrete base surrounding the eye wash drain #147 in C-400 was discovered to be broken loose from the floor so that it could no longer provide a seal against spilled uranium solution getting into the drain system.

SAFETY SIGNIFICANCE OF EVENTS
"Although the concrete block has broken loose from the floor, only a small crack exists at the base of the concrete block which would present a torturous solution path to the drain. Therefore, a large release will be prevented from transporting a significant amount of solution to the drain system. While the Safety Related Item failed, no fissile material was released onto the C-400 building floor and no fissile material entered the drain system through this drain.

POTENTIAL CRITICALITY PATHWAYS INVOLVED
"In order for a criticality to occur a release of greater than a safe mass of uranium onto the floor of C-400 would have to occur. A solution containing greater than a safe mass would then have to migrate to the drain, leak into the drain system, and accumulate in an unfavorable geometry.

CONTROLLED PARAMETERS
"The two process conditions relied upon for double contingency for this scenario are mass and geometry.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL
"Process is designed to handle uranium contaminated solutions with a maximum assay of 5.5 wt.% U235.

NUCLEAR CRITICALITY SAFETY CONTROL AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES
"The first leg of double contingency is based on the mass of uranium in solution form that leaks out of the system. The analysis credits both the integrity of the system and the fact that the tanks and piping are inspected for leakage. Small leaks will be identified and fixed before they have leaked enough uranium mass in solution to be a concern. Since no leakage has occurred, this control was not violated. The second leg of double contingency relies on the integrity of the floor drain seals to prevent uranium solution from getting into the unsafe geometry drain system. Since a pathway from the floor to the drain system exists, this control was violated and the parameter was not maintained. Because the parameter was not maintained double contingency was not maintained. Double contingency was not maintained because the geometry parameter was not maintained.

CORRECTIVE ACTIONS
"1. Stop fissile solution operations in the vicinity of the eyewash drain. This was completed at 1000 CST on
11-28-11.
2. Restore the seal to this drain. Pending
3. Upon successful restoration of the seal for the eyewash drain #147, fissile solution operations may be
resumed. Pending

"Since one leg of double contingency was lost, this is being reported to the NRC as a 24-hour Event Report in accordance with NRC BL 91-01 Supplement 1.

"The NRC Resident Inspector has been notified of this event.

"PGDP Problem Report No. ATRC-11-3171 and PGDP Event Report No. PAD-2011-20."

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Thursday, March 29, 2012