Event Notification Report for June 04, 2012

KENTUCKY AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING PROSTATE SEED IMPLANTS

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

"A prostate seed implant was performed on June 4, 2012. The procedure presented with some complications related to a deficit from a TURP [Transurethral Resection of the Prostate] surgery performed on the patient over 15 years ago. When the procedure was completed cystoscopy identified no seeds in the bladder or urethra.

"The patient returned for the post implant CT on July 9, 2012. During the post implant visit with the Authorized User, the patient identified he had passed what was thought to be two seeds. Further discussion with the Authorized User identified it was two strands of seeds. The patient flushed one strand into his septic system and will bring the second strand back to the licensee for proper disposal.

"The post implant CT determined approximately 15 seeds were missing from the implant. It appears the two strands containing these seeds were in the deficit resulting from the earlier TURP surgery.

"The licensee is preparing a report for submission to the RHB within the next 15 days."

Radiation Oncologist (AU): [Deleted]
Referring Physician: [Deleted]
Implant Date: 6/4/2012
Prescribed dose: 108 Gy to the prostate
Post implant CT dosimetry: D-90 = 54%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.24 mCi
Number of seeds implanted: 85

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.

REACTOR COOLANT SYSTEM IN A DEGRADED CONDITION DUE TO AN INSTRUMENT RACK SEISMIC DESIGN ISSUE

"During a review of plant installed instrumentation racks inside containment, two instrument racks were identified that were over the analyzed weight for the seismic analysis. The instruments on these racks are used for reactor coolant pressure transmitters that are part of the Reactor Coolant System (RCS) pressure boundary, as they are connected via instrument lines to the RCS with no remote closure capabilities. A failure of these racks during a seismic event due to the excessive weight could result in an unisolable leak from the RCS within containment based on engineering judgment. This results in the RCS principal safety boundary being in a degraded nonconforming condition as the Updated Safety Analysis Report (USAR) specified Class 1 requirement is not being met for the current seismic design. Further engineering analysis is in progress to address the weight issue for these racks and mounting requirements. The plant is shutdown and in Mode 5 with the reactor vessel head removed, so RCS is not intact and not required to be for current plant conditions. This report is being made in accordance with 10CFR72(b)(3)(ii)(A) for a degraded condition."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 8/3/12 AT 1708 EDT FROM JULIE BISSEN TO DONG PARK * * *

"On June 4, 2012, at 2059, Fort Calhoun Station made an 8-hour non-emergency notification for a degraded condition. Subsequent internal review has determined that the initial reporting criterion for degraded condition, 10 CFR 50.72(b)(3)(ii)(A), was incorrect. The instrument racks were identified as being over the analyzed weight for the seismic analysis. This is an unanalyzed condition, not a degraded condition. The report made on June 4, 2012 should have been made under 10 CFR 50.72(b)(3)(ii)(B), unanalyzed condition."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Werner).

TENNESSEE AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED GAUGE

The following information was obtained from the state of Tennessee via fax:

"On June 4, 2012 Eastman Chemical Company contacted the [Tennessee] Division of Radiological Health concerning an incident that had just occurred. A shutter on a fixed level gauge was difficult to operate and could not be completely closed. In an attempt to close the shutter, a viscous polymer material which had leaked onto the top part of the gauge was removed. However, removal of the polymer still did not allow for complete closing of the shutter. Surveys have confirmed that radiation levels around the gauge are normal. The vessel manway is posted and procedures are in place to prevent entry into the vessel prior to the gauge being repaired or replaced."

The level gauge contained 173 mCi of Cs-137. No personnel overexposures were reported.

Tennessee Event: TN-12-148

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