| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
06/08/2012 - 06/11/2012 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 47648 | Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-211-27
Agreement: Y
Docket:
NRC Notified By: TERESA PURRINGTON
HQ OPS Officer: CHARLES TEAL | Notification Date: 02/08/2012
Notification Time: 16:00 [ET]
Event Date: 02/02/2012
Event Time: [CST]
Last Update Date: 06/08/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN GIESSNER (R3DO)
PAUL MICHALAK (FSME)
| Event Text AGREEMENT STATE REPORT - Y-90 DOSAGE TO UNINTENDED AREAS
The following was received from the State of Minnesota via email:
"On February 3, 2012, Minnesota Department of Health Radioactive Materials unit received notice that a licensee had a medical event during a Y-90 SIRS spheres procedure. After infusion of radioactive Y-90, in the form of SIRS spheres for treatment of the liver, it was discovered, by follow-up radionuclide scanning, that some of the material was not in the liver as intended. Material appeared in vessels involving the spleen and digestive track instead. The amount has not been determined at this time, but it is possible that this may cause unintended, permanent, functional damage. The interventional radiologist involved with the treatment has ensured us that the patient will be notified along with the referring physician today. It is likely that some form of medical intervention will be taken.
"On February 6, 2012, the Radioactive Material supervisor and inspector met with the licensee to discuss the medical event. The Y-90 SIRS spheres procedure went accordingly to plan; it was discovered on the follow-up SPECT imaging that an estimated 10%-15% of the material was in the spleen, gastric fundus, and duodenum. The patient and ordering physician had been notified. The intended area for the material was the liver with an activity of 50 GBq. The three unattended areas that were discovered with material were estimated to receive a dose of 0. The Medical Physicist gave us the best preliminary dose estimates based on CT images obtained the day after the procedure at which the stomach and duodenum were different in shape. Early dose estimates for each region (spleen, gastric fundus, and duodenum) estimates approximately 30 Gy for each area.
"The Minnesota Department of Health Radioactive Materials unit will continue communication and obtain the final estimation for dose estimates."
* * * UPDATE FROM TERESA PURRINGTON TO VINCE KLCO AT 1055 EST ON 2/14/2012 * * *
The following information was received by email:
"Abbott Northwestern has submitted final best estimates pertaining to the medical event of Y-90 SIRS Spheres that occurred on Thursday, February 2, 2012. The final administered activity after accounting for loss in the delivery system was 1.53 GBq, original activity was 1.55 GBq. Estimates of radioactivity, organ volumes and radiation dose were derived by evaluation of SPECT CT images. The final best estimates are determined as follows:
"Organ / tissue Fraction of activity Volume (cc) Average dose (Gy)
Liver 0.839 1209 53
Fundus of stomach 0.058 101 44
Spleen 0.093 200 35
Portion of duodenum 0.010 41 35
"These estimates have a relatively high uncertainty (at least 20%) and local concentrations and doses may be significantly higher. Maximum concentrations per pixel in the SPECT images were as much as 50% higher than the average concentration."
Notified the R3DO (Passehl) and FSME EO (McIntosh).
* * * UPDATE FROM TERESA PURRINGTON TO DONALD NORWOOD at 1141 EDT on 6/8/2012 * * *
Event title edited to better characterize the event.
Notified R3DO (Passehl) and FSME_Events Resource both via E-mail.
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. |
| Agreement State | Event Number: 47714 | Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: INTERNATIONAL TESTING AND INSPECTION SERVICES
Region: 4
City: MABELVALE State: AR
County:
License #: ARK-0773-0332
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: JOHN KNOKE | Notification Date: 03/02/2012
Notification Time: 11:41 [ET]
Event Date: 02/20/2012
Event Time: [CST]
Last Update Date: 06/08/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)
| Event Text RADIOGRAPHY CAMERA SOURCE ASSEMBLY SLIDE CONNECTOR INOPERABLE
The following information was provided by the State of Arkansas via E-mail.
"During a telephone call on February 29, 2012 with International Testing and Inspection Services, Inc., the company president stated that they had returned a sealed source (QSA Global, Inc., Model Number 87703, Serial Number 70162B) contained in a radiography camera (Industrial Nuclear Company, Inc., Model Number IR-100, Serial Number 4311) after the slide connector on the source assembly would not move.
"On March 1, 2012, two health physicists from the Arkansas Department of Health, Radiation Control Program went to the licensee's facility to determine if this met the reporting requirements of 10CFR 30.50(b)(2). The Arkansas equivalent regulation is RH-1502.f.2.
"The Radiation Safety Officer was not available at the time; however, the health physicists were able to interview the radiography crew using the camera during the failure. The radiography crew indicated that upon arrival at a job site on February 20, 2012, while attempting to connect the control assembly cable, they were unable to move the slide connector on the source assembly. They contacted the company president and returned to the office. The company president informed the Radiation Safety Officer.
"After returning to the office the camera and source were removed from service and returned to Industrial Nuclear Company, Inc. (manufacturer of the camera) on February 24, 2012. Leak tests performed on the camera and sealed source upon arrival at INC, Inc. indicated no contamination.
"Since the source assembly was manufactured by QSA Global, Inc.; Industrial Nuclear Company, Inc. indicated to the licensee that a cause was not identified but that the source assembly needs to be replaced.
"The Arkansas Radiation Control Program has determined that this is reportable under 10CFR 30.50(b)(2) and is making this report to the [NRC] Operations Center. The Program [Arkansas Department of Health, Radiation Control Program] continues to investigate to identify the problem with the source assembly.
"No overexposures to the public or to the radiography crew resulted from this event."
* * * UPDATE FROM STEVE MACK TO DONALD NORWOOD AT 1556 EDT ON 6/8/2012 VIA E-MAIL * * *
"A written report was received from the licensee dated March 23, 2012 describing the discovery of the damaged slide connector on the source assembly.
"A routine compliance inspection was performed on May 22, 2012.
"The cause of the damage to the slide connector on the source assembly was not determined.
"The Arkansas Department of Health considers this event closed."
Notified R4DO (Gepford) and FSME Events Resource by E-mail. |
| Agreement State | Event Number: 47980 | Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OWENSBORO MEDICAL HEALTH SYSTEM
Region: 1
City: OWENSBORO State: KY
County:
License #: 202-161-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 05/31/2012
Notification Time: 15:20 [ET]
Event Date: 06/04/2009
Event Time: [CDT]
Last Update Date: 06/05/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()
| Event Text AGREEMENT STATE REPORT - THREE MEDICAL EVENTS DISCOVERED DURING AN INSPECTION
The following report was received via e-mail:
"During a routine inspection, three unreported [prostate brachytherapy] medical events were identified.
"Case One:
Implant Date: 6/4/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 69
"Case Two:
Implant Date: 6/19/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 80
"Case Three:
Implant Date: 10/29/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 84
* * * UPDATE FROM CURT PENDERGRASS TO HOWIE CROUCH VIA EMAIL ON 6/5/12 AT 1018 EDT * * *
"D90 is defined as minimum dose received by 90% of CT-defined prostate volume
Case 1 D90 = 72.80% of 145Gy
Case 2 D90 = 58.86% of 145Gy
Case 3 D90 = 54.00% of 145Gy"
Notified R1DO (Cahill) and FSME Events via email.
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. |
| Agreement State | Event Number: 47982 | Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: SAMUEL STRAPPING SYSTEMS
Region: 1
City: FORT MILL State: SC
County:
License #: GL-0096
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 05/31/2012
Notification Time: 15:37 [ET]
Event Date: 04/17/2012
Event Time: [EDT]
Last Update Date: 05/31/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()
| Event Text AGREEMENT STATE REPORT - GAUGE SHUTTER FAILED IN THE OPEN POSITION
The following report was received via fax:
"On May 31, 2012 at 1530 hrs [EDT], the SC Department of Health and Environmental Control was notified by phone that during a routine shutter check on April 17, 2012, an Automation and Control Technology (ACT) Model TG-7 gauging device containing 100 mCi of Sr-90, had a shutter mechanism that was harder to operate than normal. An ACT Model TG-7 technician was evaluating the operation of the shutter when it failed and was unable to be moved into the closed position. The ACT technician was able to replace the shutter assembly and switch on April 19, 2012. A survey, as well as a shutter check was performed to insure proper function. A report was sent from ACT to Samuel Strapping Systems on April 30, 2012." |
| Agreement State | Event Number: 47983 | Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINA EAST MEDICAL CENTER
Region: 1
City: NEW BERN State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDY CROWE
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 05/31/2012
Notification Time: 18:18 [ET]
Event Date: 05/29/2012
Event Time: [EDT]
Last Update Date: 05/31/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()
| Event Text AGREEMENT STATE REPORT - PROSTATE SEED MEDICAL EVENT
The following report was received via fax:
"Patient underwent Iodine 125 surgical prostate seed implants (total dose 145 Gy). Initial post operative X-ray film revealed complete seed count. Day zero computed tomography revealed all seeds inferior to true base and resulted in placement in the penile bulb vs. the prostate gland. There were no instrument malfunctions to include the ultrasound. Urologist notified and in-turn patient was immediately notified. Risk to urethra was discussed. Further investigation to occur from NC RPS [North Carolina Radiation Protection Section] Inspectors on Tuesday, June 12, 2012 awaiting the return of the authorized user/physician."
North Carolina incident: 12-37
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. |
| Power Reactor | Event Number: 48006 | Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: NEEL SHUKLA
HQ OPS Officer: DONG HWA PARK | Notification Date: 06/08/2012
Notification Time: 11:32 [ET]
Event Date: 04/11/2012
Event Time: 15:15 [CDT]
Last Update Date: 06/08/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
| Person (Organization):
MALCOLM WIDMANN (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | N | 0 | Refueling | 0 | Refueling | Event Text INVALID SYSTEM ACTUATION RESULTING FROM POST MAINTENANCE TESTING
"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.
"On April 11 , 2012, at 1515 hours Central Daylight Time (CDT), Operations personnel attempted to transfer the 3B 480V Reactor Motor Operated Valve (RMOV) Board to its alternate power supply for post maintenance testing on the alternate feeder breaker. The 3B 480V RMOV Board failed to transfer to the alternate power supply. Power to the 3B Reactor Protection System (RPS) Bus was lost resulting in a half-scram and actuation of Primary Containment Isolation System (PCIS) Group 6 with the initiation of all three trains (A, B, and C) of Standby Gas Treatment and the initiation of Train 'A' of the Control Room Emergency Ventilation System.
"Plant Conditions, which initiate PCIS Group 6 actuations, are Low Reactor Vessel Water Level, High Drywell Pressure, High Reactor Building Vent Radiation, or High Refuel Zone Radiation. At the time of the event, these conditions did not exist; therefore, the partial actuations were invalid.
"The affected equipment responded as designed. On April 11, 2012, at 1520 hours CDT, Operations personnel reset the half-scram from the loss of the 3B RPS Bus.
"This condition is the result of a bad connection of the breaker to panel contacts due to alignment and/or infrequent manipulation.
"There were no safety consequences or impact to the health and safety of the public as a result of these events.
"This event was entered Into the Corrective Action Program as Problem Evaluation Report 535537.
"The NRC Resident Inspector has been notified of this event." |
| Power Reactor | Event Number: 48007 | Facility: SUMMER CONSTRUCTION
Region: State: SC
Unit: [2] [3] [ ]
RX Type:
NRC Notified By: APRIL RICE
HQ OPS Officer: DONALD NORWOOD | Notification Date: 06/08/2012
Notification Time: 13:43 [ET]
Event Date: 06/07/2012
Event Time: 19:44 [EDT]
Last Update Date: 06/08/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
MALCOLM WIDMANN (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | N | 0 | | 0 | | | 3 | N | N | 0 | | 0 | | Event Text VIOLATION OF THE FITNESS FOR DUTY PROGRAM
A non-licensed, contract employee supervisor had a confirmed positive for alcohol during a "for cause" fitness-for-duty test. The individual's site access was revoked, and he was removed from the site. Contact the Headquarters Operations Officer for additional details. |
| Power Reactor | Event Number: 48009 | Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: DAVID CARRICK
HQ OPS Officer: DONG HWA PARK | Notification Date: 06/10/2012
Notification Time: 10:00 [ET]
Event Date: 06/10/2012
Event Time: 03:00 [CDT]
Last Update Date: 06/10/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
DAVE PASSEHL (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text HPCI DECLARED INOPERABLE DUE TO LEAKAGE
"On Sunday June 10, 2012 at 0112 (Central Time), a through-wall leak was discovered on a piping elbow upstream of the High Pressure Coolant Injection (HPCI) Inlet Drain Pot Inboard Drain valve to the Main Condenser, AOV 3-2301-29. This piping elbow is safety-related, ASME Code Class 2 piping. Dresden Technical Requirements Manual 3.4.a, Condition B requires the leak to be isolated which renders the HPCI system inoperable. The Unit 3 HPCI system was isolated and declared inoperable at 0300 (Central Time), and Technical Specification 3.5.1 Condition G has been entered. The HPCI system is a single train system.
"The event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D), any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"The licensee notified the NRC Resident Inspector." |
| Power Reactor | Event Number: 48010 | Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TOM FOWLER
HQ OPS Officer: DONG HWA PARK | Notification Date: 06/11/2012
Notification Time: 03:56 [ET]
Event Date: 06/11/2012
Event Time: 03:35 [EDT]
Last Update Date: 06/11/2012 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
CHRISTOPHER CAHILL (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED MAINTENANCE
"On June 11, 2012, at approximately 0335 hours, the Hope Creek Technical Support Center (TSC) ventilation system was removed from service to perform planned maintenance to the system. The maintenance consists of a 12-year preventative maintenance overhaul of the ventilation supply fan and emergency filtration unit. The removal of ventilation potentially affects the TSC habitability during a declared emergency requiring activation. Appropriate compensatory measures are in place while ventilation is out of service. The Emergency Response Organization duty team has been notified of the maintenance and the possible need to activate the TSC in an alternate location. The ventilation system is scheduled to be out of service for approximately 60 hours."
The licensee has notified the NRC Resident Inspector. The local township will be notified. | |