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Event Notification Report for February 22, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/21/2013 - 02/22/2013

** EVENT NUMBERS **


48640 48749 48752 48753 48775

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Agreement State Event Number: 48640
Rep Org: TEXAS DEPARTMENT OF HEALTH SERVICES
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: 00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/02/2013
Notification Time: 09:44 [ET]
Event Date: 12/04/2012
Event Time: [CST]
Last Update Date: 02/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

THERAPY SOURCE JAMMED AT THE DEVICE ENTRY PORT

"On January 2, 2013, the Agency [Texas Department of State Health Services] was notified by the licensee that on December 4, 2012, a medical event had occurred. The licensee reported that while performing a therapy procedure using a Novoste Beta-Cath IVB device the last strontium-90 source in the ribbon of sources could not be retracted into the device. The source was jammed at the device entry port. All of the sources had been removed from the patient, therefore the patient did not receive any additional exposure. The device was placed into an emergency safety box designed for such events and the box was then covered with a lead apron. No one in the treatment room received any additional exposure form the event. The licensee will return the device to their supplier. Additional information will be provided as it is received in accordance with SA-300."

Texas State Report # I-9029

* * * UPDATE FROM ART TUCKER TO VINCE KLCO ON 2/21/2013 AT 1526 EST * * *

The following information was received by facsimile:

"The Best Vascular Technical Team based in Norcross, Georgia evaluated the returned system that was involved in the subject complaint. The team confirmed the complaint based on the evidence of discoloration to the proprietary connector and acrylic body of the main chamber distal to the pin gate, indicating prolonged exposure to radiation; however upon arrival the Jacketed Radiation Source Train (JRST) was no longer stuck at the pin gate or proprietary connector of the delivery catheter.

"During testing, interlocks performed as expected to provide safety in the case of a manual removal. The team was unable to duplicate the complaint after exhaustive cycle testing. Visual examination identified a kink in the tubing leading to the fluid collection bag.

"A fluid sample that had been run through the transfer device and over the jacketed radioactive source train was analyzed for unsealed radiation; no radiation leakage was detected.

"Due to the size of the 3.5F delivery catheter, Best Vascular utilizes tubing materials that exhibit high column strength to ensure adequate trackability of the catheter during placement. The smaller size of the catheter is a desired feature that minimizes ischemia caused by cessation of blood flow during treatment. Unimpeded hydraulic flow is essential to performance of the system and as such, it is necessary to avoid the compression that may occur to the delivery catheter due to the configuration of the system in conjunction with other interfaces (e.g., interventional tools, patient, etc.). It is also essential that the path to the fluid collection bag be maintained in an unobstructed manner in order to provide the hydraulic pressure necessary for smooth movement of the JRST through the entire system.

"Additional information on this event has been provided in the Nuclear Materials Event Database in accordance with SA-300."

Notified R4DO(Miller) and FSME 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.

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Agreement State Event Number: 48749
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BARD BIOPSY
Region: 4
City: NEW IBERIA State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/13/2013
Notification Time: 14:46 [ET]
Event Date: 02/06/2013
Event Time: 17:52 [CST]
Last Update Date: 02/13/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURSE (E-MA)

Event Text

AGREEMENT STATE REPORT - STOLEN SENORX GAMMA FINDER II SURVEY METER RECOVERED

The following information is a synopsis of information received from the State of Louisiana:

On 2/6/2013 at 1752 CST, the Iberia Parish Sheriff's Office (IPSO) notified the Louisiana Department of Environmental Quality (LDEQ) that radioactive material had been found in a vehicle which had been towed and impounded by IPSO. LDEQ personnel conducted an investigation on 2/8/2013 at the IPSO.

A metal briefcase containing a SenoRx Gamma Finder II survey meter and two calibration sources was found in the impounded vehicle by the IPSO. Survey readings done at a local hospital before LDEQ was called read 0.008 mR/hr for the two calibration sources. The briefcase containing the survey meter and calibration sources was then taken to the IPSO.

Description of the first source: Co-57, serial number D-138-21, last calibration date 10/21/2008, activity 11.5242 microCuries. Description of the second source: Co-57, serial number D-139-6, last calibration date 10/22/2008, activity 1.1419 microCuries. The IPSO traced the serial numbers and found that the survey meter and calibration sources belonged to Bard Biopsy Systems in Philadelphia, Pennsylvania. The IPSO confirmed that Bard Biopsy Systems had reported the survey meter and calibration sources stolen from their location in Philadelphia, Pennsylvania in 2009. A report had been filed with the Philadelphia Police Department, District 26, at that time.

LDEQ personnel performed a survey on both calibration sources using a Ludlum 14C survey meter. The first source read 0.05mR/hr on the surface and the second source read 0.03 mR/hr on the surface. A background reading of 0 mR/hr was noted during these readings.

The Philadelphia PD, District 26 is following up on the stolen equipment. The IPSO will ship the survey meter and sources to the Philadelphia PD. Philadelphia PD will return the survey meter and calibration sources to the owner.

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Agreement State Event Number: 48752
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENN STATE MILTON S. HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: PA-0127
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2013
Notification Time: 14:28 [ET]
Event Date: 08/28/2012
Event Time: [EST]
Last Update Date: 02/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 SIR-SPHERES

The following information was obtained from the Commonwealth of Pennsylvania via email and facsimile:

"Notifications: On February 13, 2013 the licensee informed the Department's [Pennsylvania Department of Environmental Protection] South-central Regional Office of the medical event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). The referring physician was notified of this event but the patient passed away in November of 2012 as a result of metastatic pancreatic cancer.

"Event Description: During a routine audit of the Y-90 written directive program, an error was noted in a SIR-Sphere procedure that was performed on August 28, 2012. The patient was prescribed 17.6 mCi of Y-90 SIR-Spheres. The patient actually received only 12.8 mCi. This corresponds to a dose that is 27.3% lower than the prescribed dose.

"Cause of the Event: The physician recorded the wrong administered dose on the written directive form. Also a small liquid volume remained in the vial after the 'air-injection' final step.

"Actions: The licensee initiated and completed an audit of all SIR-Sphere procedures and no other issues were identified in any other patients since inception of the program. The South-central Regional Office has been in discussion with the licensee regarding corrective actions that will be implemented."

Pennsylvania Event Report ID No.: PA130006

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: 48753
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: UNKNOWN
Region: 4
City: PORTLAND State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2013
Notification Time: 18:29 [ET]
Event Date: 02/14/2013
Event Time: [PST]
Last Update Date: 02/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME_EVENTS RESOURCE (EMAI)
ILTAB (EMAI)

Event Text

AGREEMENT STATE REPORT - DISCOVERY OF GAS CHROMATOGRAPH IN BUILDING ATTIC

The following is a synopsis of information received from the State of Oregon via email:

When cleaning out an attic storage space acquired from a business partner (Philco International), an employee of the Evonik Corporation discovered a gas chromatograph containing a Ni-63 electron capture device (ECD). The ECD was manufactured in 1993 and contained 15 mCi of Ni-63 at the time of manufacture. The ECD is model number N610-0133 and serial number 1121.

The chromatograph was manufactured by Perkin Elmer and was originally sold to InterMedics of Angleton, TX in October, 1993. In 1998, Guidant bought out InterMedics and eventually closed the facility in 1999. It is unknown what happened to the device after the 1999 closure.

Evonik Corporation will be contracting out proper disposal of the unit and will inform the State of Oregon when it has been removed.

Oregon Incident No.: 13-0009

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Power Reactor Event Number: 48775
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TONY COOK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/21/2013
Notification Time: 12:49 [ET]
Event Date: 02/21/2013
Event Time: 09:57 [EST]
Last Update Date: 02/21/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP ON LOSS OF BOTH MAIN FEED PUMPS

At 0957 EST on 02/21/13, Unit 1 Reactor automatically tripped from 100% power, due to a turbine trip. The turbine trip was caused by a loss of both main feedwater (MFW) pumps. The 1A motor driven auxiliary feedwater (AFW) pump auto started to feed the "A" and "B" Steam Generators (S/G). The 1B motor driven AFW pump was unavailable due to planned maintenance, so the turbine driven AFW pump was manually started to feed the "C" and "D" S/Gs.

The reactor trip was uncomplicated. All control rods fully inserted. Decay heat removal is to the main condenser via the turbine bypass valves. There was no primary to secondary leakage. Electrical buses are being supplied via offsite power. Steam generator levels are being returned to normal and MFW has been reset and is available. All other plant systems functioned as designed during and after the reactor trip. There is no impact on Unit 2. There is no impact on the health and safety of the public. The loss of the MFW pumps is still under investigation.

The licensee has informed the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, February 22, 2013
Friday, February 22, 2013