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Event Notification Report for March 5, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/04/2013 - 03/05/2013

** EVENT NUMBERS **


48762 48776 48780 48804 48805 48806

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Agreement State Event Number: 48762
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: WELDSONIX INC.
Region: 4
City: HOUSTON State: TX
County:
License #: 05718
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 02/17/2013
Notification Time: 00:14 [ET]
Event Date: 02/16/2013
Event Time: [CST]
Last Update Date: 02/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT FROM RADIOGRAPHY CAMERA

The State of Texas submitted the following via email:

"On February 16, 2013, the Agency [Texas Department of Health] was contacted by the Radiation Safety Officer (RSO) for QSA Global requesting reciprocity to work in the State of Texas. The RSO stated they had been contacted by a Texas licensee who requested the recovery of an iridium - 192 source at a work site near the city of Jacksonville, Texas. The source was out of a Sentinel model 880 exposure device. The RSO stated that the disconnect occurred at about 0900 hours [CST] during the first exposure of the day on February 16, 2013. The RSO stated that the dose rate at the exposure device was 5 millirem per hour leading them to believe the source was still in the collimator. At 2134 hours the RSO for QSA Global contacted the Agency and reported that the source had been recovered. The individual recovering the source received 10 millirem during the recovery. No overexposures occur due to this event. The source and exposure device will be returned to the manufacturer for inspection. Additional information will be provided as it is received in accordance with SA-300."

TX Incident # I - 9060

* * * UPDATE FROM ART TUCKER TO CHARLES TEAL AT 0753 EST ON 02/19/13 * * *

"The Texas incident number for this event has been changed to I-9042. The spelling of the company's name has been corrected."

Notified R4DO (Hagar) and FSME Event Resource.

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Agreement State Event Number: 48776
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: PRINCE WILLIAM HOSPITAL
Region: 1
City: MANASSAS State: VA
County:
License #: 683-166-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMEN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/22/2013
Notification Time: 09:55 [ET]
Event Date: 12/13/2012
Event Time: [EST]
Last Update Date: 02/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING MEDICAL PROCEDURE

"On December 13, 2012, a patient received a permanent implant of I-125 seeds to the prostate as part of a combined external beam treatment and brachytherapy. It was determined during a post-surgical CT that the tumor may have been underdosed and a follow-up MRI was performed. As a result of the MRI, it was discovered, on February 21, 2013, that the dose received for the brachytherapy was 70 percent of the written directive. The licensee will submit a written report to the Virginia Radiation Materials Program."

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: 48780
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: MERCY MEDICAL CENTER
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #: 0017157M1
Agreement: Y
Docket:
NRC Notified By: RANDY DAHLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/25/2013
Notification Time: 10:28 [ET]
Event Date: 01/17/2013
Event Time: [CST]
Last Update Date: 03/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
FSME RESOURCES ()

Event Text

AGREEMENT STATE REPORT - PROSTATE SEED IMPLANT UNDERDOSE

A prostate patient received a medical order for 74 I-125 seeds (144 Gray). The implantation was performed on January 17, 2013 with three seeds being recovered in the operating room and the patient passed two seeds. The post surgery CT scan was performed on February 20, 2013 and the post plan was performed on February 25, 2013. It was determined that the D90 dose was 60% of the prescribed dose. The physician and patient will be notified today, February 25, 2013.

The Iowa Department of Public health is planning an on-site inspection for February 27, 2013.

* * * UPDATE FROM DAHLIN TO KLCO ON 3/4/2013 AT 1257 EST * * *

The following information was received from the State of Iowa by email:

"...The post plan dosimetry was completed on February 25, 2013 where it was discovered that the D90 for the implant was 60%. The licensee immediately notified IDPH [Iowa Department of Public Health]. The patient and referring physician were also notified that same day. An IDPH inspector conducted an onsite investigation of the event on February 28, 2013. The inspector met with and interviewed the radiation oncologist, the medical physics staff and several hospital administrators. The inspector reviewed the patient chart including the written directive, the treatment pre-plan, the operating room notes and the treatment post plan. During the interviews and chart review it was determined that an additional nine I-125 seeds had migrated out of the prostate to an area slightly inferior to the prostate. The radiation oncologist and medical physics staff believe that the seed migration occurred along the needle path and was due to the bowel movement issues that the patient experienced post implant. Additionally, the treatment pre-plan was based on an ultrasound contoured prostate volume of 38.59 cc. The treatment post-plan was based on a CT scan contoured prostate of 21.61 cc. The urologist, radiation oncologist and medical physics staff determined that the D90 of 60% was due to the loss of the additional nine I-125 seeds that migrated out of the prostate and the shrinking of the prostate from 38.59 cc to 21.61 cc. The patient will receive an external beam boost to the prostate. In addition, the post-plan dosimetry showed that the rectum and bladder received a dose less than expected on the preplan. The radiation oncologist and urologist stated that the under dose to the prostate from the seed implant therapy will not have an adverse effect on the health of the patient. No corrective actions can be performed due to the licensee having no control over seeds that migrate out of the prostate."

Iowa Item Number: IA130001

Notified the R3DO (Valos) and FSME Resources via email.

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Power Reactor Event Number: 48804
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: RICHARD HUNNICUTT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/04/2013
Notification Time: 08:59 [ET]
Event Date: 03/04/2013
Event Time: 04:15 [EST]
Last Update Date: 03/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RANDY MUSSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text

RADIATION MONITOR INOPERABLE FOR PRE-PLANNED MAINTENANCE

"This is a non-emergency notification.

"At 0415 EST on March 4, 2013, REM-01MD-3528, Turbine Building Floor Drain Liquid Effluent Radiation Monitor, was declared inoperable for pre-planned corrective maintenance and surveillance testing. The pre-planned maintenance and surveillance testing is scheduled to take approximately 62 hours. Proceduralized compensatory measures are in place to sample and analyze for radioactivity at a lower limit of detection of no more than 10E-7 microCuries/ml at least once per 12 hours when the specific activity of the secondary coolant is greater than 0.01 microCuries/gram Dose Equivalent I-131, or at least once per 24 hours when the specific activity of the secondary coolant is less than or equal to 0.01 microCuries/gram Dose Equivalent I-131. The expected return to service and operability date is March 6, 2013.

"The Liquid Effluent Radiation Monitor is necessary for accident assessment and is credited for Emergency Action Level (EAL) classification in the Harris Nuclear Plant Emergency Plan. Inability to classify an EAL due to an out of service monitor is considered a loss of accident assessment capability and is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2.

"The NRC Resident has been notified."

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Power Reactor Event Number: 48805
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ANGELIQUE BRAY
HQ OPS Officer: VINCE KLCO
Notification Date: 03/04/2013
Notification Time: 11:58 [ET]
Event Date: 03/04/2013
Event Time: 09:27 [CST]
Last Update Date: 03/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NICK VALOS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Cold Shutdown

Event Text

OFFSITE NOTIFICATION DUE TO A FISH KILL

"At 0927 CST on March 4, 2012, XCEL Energy Environmental Services made a report to the State of Minnesota regarding 475 fish killed from the discharge canal temperature transient following reactor shutdown on March 2, 2013."

Monticello was in the process of performing a planned shutdown in preparation for a refueling outage.

The NRC Resident Inspector, Wright County Sheriffs Department and Sherburne County Sheriffs Department have been notified by the licensee.

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Power Reactor Event Number: 48806
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: SCOTT MOECK
HQ OPS Officer: VINCE KLCO
Notification Date: 03/04/2013
Notification Time: 18:32 [ET]
Event Date: 03/04/2013
Event Time: 14:00 [CST]
Last Update Date: 03/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RYAN LANTZ (R4DO)

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

UNANALYZED CONDITION DUE TO MECHANICAL SEAL MATERIAL DESIGN

"It has been determined that the mechanical seals used in two Low Pressure Safety Injection Pumps and three Containment Spray Pumps are made of a material that may not maintain the designed integrity of the systems under certain accident conditions. These seals have been installed since original plant construction. This issue was discovered by plant personnel while researching requirements for the replacement parts during scheduled outage activities."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, March 05, 2013
Tuesday, March 05, 2013