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Event Notification Report for March 27, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/26/2013 - 03/27/2013

** EVENT NUMBERS **


48784 48826 48831 48851 48852 48853

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 48784
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 4
City: LEWISTON State: ID
County:
License #: 11-27371-01
Agreement: N
Docket:
NRC Notified By: DOUG HEIDORN
HQ OPS Officer: VINCE KLCO
Notification Date: 02/26/2013
Notification Time: 12:42 [ET]
Event Date: 01/18/2013
Event Time: [MST]
Last Update Date: 03/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
DON ALLEN (R4DO)
FSME RESOURCE(email) ()

Event Text

UNPLANNED IODINE-131 DOSE TO AN EMBRYO

A female patient with a previously removed thyroid, was treated for remnant thyroid cancer on January 18, 2013. She received an I-131 therapy dose of 58 mCi. On February 21, 2013, the radiation oncologist was informed by the primary physician that the patient had tested positive on a pregnancy test. The patient received an ultrasound on February 25, 2013 and the conception date was determined to be January 14, 2013. Based on the patient therapy activity received, an embryo dose of 15 Rem was calculated. Physician review of the ultrasound was determined to be normal for the embryo. The radiation oncologist is in contact with the primary physician and the patient.


* * * RETRACTION FROM DOUGLAS HEIDORN TO DONALD NORWOOD AT 1324 EDT ON 3/26/2013 * * *

Based on a telephone notification made by Douglas Heidorn, Radiation Safety Officer (RSO) at 1950 EDT on 3/25/2013, it was agreed that a written justification for a retraction would be submitted. The following is a synopsis of what Dr. Heidorn submitted.

The Radiation Oncologist (Prescribing Physician) and RSO originally thought that the fetal dose was 14.6 rem, but upon further investigation, it was determined that the fetal dose was only 52 mrem. The discrepancy in the dose estimate was due to confusion about the exact conception date (fetal age).

The Prescribing Physician has been corresponding with a Professor of Pediatrics and Radiology (Expert Physician) regarding this issue. The Expert Physician believes that conception occurred between 1/27/2013 and 1/29/2013. Another obstetrician at SJRMC and the Referring Physician concur with the Expert Physician's date range for conception. The 52 mrem fetal dose rate is based on this conception date.

On 3/11/2013, a second ultrasound was performed that confirms the above information. Both ultrasound reports indicate the fetus is growing and has normal characteristics.

As a corrective action, the Radiation Department will immediately adopt a policy that requires any female aged 12-60 shall receive a pregnancy test 48 hours prior to an I-131 administration.

Notified R4DO (Pick) and FSME Event Resources (via E-mail).

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Agreement State Event Number: 48826
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: CARILION CLINIC
Region: 1
City: ROANOKE State: VA
County:
License #: 770-051-1
Agreement: Y
Docket:
NRC Notified By: CAHRLES COLEMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/18/2013
Notification Time: 14:31 [ET]
Event Date: 03/15/2013
Event Time: [EDT]
Last Update Date: 03/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was received via fax:

"On March 15, 2013, a patient was treated with Y-90 microspheres (Sirtex SIR-Spheres) for a liver lesion. The prescribed activity was 35.8 millicuries. Measurements of the residual activity in the delivery system indicated 24.6 millicuries was delivered to the patient. Because of this, the total dose to the treatment site differed from the prescribed dose by 31.3 percent. The need for additional treatment is being evaluated. The licensee will submit a written report within 15 days."

Virginia Event ID: VA-13-0004

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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Non-Agreement State Event Number: 48831
Rep Org: BIOCOMPATIBLES INC.
Licensee: BIOCOMPATIBLES INC.
Region: 1
City: Oxford State: CT
County:
License #: 06-30764-02MD
Agreement: N
Docket:
NRC Notified By: WAYNE RICHARDSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2013
Notification Time: 14:45 [ET]
Event Date: 02/26/2013
Event Time: 09:00 [EDT]
Last Update Date: 03/20/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMES TRAPP (R1DO)
FSME EVENT RESOURCES (EMAI)
GREG WERNER (R4DO)
DARYL JOHNSON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

POTENTIAL LOSS OF BRACHYTHERAPY SEEDS

On 2/25/2013, four Mick applicator kits with fifteen I-125 seeds in each applicator kit (60 seeds total) were shipped to the Dameron Hospital in Stockton, CA. Each seed contained 0.45 milliCuries. On 2/26/2013, 49 seeds were implanted with one seed jamming in the applicator. After the medical procedure, the radiologist stated that only 50 seeds were in the applicators i.e. ten missing. Surveys were performed but the missing seeds could not be found. The jammed seed is being returned to Biocompatibles.

* * * UPDATE AT 0748 EDT ON 3/20/13 FROM RICHARDSON TO HUFFMAN VIA FACSIMILE * * *

The following detailed event text was received from the licensee (Biocompatibles, Inc.) via fax:

"Biocompatibles, Inc. ('Biocompatibles') has investigated a report that ten (10) I-125 sources (0.450 mCi each Ref date 2/26/13) that Biocompatibles sent to Dameron Hospital in Stockton CA (the 'Hospital') are unaccounted for.

"On February 26, 2013, Biocompatibles received a report that at the end of an implant procedure for which Biocompatibles provided (60) sealed sources in four (4) Mick magazines of fifteen (15) sources each that:

* Forty-nine (49) sources were implanted in the patient
* One (1) source had jammed in the Mick Applicator and had been retained by the Hospital
* Ten (10) sources were unaccounted for at the end of the procedure

"A Biocompatibles sales representative was present during most of the procedure performed on February 26, 2013 and reported that there was no indication that there were not four (4) full magazines of (15) sources each at the start of the procedure. In addition, the Hospital has confirmed that the decision to implant forty-nine (49) sources was made by the operating physician at the time of the surgery.

"Several communications led Biocompatibles to believe that the sources were accounted for at the Hospital, but on March 13, 2013, a conversation with relevant personnel confirmed that the Hospital did not have the sources.

"Biocompatibles received the sources from its Supplier on February 19, 2013, and loaded all sources received into four (4) magazines on the same day. Biocompatibles' production records confirm that Biocompatibles received sixty (60) sources from its Supplier (OPSRAD SOP09-01), and subsequently confirmed with its Supplier that exactly sixty (60) sources were sent to Biocompatibles. Biocompatibles verified the source counts at magazine loading. Biocompatibles also performed Ludlum meter surveys for line clearance after both the assay (OPSRAD SOP09-02) and loading operations (OPSRAD SOP09-03) to ensure that no sources had been left behind. A final inspection (OPSRAD SOP09-04), performed by the Biocompatibles Quality Department, verified that the magazine plunger heights on the four (4) full magazines were identical, indicating fifteen (15) sources per magazine. After all of these quality control measures took place, all sixty (60) sources were sent to the Hospital.

"Biocompatibles delivered a sterile Applicator Kit (Case 75152), containing four (4) Mick magazines of fifteen (15) sources each, for a total of sixty (60) sources, to the Hospital on February 25, 2013. The lot number for the I-125 sealed sources was Lot 2013-24638.

"When first notified by the Hospital on February 26, 2013 of the possible issue, the Biocompatibles Radiation Lab performed additional meter surveys. Biocompatibles performs production station surveys at the completion of each production operation, and performs meter surveys of the entire facility at shift end. All surveys performed on February 26, 2013 through March 13, 2013 have not identified any misplaced seeds.

"The empty Supplier vial and pig used to deliver the sources to Biocompatibles was shipped to the Hospital with the case in question. Biocompatibles has requested all empty packing associated with the case to be returned to Biocompatibles for further investigation."

Notified R1DO (Trapp) and R4DO (Werner). ILTAB and FSME Events Resource notified via e-mail.


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

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Part 21 Event Number: 48851
Rep Org: ELECTROSWITCH
Licensee: ELECTROSWITCH
Region: 1
City: WEYMOUTH State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LARRY FRIEDMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/26/2013
Notification Time: 09:01 [ET]
Event Date: 03/26/2013
Event Time: [EDT]
Last Update Date: 03/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
GREG PICK (R4DO)
DANIEL RICH (R2DO)
PART 21 REACTORS (EMAI)
PAUL KROHN (R1DO)

Event Text

PART 21 - SERIES 24 CSR RELAYS WITH OVERSIZED CAM DRIVE COMPONENTS

The following is a summary of a Part 21 report received from Electroswitch, via facsimile:

"The root cause has been determined to be oversized OD dimension on the drive cam. This tight fit in the nylon bushing and mounting plate did not allow the drive cam to close when deenergized.

"NOTE: Any switches that have passed the bench test and/or are in operation will not degrade nor have the condition as found with the returned switches."

Affected Facilities: Waterford, Surry, and Harris.

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Power Reactor Event Number: 48852
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: SEAN BLOOM
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/26/2013
Notification Time: 19:06 [ET]
Event Date: 03/26/2013
Event Time: 06:20 [EDT]
Last Update Date: 03/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 95 Power Operation 95 Power Operation
4 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

TSC EMERGENCY VENTILATION SYSTEM CONTROL SWITCH DISCOVERED IN THE OFF POSITION

"This is a non-emergency notification to the NRC Operations Center in accordance with 10 CFR 50.72(b)(3)(xiii), Loss of Emergency Preparedness Capabilities.

"On 3/26/13 at 0620 EDT, during a routine surveillance of the Technical Support Center (TSC), the TSC emergency ventilation system control switch was discovered in the off position (vs. auto). The Operations department was notified and the TSC emergency system ventilation was returned to normal alignment (auto) at 0644 EDT.

"The switch normally operates in the 'auto' position, so that TSC emergency ventilation system can be automatically initiated from a control room isolation signal. In accordance with station operating procedures, upon initial responder activation to the TSC, the TSC ventilation system is also manually placed in service. The TSC emergency ventilation system was capable of manual initiation and was not out of service for repair or maintenance.

"An investigation is underway to understand the circumstances associated with the control switch misalignment."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48853
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DREW GRIFFITHS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/27/2013
Notification Time: 04:21 [ET]
Event Date: 03/27/2013
Event Time: 02:45 [CDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
GREG PICK (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

REACTOR PRESSURE BOUNDARY LEAKAGE

"On March 26, 2013, at 1635 [CDT], with Unit 1 shutdown for refueling, leakage was identified from the 2-inch reactor head vent line during a Reactor Pressure Vessel (RPV) pressure test. The leakage was approximately 20 drops per minute. The RPV pressure test was stopped and the reactor vessel depressurized to facilitate examination of the piping and associated flange connections. At 0245 hours on March 27, 2013, the leak was confirmed to be through-wall originating from a socket weld (i.e., pipe elbow). The cause and resolution are under evaluation. The condition is being reported under 50.72(b)(3)(ii)(A) given the defect was associated with the primary coolant system pressure boundary."

The licensee notified the NRC Resident Inspector

Page Last Reviewed/Updated Wednesday, March 27, 2013
Wednesday, March 27, 2013