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Event Notification Report for April 5, 2013

U.S. Nuclear Regulatory Commission
Operations Center

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

** EVENT NUMBERS **


48856 48857 48858 48859 48864 48879 48887

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Agreement State Event Number: 48856
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: VANDERBILT UNIVERSITY
Region: 1
City: NASHVILLE State: TN
County:
License #: R-19021-I15
Agreement: Y
Docket:
NRC Notified By: SASI KRISHNASARMA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/26/2013
Notification Time: 15:23 [ET]
Event Date: 01/29/2013
Event Time: [EDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENT RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - CATHETER LEAKAGE DURING TREATMENT

"The Division of Radiological Health was notified on Tuesday March 26, 2013, by a representative from Vanderbilt [University], of a misadministration. A patient was treated January 29, 2013, with Iodine 131-MIBG [metaiodobenzylguanidine]. The patient stayed in the hospital for 4 days until February 2, 2013. Foley catheter leakage occurred during this interval, but not recognized as a misadministration because there was no visible effect.

"The patient returned for a second treatment on March 19, 2013, at that time a rash was noted and attributed to the catheter leakage during the initial treatment in January.

"Inspectors from the Nashville Field Office will [request additional information and] follow-up and keep NRC informed of the status of our investigation."

Tennessee Division of Radiological Health Report Number: TN-13-044

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: 48857
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PETROCHEM INSPECTION SERVICES
Region: 4
City: PORT ARTHUR State: TX
County:
License #: L-04460
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2013
Notification Time: 11:47 [ET]
Event Date: 03/26/2013
Event Time: [CDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE DUE TO DAMAGED GUIDE TUBE

The following information was obtained from the State of Texas via email:

"On March 27, 2013, the Agency [Texas Bureau of Radiation Health] was notified by the licensee that a radiography [camera] guide tube at a temporary field site had suffered damage, causing the source to become unretractable. The source was recovered by the licensee according to the terms of the license. The source was part of a GRP model 880D Sentinel radiography camera, S/N 9185. The source was a 51 Ci Ir-192 sealed source, S/N 91313B. Initial dose estimates show 1.4R exposure to whole body and 2R exposure to the hand by the retrieval worker. The work site was closed so no dose was received by members of the public. More information will be provided as needed per SA300."

Texas Incident # I-9060

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Non-Agreement State Event Number: 48858
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2013
Notification Time: 16:06 [ET]
Event Date: 03/27/2013
Event Time: 12:48 [CDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
JULIO LARA (R3DO)
GREG PICK (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE EXCEEDING NRC REPORTING LIMITS

"Per 10 CFR 20.1906(d)(1), [the Veterans Health Administration (VHA) is] reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.

"The package was received today (March 27, 2013) around 12:48 PM CDT by South Texas Veterans Health Care System, San Antonio, Texas. This medical center holds permit number 42-15881-01 under the VHA master materials license.

"Wipe tests performed on the external surface of the package indicated a removable contamination level of 993 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters.

"The package contained one 30-millicurie dosage of Technetium-99m and was shipped and delivered by Cardinal Health in San Antonio, Texas. The inner packaging materials were slightly contaminated but the dosage itself was not impacted and was able to be used.

"The VA facility Nuclear Medicine Technologist immediately notified, by telephone, the Radiation Safety Officer at Cardinal Health about the contaminated package.

"As corrective actions: the packaging materials were bagged and set aside in a restricted area at the medical center for decay; staff with access to the area were notified about the contaminated packaging materials; and surveys were performed in the package receipt area to ensure that contamination was not spread beyond the area.

"[Veterans Health Administration] notified NRC Region III (K. Null) by telephone of this event."

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Agreement State Event Number: 48859
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS PORT AUTHORITY
Region: 1
City: WORCHESTER State: MA
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: TONY CARPENTINO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2013
Notification Time: 17:02 [ET]
Event Date: 01/16/2013
Event Time: [EDT]
Last Update Date: 03/27/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)

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

Event Text

DISCOVERY OF TWO RADIOACTIVE GAUGES IN LOCKED STORAGE

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

"[On approximately] 1/16/13, two surface gauges [manufactured in 1961 were] found in locked storage within [a] remote airfield facilities building at Worcester Regional Airport, Worcester, MA. Third-party waste brokers [were] contacted to bid on proper removal. Wipe tests by a third-party waste broker indicate no leakage of radioactive contamination from [the] gauge sources. [The Massachusetts Radiation Control Program (the Agency) received the information via email] on 3/19/13. The Agency conducted a site visit to confirm device identifications on 3/26/13. A waste brokers' bid [was] accepted [and] packaging and removal [is] scheduled for 4/17/13. Gauges [are being] held in locked storage until removal by [the] waste broker.

"[The] items [are] described as one Nuclear-Chicago Corporation Model P21 Surface Moisture Probe, SN 136, containing 5 mCi Ra-Be, date stamped 5/2/61; and one Nuclear-Chicago Corporation Model P22A Surface Density Probe, SN 139, containing 3 mCi Cs-137, date stamped 5/23/61.

"The Agency considers this matter to be open until [the] items [are] confirmed removed on 4/17/13."


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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Agreement State Event Number: 48864
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ROSA OF NORTH DALLAS LLC
Region: 4
City: DALLAS State: TX
County:
License #: 06186
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/28/2013
Notification Time: 17:58 [ET]
Event Date: 03/27/2013
Event Time: [CDT]
Last Update Date: 03/28/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE IN BRACHYTHERAPY TREATMENT DUE TO USE OF WRONG LENGTH GUIDE WIRE

The following information was provided by the State of Texas via email:

"On March 28, 2013, the Agency [Texas Department of Health] was notified by the licensee that a medical event occurred on March 27, 2013. The licensee stated that the wrong length guide wire was used during 3 of 4 HDR [High-Dose Rate Brachytherapy] treatments. The error was discovered after the third treatment. The Radiation Safety Officer (RSO) stated the desired area of treatment was under dosed by more than 50 percent. The treatment plan prescribed 2400 cGy over 4 treatments. He stated that the patient and their physician were notified as soon as the error was discovered. The RSO is not at the facility and is trying to gather the information on the event over his phone. The licensee has suspended all HDR treatments until their process and procedures have been reviewed. Additional information will be provided as it is received in accordance with SA - 300.

"Texas Incident #: I-9059"

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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Power Reactor Event Number: 48879
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TIM HOLLAND
HQ OPS Officer: PETE SNYDER
Notification Date: 04/02/2013
Notification Time: 20:30 [ET]
Event Date: 04/02/2013
Event Time: 17:07 [CDT]
Last Update Date: 04/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAY KELLAR (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 88 Power Operation 88 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO ELECTRICAL FAULT IN SWITCHYARD RESULTING IN PERSONNEL INJURIES

"At 1707 CDT on 4/2/13 an arc flash occurred at the 'B' safeguards transformer (XMDV24) in the plant switchyard at Callaway. At the time of the flash, ground straps were being placed on the 'B' safeguards transformer which had been removed from service for maintenance. The event resulted in a loss of power to areas/buildings outside the power block. There was no impact to equipment and systems in the plant.

"Four workers were injured or affected by the flash. The extent of the electrical-related injuries has not been determined. However, based on reports from the scene, all of the workers were conscious and walked away from the scene. One person was transported by helicopter and two by ambulance to a local hospital. The fourth person experienced only a minor injury.

"The hazard has been isolated and investigation of the cause is in progress.

"Notifications of this event are planned to be made to OSHA and the Missouri Public Service Commission."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM ROB STOUGH TO VINCE KLCO AT 1955 EDT ON 4/4/2013 * * *

"Ameren Missouri issued a press release about the event described above at approximately 1507 CDT on April 4, 2013.

"The NRC Resident Inspector was notified."

Notified the R4DO (Kellar).

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Power Reactor Event Number: 48887
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: KELLEY BELENKY
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/04/2013
Notification Time: 08:35 [ET]
Event Date: 04/04/2013
Event Time: 04:06 [EDT]
Last Update Date: 04/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ROBERT DALEY (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 65 Power Operation 65 Power Operation

Event Text

FAILURE OF THE INTEGRATED PLANT COMPUTER SYSTEM

"At 0406 [EDT] on April 4, 2013, the Fermi 2 Integrated Plant Computer System (IPCS) failed. This resulted in a loss of approximately 60 percent of data on the Safety Parameters Display System (SPDS).

"While IPCS and SPDS are not fully functional, the Emergency Plan can still be implemented if a plant emergency does occur, as assessment capabilities are available under alternate means.

"Investigation is in progress. A follow up message will be made when IPCS and SPDS are restored to fully functional status.

"This notification is being made per the requirements of 8 Hour Non-Emergency Notification 10CFR50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, April 05, 2013
Friday, April 05, 2013