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Event Notification Report for July 26, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/25/2013 - 07/26/2013

** EVENT NUMBERS **


49197 49199 49203 49215

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Agreement State Event Number: 49197
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/17/2013
Notification Time: 13:21 [ET]
Event Date: 07/16/2013
Event Time: 11:30 [CDT]
Last Update Date: 07/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PERMANENT PROSTATE BRACHYTHERAPY UNDERDOSE

The following information was obtained from the Commonwealth of Kentucky via facsimile:

RHB [Kentucky Radiation Health Branch] was notified by telephone on 7/16/13 at approximately 1445 [EDT] by the licensee's authorized medical physicist of a medical event involving a permanent prostate brachytherapy implant. A CT scan performed at 30 days post-implant revealed that 16 of the 60 I-125 seeds (lsoAid IAI-125A) representing 26% of the implanted activity had migrated from the planning treatment volume to a region cephalad to the prostate. Post implant dosimetry revealed the dose to 90% of the prostate to be 113 Gy rather than the prescribed dose of 144 Gy (78% of prescribed). This represents a V100 of 54% with the current prostate delineation on CT. The licensee is now undertaking a complete investigation as to why these seeds migrated from their initial implantation site. The referring physician is scheduled to perform a cystoscopy 7/25 to check for seeds that may have migrated into the bladder based on CT visualization. The prescribing physician will be scheduling an MRI for final target and adjacent organ delineation. Final dose to the tissues at risk will then be calculated.

"The referring physician was notified 7/17/13 at 1045 EDT. The patient was notified 7/17/13 at 1130 EDT."

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: 49199
Rep Org: PARADISE FOSSIL PLANT
Licensee: TENNESSEE VALLEY AUTHORITY
Region: 1
City: DRAKEBORO State: KY
County:
License #: 16-25243-01
Agreement: Y
Docket:
NRC Notified By: LEE MILLER
HQ OPS Officer: DANIEL MILLS
Notification Date: 07/17/2013
Notification Time: 15:42 [ET]
Event Date: 07/17/2013
Event Time: 10:30 [CDT]
Last Update Date: 07/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
HAROLD GRAY (R1DO)
EUGENE GUTHRIE (R2DO)
FSME EVENTS RESOURCE (FSME)

Event Text

MOISTURE GAUGE SHUTTER STUCK IN OPEN POSITION

"TVA's Paradise Fossil Plant uses a coal scan moisture monitor with a sealed source containing 3 millicuries of Cesium-137. The gauge is used to monitor the moisture in the coal being transferred on a common feed line to three units at Paradise Fossil Plant. On July 17, 2013 at 1030 CDT, the shutter on the moisture gauge was determined not to be operable. The shutter failed in the open position. The shutter failure discovery was made during the six month shutter test. The issue is being entered into the corrective action program. No personnel radiation exposure was received. The source is not shuttered, but the gauge is in the operating position and is in a safe condition.

"A twenty-four hour notification is required per 10 CFR 30.50(b)(2) due to failure of the moisture monitor shutter to close.

"NRC Region II Duty Officer and NRC Region I Duty Officer will be notified."

Gauge model TBM-201.

Licensee stated that there is no danger of personnel exposure.

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Agreement State Event Number: 49203
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: COOPER HEALTH SYSTEMS AT CAMDEN
Region: 1
City: CAMDEN State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/18/2013
Notification Time: 09:30 [ET]
Event Date: 07/16/2013
Event Time: 11:30 [EDT]
Last Update Date: 07/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT DUE TO EQUIPMENT FAILURE

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

"At 11:30 a.m. [EDT] on July 16, 2013, a patient was being treated for three lesions with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, at Cooper Health System in Camden, New Jersey. The prescribed total dose for all three lesions was 58 Gray.

"The first two lesions were treated as planned without incident.

"During treatment of the third lesion, treatment was interrupted because of mechanical failure. A 'Sensor Failure' error occurred, which caused the patient couch to retract and the shielding doors to close. An Elekta service engineer was called and no other treatments were attempted after the 'Sensor Failure'. Treatment of the third lesion was to be re-scheduled.

"It is estimated that only 44.8 Gray out of the prescribed dose of 58 Gray was actually delivered, which is an underdose of greater than 20%."

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: 49215
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: EDWARD BURKETT
HQ OPS Officer: PETE SNYDER
Notification Date: 07/25/2013
Notification Time: 16:58 [ET]
Event Date: 07/25/2013
Event Time: 11:35 [EDT]
Last Update Date: 07/25/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEORGE HOPPER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

MALFUNCTIONING NOAA TONE ALERT RADIO SYSTEM

"On Thursday, July 25, 2013, at 1135 EDT, Hatch Nuclear Plant [HNP] experienced of a loss of the National Weather Service (NWS) Tone Alert Weather Radio System and was unable to contact the NWS Jacksonville, Florida Office. Site emergency procedures define a loss of Tone Alert Radio for greater than 15 minutes as a significant loss of emergency communications. Plant Hatch EP contacted NOAA and was told they had lost phone service and were attempting to restore it.

"The NWS Tone Alert Weather Radio is utilized as the Prompt Notification System (PMS) for HNP. The loss impacts the ability to notify the Emergency Planning Zone (EPZ) population for the HNP. This failure meets NRC 8-hour reporting criteria 10 CFR 50.72(b)(3)(xiii). The State of Georgia Department of Homeland Security/Georgia Emergency Management Agency (GEMA) 24 hour warning point and the '911' dispatch centers of Appling, Jeff Davis, Tattnall and Toombs Counties were notified so compensatory measures would be available should the Prompt Notification System be needed. This consists of utilizing route alerting and the 'Code Red' system which is a reverse 911 feature available from the county 911 center.

"As of the time of this report, the NOAA [system] has not been returned to service nor does the Jacksonville Office have a cause for the loss or a projected RTS [return to service] time."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM SCOTT BRITT TO PETE SNYDER AT 2005 EDT ON 7/25/13 * * *

As of 1910 EDT on 7/25/13, the tone alert radio systems have been returned to service and are fully operational. The licensee notified the NRC Resident Inspector.

Notified R2DO (Hopper).

Page Last Reviewed/Updated Friday, July 26, 2013
Friday, July 26, 2013