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Event Notification Report for January 27, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2014 - 01/27/2014

** EVENT NUMBERS **


49734 49737 49765

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Agreement State Event Number: 49734
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CENTRAL ARKANSAS RADIATION THERAPY INSTITUTE INC
Region: 4
City: CONWAY State: AR
County:
License #: ARK-0654-0220
Agreement: Y
Docket:
NRC Notified By: STEVE MACK
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/17/2014
Notification Time: 11:41 [ET]
Event Date: 01/15/2014
Event Time: 18:00 [CST]
Last Update Date: 01/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PROSTATE SEED IMPLANT MISADMINISTRATION

The following was received from the State of Arkansas via email:

"Central Arkansas Radiation Therapy Institute, Inc. (CARTI), ARK-0654-02200, reported a medical event involving a patient treated for prostate cancer. The treatment plan included implanting 128 I-125 brachytherapy seeds (6 seeds were not implanted), containing a total activity of 1.592 GBq (43.036 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14,400 cGy. It appears that approximately 40 of the total number of seeds were implanted into the prostate gland. The seeds were implanted on December 31, 2013. On January 15, 2014, the patient returned to the facility for a post implant CT scan. The scan showed that the implanted seeds, although in an appropriate pattern, were placed outside the intended target.

"The State performed an on-site review on January 16, 2014, of the event and discussed the initial details of the event.

"The licensee is continuing to investigate the cause and is preparing a written report.

"The State is continuing to investigate and will update this report when the report is received from the licensee.

"This event is reportable under 10 CFR 35.3045 of the NRC Regulations and RH-8800 of the Arkansas State Board of Health Rules and Regulations for Control of Sources of Ionizing Radiation."

State Event Report Number: AR-2014-001

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: 49737
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PQ CORPORATION
Region: 1
City: AUGUSTA State: GA
County:
License #: GA 976-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/17/2014
Notification Time: 12:58 [ET]
Event Date: 01/16/2014
Event Time: [EST]
Last Update Date: 01/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - STUCK OPEN SHUTTER ON LEVEL GAUGE

The following was received from the State of Georgia via email:

"Licensee's Radiation Safety Officer for PQ Corporation with Georgia Radioactive Materials License GA 976-1 reported to the Georgia Radioactive Materials Program [GRMP] on 1-16-14 that an Industrial Source Holder shutter failed to close (used for level measurements) leaving the source in the exposed position. This was discovered when the licensee was performing a semiannual shutter check and inventory for their gauges and source holders. Once this was discovered by the licensee, the entrances to the unoccupied building where the source holder is located was taped off to prevent any unauthorized entrance to the building. The licensee then contacted Thermo Fisher who will be sending a technician to repair the malfunctioning source holder on 1-28-14. The licensee indicated to the GRMP that the building will remain inaccessible until Thermo Fisher arrives to perform repairs on the source holder. The Licensee will inform the GRMP once the repairs have been completed.

"Source Holder: TN Technologies, Inc.
"Model: 5205
"Source: Cs-137
"Source Activity: 200 mCi
"Source S/N: B597"

Complaint ID: 72888

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Power Reactor Event Number: 49765
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: BRYAN HEAVILIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/27/2014
Notification Time: 05:05 [ET]
Event Date: 01/27/2014
Event Time: 00:45 [PST]
Last Update Date: 01/27/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAIR SPITZBERG (R4DO)

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

Event Text

TURBINE AND RAD WASTE BUILDINGS RADIATION MONITORS INOPERABLE DUE TO PLANNED MAINTENANCE

"At 0045 PST on 1/27/14, the Turbine Building Exhaust Low and Intermediate radiation monitors and the Rad Waste Building Exhaust Low and Intermediate radiation monitors were declared inoperable because of planned maintenance for replacement of the monitors. Compensatory measures have been implemented per station procedures; however, the time required for installation, testing, and acceptance of the new equipment is expected to last several weeks. Therefore, this radiological monitoring equipment outage is being reported as a major loss of assessment capability under regulation 10 CFR 50.72(b)(3)(xiii). Compensatory measures will be in place throughout the duration of the planned equipment outage."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014