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Event Notification Report for December 10, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/09/2014 - 12/10/2014

** EVENT NUMBERS **


50646 50647 50648 50662 50663

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Non-Agreement State Event Number: 50646
Rep Org: HYDROLAKE INC
Licensee: HYDROLAKE INC
Region: 3
City: MCBAIN State: MI
County:
License #: GL644751
Agreement: N
Docket:
NRC Notified By: JESS ROLSTON
HQ OPS Officer: DANIEL MILLS
Notification Date: 12/01/2014
Notification Time: 16:44 [ET]
Event Date: 11/28/2014
Event Time: 06:33 [EST]
Last Update Date: 12/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(a) - PROTECTIVE ACTION PREVENTED
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS EVENT NOTIFICAT (EMAI)

Event Text

FIRE DAMAGED LABORATORY CONTAINING NRC GENERAL LICENSED MATERIAL

An NRC general licensee reported that a fire damaged their facility. Inside this facility was an ASOMA Model 200 (Serial # 4649) device containing 13 mCi of Cm-244. The device is assumed to be damaged or destroyed. The licensee has limited access to the area and is contacting a qualified contractor to assist with disposal of the device.

The ASOMA Model 200 is an Energy Dispersive-X-Ray Fluorescent (ED-XRF) benchtop analyzer.

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Agreement State Event Number: 50647
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CEDARS SINAI MEDICAL CENTER
Region: 4
City: LOS ANGELES State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: JOSEPHINE ORTEGO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2014
Notification Time: 17:15 [ET]
Event Date: 11/07/2014
Event Time: [PST]
Last Update Date: 12/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - MEDICAL EVENT INVOLVING UNDERDOSAGE TO PATIENT OF Y-90 SIR-SPHERES

The following is a synopsis of information received via E-mail:

The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center.

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: 50648
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: ONCOLOGY ASSOCIATES OF OREGON
Region: 4
City: EUGENE State: OR
County:
License #: ORE-90862
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2014
Notification Time: 17:15 [ET]
Event Date: 12/02/2014
Event Time: 09:00 [PST]
Last Update Date: 12/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - MEDICAL EVENT INVOLVING OVERDOSAGE DURING HDR BRACHYTHERAPY TREATMENT

The following information was received via email:

"The licensee reported a medical event at 0958 PST involving a patient treated for vaginal cancer. The treatment involved an Ir-192 high dose rate afterloader (HDR) source at 5.369 Curies activity (December 2nd) delivered to the vaginal vault via a 3 cm single-channel cylinder for a prescribed dose fraction of 400 cGy (rad). Instead, a 5 cm single-channel cylinder was used that delivered a 700 cGy dose (rad), or 75 percent (300 cGy) above the prescribed dose. The licensee stated that an afternoon patient's treatment plan was being reviewed on the console while the morning patient was being prepped for treatment and the patient subsequently treated with the other patient's plan. The licensee failed to verify the patient's identification before starting the treatment. The cause is therefore determined to be human error. The licensee stated that the patient was scheduled for three fractionated doses at 400 cGy (rad) each for a total dose of 1200 cGy (rad). This was the 2nd fraction so the total dose delivered to the patient is currently 1100 cGy (rad). The licensee performed a biological effective dose (BED) calculation and that the final effective dose is within 4 percent and 10 percent of the intended dose in terms of short/long term effects and the final fraction dose will most likely not be administered. The licensee notified the patient's physician who will notify the patient of the error. The licensee will submit a formal report to Oregon RPS including corrective actions to prevent recurrence."

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: 50662
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STANLEY STONE
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/09/2014
Notification Time: 20:02 [ET]
Event Date: 12/09/2014
Event Time: 18:25 [EST]
Last Update Date: 12/09/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BINOY DESAI (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

Event Text

NON-FUNCTIONAL FIRE BARRIER DISCOVERED AFFECTING BOTH SAFE SHUTDOWN PATHS

"During an inspection of a fire penetration between Fire Area 1404, Switchgear Room 1G and Fire Area 1408, Switchgear Room 1F in the diesel generator building, the penetration was determined to be non-functional as a 3 hour fire barrier. In the event of a postulated fire in the affected areas, both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10 CFR 50.72(b)(3)(ii)(B).

"Compensatory measures were established in accordance with the plant's Fire Hazard Analysis (FHA). The presence of the compensatory measures in addition to automatic fire detection in the fire areas ensure that the safe shutdown paths are preserved until the degraded condition can be repaired.

"[Condition report No.] CR904013"

The licensee notified the NRC Resident Inspector

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Power Reactor Event Number: 50663
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: WILLIAM STANG
HQ OPS Officer: DANIEL MILLS
Notification Date: 12/10/2014
Notification Time: 00:31 [ET]
Event Date: 12/09/2014
Event Time: 18:30 [CST]
Last Update Date: 12/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 90 Power Operation 90 Power Operation

Event Text

HIGH ENERGY LINE BREAK DOOR FOUND CLOSED

"At 1830 [CST] on December 9, 2014 Door 410B, a HELB (High Energy Line Break) door between the east and west sides of the ground floor of the reactor building, was found closed. This door is one half of a pair of double doors that are normally open to provide a HELB energy and flooding release path to mitigate postulated HELB events. The closed HELB door has the potential to impact safe shutdown by exposing both divisions of safe shutdown components to unanalyzed environmental conditions. With the potential loss of both divisions of safe shutdown equipment, no safe shutdown path would exist. This condition is being reported as an unanalyzed condition as defined by [10 CFR] 50.72(b)(3)(ii)(B). The HELB door was immediately opened and returned to normal configuration. Door 410A remained open during the time that Door 410B was closed and provided an available, but not yet analyzed, release path that could have mitigated the consequences of this event. The health and safety of the general public was not impacted as a result of this condition.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, December 10, 2014
Wednesday, December 10, 2014