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Event Notification Report for December 11, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/10/2014 - 12/11/2014

** EVENT NUMBERS **


50647 50648 50651 50663 50666

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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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Agreement State Event Number: 50651
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: ADVANCED INSPECTION TECHNOLOGIES
Region: 4
City: TULSA State: OK
County:
License #: OK-27588-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/03/2014
Notification Time: 09:52 [ET]
Event Date: 11/10/2014
Event Time: [CST]
Last Update Date: 12/03/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE - POTENTIAL RADIOGRAPHER OVER-EXPOSURE

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

"Advanced Inspection Technologies (OK-27588-02) has reported [to the State of Oklahoma] that the dosimeter issued to one of their radiographers reported a dose of 16.294 R for the period of October 10 to November 10. The report from Landauer states that the results are 'inconclusive' and the dosimeter was reprocessed. The second read was also inconclusive. Energy level was characterized as high but type not specified. The licensee believes the dosimeter was damaged or otherwise compromised. Investigation is ongoing."

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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."

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Power Reactor Event Number: 50666
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: BOB PAGE
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/10/2014
Notification Time: 17:13 [ET]
Event Date: 12/10/2014
Event Time: 13:44 [EST]
Last Update Date: 12/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

INADVERTENT LOSS OF VITAL INDICATION DURING MAINTENANCE

"On December 10, 2014, at 1344 [EST], channel 1 of Refueling Water Storage Tank (RWST) level indication failed low during maintenance activities on channel 2. At that time, operators entered abnormal procedure 1-AP-3, 'Loss of Vital Indication, on Unit 1.' Additionally, Technical Specification (TS) 3.0.3 was entered due to 2 channels inoperable that affect Recirculation Spray (RS) pump auto-start capability. Had a Containment Depressurization Actuation (CDA) occurred during the time that both channels were inoperable, accident mitigation would have been adversely impacted. At 1356, both level indications returned to normal. At 1417, channel 2 was declared Operable and TS 3.0.3 was cleared. At 1439, channel 1 was declared Operable.

"Therefore, this 8-hour report is being made per 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function due to the RS pump auto-start concern."

Technicians inadvertently went to the incorrect channel (Channel 1) during planned maintenance activity of Channel 2, causing the loss of both channels simultaneously for a short period of time.

The licensee has notified the NRC Resident Inspector and will be notifying the Louisa County Administrator.

Page Last Reviewed/Updated Thursday, December 11, 2014
Thursday, December 11, 2014