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Event Notification Report for July 21, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/18/2008 - 07/21/2008

** EVENT NUMBERS **

Hospital	Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM Licensee: VA MEDICAL CENTER, PHILADELPHIA Region: 1 City: PHILADELPHIA State: PA County: License #: 03-23853-01VA Agreement: Y Docket: NRC Notified By: EDWIN LEIDHOLDT HQ OPS Officer: JEFF ROTTON	Notification Date: 05/16/2008 Notification Time: 20:30 [ET] Event Date: 05/05/2008 Event Time: 09:30 [EDT] Last Update Date: 07/18/2008
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): PAUL KROHN (R1) HIRONORI PETERSON (R3) REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."

* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *

"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.

"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).

R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.

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.

* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *

"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

"VHA provided an initial update on June 6, 2008. This update reflects the most current information.

"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

"Patient notification:

"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).

* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *

"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.

"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.

"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program is suspended and an external review is in progress.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.

"Patient notification:

"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."

Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).

* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *

"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *

A 15-day written report of one of the medical events was submitted to NRC Region III.

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)

* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).

* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "

Notified R1DO (Dentel), R3DO (Lara), and FSME (White).

General Information or Other	Event Number: 44348
Rep Org: MISSISSIPPI DIV OF RAD HEALTH Licensee: W.G. YATES & SONS CONSTRUCTION COMPANY Region: 4 City: State: MS County: RANKIN License #: MS-656-01 Agreement: Y Docket: NRC Notified By: JASON MOAK HQ OPS Officer: PETE SNYDER	Notification Date: 07/16/2008 Notification Time: 12:09 [ET] Event Date: 07/14/2008 Event Time: 02:35 [CDT] Last Update Date: 07/16/2008
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CLAUDE JOHNSON (R4) MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - CRUSHED MOISTURE DENSITY GAUGE

"Approximately 02:35 a.m. on 7-14-08, an employee who coordinates nuclear gauge use with W. G. Yates & Sons Construction Company notified MEMA that a Troxler 4640-B thin lift density gauge had been crushed by an 18-wheeler truck when the truck drove through the cone barrier. The Gauge contents were scattered over a 10 ft X 10 ft area in the middle of highway 49 South, Richland, Mississippi. MEMA then notified [redacted] Director of Radiological Health at approximately 3:03 a.m.

"[The director] picked up the gauge parts off Highway 49 South and packed them in the original shipping container with dirt. Surveys were conducted of the accident scene revealing only background readings after the gauge parts were put back into the gauge box. At 4:10 a.m., [the director] reported to MEMA the contents of the crushed gauge and that one lane of traffic was open on Highway 49 South in Richland, Mississippi. Confiscation of the gauge by the Division of Radiological Health was reported to MEMA at 4:38 a.m., when [the director] was leaving the accident site.

"[The director] returned with the gauge to Radiological Health at approximately 8:30 a.m., on 7-14-08. Pictures of the crushed gauge were taken by [a Senior Health Physicist of the] Division of Radiological Health. Then the gauge was surveyed and placed in a lead storage cask. Surveys revealed 600 Mr/hr at 6 in from the gauge source rod.

"The RSO for W. G. Yates & Sons Construction Company was contacted by [the director] and asked to give a report on how the accident happened. The report issued to the Mississippi State Department of Health / Division of Radiological Health was received 7-15-08. In summary, the RSO said work was being performed on two of the three South bound lanes of Highway 49 South. The center and right hand lanes of Highway 49 South were blocked off with cones. The RSO said one employee on site walked away from his profiler machine which was in the center lane of Highway 49 South to ask another employee about the measurements from the thin lift density gauge, also located in the center lane of Highway 49 South. Standing approximately 5 feet from the gauge, they witnessed an 18 wheeler veer from the left hand lane and travel to the center lane crossing the cone barrier. The driver of the 18-wheeler veered further to the right of the profile machine which was in the center lane of the highway. One employee's truck was parked in the right hand lane while he was taking readings from the profile machine. Upon approaching the employees truck, the 18-wheeler veered back into the center lane from the right hand lane and crushed the thin lift density gauge. Both employees were uninjured.

"Upon further review of the accident, the authorized user for the thin lift density gauge was trained and certificates are on file with the Division of Radiological Health. The gauge was also last leak tested on 11/1/07. The RSO said three employees with W. G. Yates & Sons Construction company who were involved in the accident have had there badges sent in for processing.

"Accident site surveys revealed the source was still in the gauge. Additional site surveys revealed only background readings. The gauge was confiscated by DRH.

"Isotope(s): Cesium-137;
"Activity: 8 mCi."

This is Mississippi Event Number MS08008.

General Information or Other	Event Number: 44349
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: RAYONIER PERFORMANCE FIBERS Region: 1 City: JESUP State: GA County: License #: GA-381-1 Agreement: Y Docket: NRC Notified By: JOSEPH FIEVET HQ OPS Officer: BILL HUFFMAN	Notification Date: 07/16/2008 Notification Time: 15:34 [ET] Event Date: 07/15/2008 Event Time: 18:15 [EDT] Last Update Date: 07/16/2008
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL PERRY (R1) ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE REPORT - RADIATION EXPOSURE TO NON-OCCUPATIONAL WORKER

Rayonier Performance Fibers is a pulp mill that utilizes a Berthold Model 2653.100-001 density gauge with a 24 millicuries Cesium-137 for measures paper density and thickness on its process line. The company employed a contract welder to perform some structural welding in the vicinity of the gauge. Another company employee noted that the welder was in a radiation restricted area and had him leave the area immediately. The RSO was notified who then informed the State of Georgia. Based on preliminary information, it appears that even though the process had been shutdown, the gauge shutter was still open for reasons unknown. The licensee's initial estimate of the welder's exposure based on his time and location is 36 millirem whole body. The State of Georgia's investigation is in progress.

General Information or Other	Event Number: 44350
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: CTI CONSTRUCTION TESTING & INSPECTION, INC Region: 1 City: HIALEAH State: FL County: License #: 3298-2 Agreement: Y Docket: NRC Notified By: CHARLES ADAMS HQ OPS Officer: BILL HUFFMAN	Notification Date: 07/16/2008 Notification Time: 16:22 [ET] Event Date: 07/16/2008 Event Time: [EDT] Last Update Date: 07/16/2008
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL PERRY (R1) ANDREA KOCK (FSME) ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following report was submitted by the State via e-mail:

"Licensee's truck was parked at a fast food restaurant, which happens to be part of the work site, while the employee was inside getting a late lunch. The [Troxler 3440A, S/N 26057] gauge was in its transport box and secured to the bed of the pick up with two cables and two locks. At approximately 3 p.m. thieves using a bolt cutter tried to cut the cables. When they couldn't, they cut the locks and took the gauge. The keys were not with the gauge. Hialeah PD is investigating. A witness provided the make of the car and a partial plate number. Licensee will submit a written report and after 48 hours consider offering a reward for the return of the gauge. Florida is investigating."

This gauge contains an 8 mCi Cs-137 source and a 40 mCi Am-141/Be source.

Florida report number FL-08-104

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.

Power Reactor	Event Number: 44355
Facility: SAN ONOFRE Region: 4 State: CA Unit: [ ] [2] [3] RX Type: [1] W-3-LP,[2] CE,[3] CE NRC Notified By: SUSAN GARDNER HQ OPS Officer: BILL HUFFMAN	Notification Date: 07/18/2008 Notification Time: 19:36 [ET] Event Date: 07/18/2008 Event Time: 08:00 [PDT] Last Update Date: 07/19/2008
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): CLAUDE JOHNSON (R4)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
2	N	Y	98	Power Operation	98	Power Operation
3	N	Y	100	Power Operation	100	Power Operation

Event Text

EMERGENCY OPERATIONS FACILITY INOPERABLE FOR MAINTENANCE WORK

"Southern California Edison (SCE) has scheduled maintenance for the electrical system of the San Onofre Emergency Operations Facility (EOF), for Saturday, July 19, 2008. While the maintenance is being performed, the EOF will be inoperable. The EOF outage is expected to begin at 0800 PDT and last approximately 4 hours.

"The alternate EOF, located in Irvine, CA, will be available should SCE need to respond to an Emergency Event.

"The Emergency Recall System, which is housed in the EOF, will be out of service while the maintenance is performed. Should recall of the Emergency Response Organization (ERO) be necessary during the EOF outage, SCE will utilize alternate methods (contained in existing site procedures) for activating the ERO.

"This planned EOF outage is being reported in accordance with 10CFR50.72(b)(3)(xiii).

"At the time of this report, Unit 2 and Unit 3 were operating at about 98 per cent and 100 per cent, respectively.

"The NRC Resident Inspector has been notified of this report and will be provided a copy."

* * * UPDATE PROVIDED BY SUSAN GARDNER TO JASON KOZAL ON 7/19/08 AT 1705 * * *

"The Emergency Operations Facility was returned to service on July 19, 2008 at 1240 PDT.

"The NRC Resident Inspector will be notified of this occurrence and will be provided with a copy of this report."

Notified R4DO (Johnson).

Fuel Cycle Facility	Event Number: 44356
Facility: PADUCAH GASEOUS DIFFUSION PLANT RX Type: URANIUM ENRICHMENT FACILITY Comments: 2 DEMOCRACY CENTER 6903 ROCKLEDGE DRIVE BETHESDA, MD 20817 (301)564-3200 Region: 2 City: PADUCAH State: KY County: McCRACKEN License #: GDP-1 Agreement: Y Docket: 0707001 NRC Notified By: BILLY WALLACE HQ OPS Officer: BILL HUFFMAN	Notification Date: 07/20/2008 Notification Time: 19:00 [ET] Event Date: 07/20/2008 Event Time: 12:20 [CDT] Last Update Date: 07/20/2008
Emergency Class: NON EMERGENCY 10 CFR Section: 76.120(c)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): ALAN BLAMEY (R2) EDWIN HACKETT (NMSS)

Event Text

FAILURE OF PROCESS GAS LEAK DETECTION SYSTEM

"At 1230 CDST, on 07-20-08 the Plant Shift Superintendent (PSS) was notified that C-315 had received an audible alarm with no visual indications. Moments later an alarm was received in C-331 for the C-315 High Voltage Process Gas Leak Detection System. Operators responded by contacting C-315 to inquire about the alarm. C-315 operators checked the system and found that the READY light for this system was not illuminated. This PGLD System contains detectors that cover the C-315 UF6 condensers, accumulators, and piping heated housing. At the time of this alarm, the areas were operating above atmospheric pressure. TSR 2.3.4.4 requires that all of detector heads in this system be operable during operations above atmospheric pressure. Operators responding to the system tried to test fire the system heads however the system would not respond and then they discovered the READY light to be off. This PGLD System was declared inoperable, TSR LCO 2.3.4.4.A.1 was entered and a continuous smoke watch was put in place within one hour. Engineering has determined that the system would not have been able to perform its intended safety function when this alarm came in. This event is reportable as a 24 hour event in accordance with 10CFR 76.120 (c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Resident Inspector has been notified of this event."