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Event Notification Report for September 8, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/07/2005 - 09/08/2005

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other	Event Number: 41937
Rep Org: LANCASTER GENERAL HOSPITAL Licensee: LEKSELL Region: 1 City: LANCASTER State: PA County: License #: 37-11866-04 Agreement: N Docket: NRC Notified By: TONY MONTAGNESE HQ OPS Officer: JOHN MacKINNON	Notification Date: 08/22/2005 Notification Time: 15:05 [ET] Event Date: 08/22/2005 Event Time: 15:05 [EDT] Last Update Date: 09/07/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21 - UNSPECIFIED PARAGRAPH	Person (Organization): WILLIAM COOK (R1) CAUDLE JULIAN (R2) KENNETH O'BRIEN (R3) LINDA SMITH (R4) LYDIA CHANG (NMSS) TOM ESSIG (email) (NMSS)

Event Text

PART 21 - GAMMA KNIFE MICROPHONE CLIP

Lancaster General Hospital has been using a Leksell Model No. 23005 Type "B" Gamma Knife since 2000. The Gamma Knife unit has a metal clip which is velcroed to the patient's couch and it holds a microphone in which the patient can talk. A patient knocked the clip off, causing the clip to become detached from the couch (it was velcroed to the couch) and the microphone. The clip ended up in the Gamma Knife shielding. Due to the metal clip being stuck in the Gamma Knife shielding, the micro switches inside the Gamma Knife would not allow the jaws of the shielding to open. This prevented the patient from receiving the third treatment. Therefore the patient received only 2 out of 5 scheduled treatments (patient was under dosed) due to the clip failure.

See event number 41928 called in by Lancaster General Hospital on 08/18/2005 for background information.

*** UPDATE FROM MONTAGNESE TO KNOKE AT 12:07 EDT ON 09/07/05 ***

The licensee discussed this event with Region 1 (Gabriel and Henderson). It was determined that this event did not meet 10 CFR 21.21 requirements and notification to the NRC under Part 21 was unnecessary. The notification for this medical event (EN 41928) is still in effect.

Notifications were provided to R1DO (Holody), R2DO (Moorman), R3DO (Cameron), R4DO (Powers), NMSS (Morell) and Part 21 NMSS (Essig).

Power Reactor	Event Number: 41954
Facility: WATERFORD Region: 4 State: LA Unit: [3] [ ] [ ] RX Type: [3] CE NRC Notified By: KENNY CAMBREY HQ OPS Officer: JEFF ROTTON	Notification Date: 08/27/2005 Notification Time: 23:22 [ET] Event Date: 08/27/2005 Event Time: 22:04 [CDT] Last Update Date: 09/07/2005
Emergency Class: UNUSUAL EVENT 10 CFR Section: 50.72(a) (1) (i) - EMERGENCY DECLARED	Person (Organization): WILLIAM JONES (R4) PAO-TSIN KUO (NRR) MEL LEACH (IRD) AKERS (DHS) CASTO (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO HURRICANE WARNING

At 2204 CDT, an Unusual Event was declared due to a Hurricane warning in St Charles Parish, LA. The licensee does not have any Limiting Conditions for Operation on safety related equipment. No electrical grid disturbances currently exist.

The licensee will be notifying the NRC Resident Inspector. The licensee notified the State and Local government agencies.

* * * UPDATE FROM J. PIERCE TO M. RIPLEY 1144 EDT 08/28/05 * * *

"Waterford 3 will commence a plant shutdown to Mode 4 on August 28, 2005 at 1100 CDT. The goal is to be approximately 325 deg F reactor coolant system temperature with both trains of Shutdown Cooling in service [expected at approximately 0100 CDT 08/29/05] . This is approximately 2 hours before hurricane force winds are expected on site."

Notified R4DO (Jones), NRR EO (Kuo), IRD Mgr. (Wilson), DHS (York), and FEMA (Canupp).

* * * UPDATE FROM J. PIERCE TO J. ROTTON 1131 EDT 08/29/05 * * *

As a result of Hurricane Katrina, all offsite power was lost at 0800 CDT. The emergency diesel generators successfully started and loaded.

Notified R4DO (R. Bywater), NSIR (Leach, Wilson), NRR EO (Kuo, Jung), FEMA (Kuzia), DHS (Stransky).

* * * UPDATE FROM LICENSEE (LEWIS) TO NRC (HUFFMAN) AT 2302 EDT ON 8/29/05 * * *

The Hurricane warning for St Charles Parish, LA, has been discontinued by the National Weather Service. Initiating condition, D UE-5, is no longer applicable. Waterford 3 remains in an Unusual Event for initiating condition C UE-1, loss of all offsite power. An agreement to relax 60 minute notification updates to State and local authorities remains in effect.

The licensee has notified State and local authorities as well as the NRC Resident Inspector.

Offsite power is available to the licensee switchyard. However, the voltage is too high for plant specification and the licensee remains disconnected from offsite power and on the emergency diesel generators.

* * * UPDATE FROM LICENSEE (LEWIS) TO NRC (KNOKE) AT 0001 EDT ON 8/31/05 * * *

Waterford 3 remains in an Unusual Event for initiating condition C UE-1, loss of all offsite power. An agreement to relax 60 minute notification updates to State and local authorities remains in effect. The communications system for Public Automatic Branch Exchange (PABX) is working internally, but not externally. Other areas where communications are lost are Emergency Operations Facility (EOF), Operations hotline, Reactor Auxiliary Building (RAB), and the Emergency Notification System (ENS). Waterford has use of an industrial hotline to a circuit in the Parish of St Charles, however, this is very limited in its capability. The Civil Defense communication system is still inoperable.

* * * UPDATE AT 1903 ON 9/6/05 FROM WAIG TO GOULD * * *

NRC exited monitoring mode at 1800 CDT on 9/6/05.

Notified R4 IRC (Waig), R4DO (Powers), IRD (Leach), DHS (Cartlidge), FEMA (Kuzia).

* * * UPDATE FROM LICENSEE (LEWIS) TO NRC (KNOKE) AT 19:12 EDT ON 09/07/05 * * *

At 17:57 CST the licensee exited from the UNUSUAL EVENT. Offsite power was restored and communications were reestablished with (1) a functional operational hotline, (2) a dedicated open line to NRC Headquarters Operations Center, and (3) having the plant PABX circuits routed through Little Rock, AK area code. The plant is holding in Mode 5 until further notice, however, this may change when the decision to (or not to) repair a check valve in the Safety Injection system is made.

Notified R4DO (Powers), IRD (McGinty), NRR EO (Hackett), DHS (Sullivan), and FEMA (Kuzia).

Other Nuclear Material	Event Number: 41962
Rep Org: MICHIGAN STATE UNIVERSITY Licensee: MICHIGAN STATE UNIVERSITY Region: 3 City: EAST LANSING State: MI County: License #: 210002129 Agreement: N Docket: NRC Notified By: PAUL ROSSI HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 08/30/2005 Notification Time: 13:27 [ET] Event Date: 08/30/2005 Event Time: 10:30 [EDT] Last Update Date: 09/07/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): MONTE PHILLIPS (R3) SCOTT MOORE (NMSS) ARMAND CARON (CANA) TAS (E-MAIL) ()

Event Text

LICENSEE REPORTED AN UNACCOUNTABLE CALIFORNIUM-249 SOURCE

The licensee reported that a 0.958 microCurie (as of 02/05/83) source of Californium 249 was unaccounted for when the device was inspected prior to usage. The source is a solid electrode deposit on a platinum foil which is used to calibrate nuclear physics instrumentation. The last inventory was conducted on 07/25/05, but it was only a visual check of the container. The last activity identification of the device was on 05/11/04. They have searched and are continuing the search to find the material. No evidence of contamination has been detected in the area at this time.

This is a IAEA Category 5 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.

For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.

*** UPDATE FROM ROSSI TO KNOKE AT 13:05 EDT 0N 09/07/05 ***

The licensee made a correction to the 3rd sentence in the first paragraph to read as follows: "The last inventory was conducted on 07/25/05, which was a physical inventory of the source."

Notified R3DO (Cameron) and NMSS (Hickey), and emailed TAS (Danis).

Other Nuclear Material	Event Number: 41971
Rep Org: CONOCO PHILLIPS Licensee: CONOCO PHILLIPS Region: 4 City: BILLINGS State: MT County: License #: 25-16250-01 Agreement: N Docket: NRC Notified By: SUSAN TAYLOR - RSO HQ OPS Officer: JOHN KNOKE	Notification Date: 09/07/2005 Notification Time: 15:10 [ET] Event Date: 09/06/2005 Event Time: 15:10 [MDT] Last Update Date: 09/07/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): DALE POWERS (R4) LAWRENCE KOKAJKO (NMSS)

Event Text

FAILURE OF OHMART "DENSITY PROFILER" GAUGE

The licensee's RSO reported that a "density profiler" gauge failed, and the 10 milliCurie Cs-137 source broke away from the gauge. The source is now at the bottom of a 10 foot deep well, which is inside a drum at the Alkalization Unit. The gauge is manufactured by OHMART, model MDTS and s/n 67524GK.

The density profiler gauge has a source on the end of a tape, and the tape reels in and out of the instrument. When the tape broke, the Cs-137 source fell to the bottom of the well. No personnel exposure occurred. The RSO surveyed the area and found readings of 3 milliRem/hr at contact and 1.8 milliRem/hr at 1 foot. The licensee contacted the manufacturer who will be sending a technician out to repair the gauge.

Hospital	Event Number: 41973
Rep Org: ST VINCENT HOSPITAL Licensee: ST VINCENT HOSPITAL Region: 3 City: INDIANAPOLIS State: IN County: License #: 13-00133-02 Agreement: N Docket: NRC Notified By: JEFF HEFFELFINGER HQ OPS Officer: CHAUNCEY GOULD	Notification Date: 09/07/2005 Notification Time: 16:34 [ET] Event Date: 09/07/2005 Event Time: [CST] Last Update Date: 09/07/2005
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): JAMNES CAMERON (R3) LAWRENCE KOKAJKO (NMSS)

Event Text

FIVE MEDICAL EVENTS WERE DISCOVERED TO HAVE OCCURRED AT ST.VINCENT HOSPITAL IN INDIANAPOLIS, IN

The five events occurred between 3 patients and are explained in the following write-up.

"Events 'A', 'B', and 'C' involve the same patient who received three high dose rate (HDR) brachytherapy administrations on three different occasions with a GYN cylinder application. The dates of treatment occurred on December 19, and 26, 2002 and January 2, 2003. In this case, a 70 year old female, was treated with a Nucletron High Dose Rate (HDR) brachytherapy remote aflerloader unit for endometrial cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 3.0 cm diameter vaginal cylinder for an active length of 6.0 cm using a 8.01, 7.506 and 7.030 Ci iridium-192 source on the three dates of treatment. The treatment plan called for 25 indexer step positions at 2.5 mm spacing. The medical physicist entered 25 indexer step positions at 5.0mm spacing rather than 2.5mm spacing and treatment was delivered.

"A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation reveals that the patient may have received as much as 360 cGy to an unintended delivery site with each of the three fractions, for a total of 1,080 cGy for the entire course of treatment. The simulation further indicates that the intended treatment site may have received as much as 28% under dosage during the same treatment period. A thorough review of the patients chart indicates that the patient reported having had some "excoriation" of the unintended site initially following treatment but this area had healed prior to a follow up exam on February 6, 2003.

"This patient was last seen by her radiation oncologist January 3, 2004, with no evidence of clinical complications or abnormalities.

"As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical complications are anticipated or expected.

"Event 'D' occurred on December 18, 2002, involved an HDR brachytherapy which also involved a GYN cylinder application.

"In this case, a 56 year old female, was treated with Nucletron High Dose Rate (HDR) brachytherapy remote after loader for cervical. Cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 2.50 cm diameter vaginal cylinder for an active length of4.0 cm. using a 8.089 Ci iridium-1.92 source. The treatment plan called for 17 indexer step positions at 2.5mm spacing. Although the first two fractions were delivered in accordance with the written directive without incident (November 19 and November 26, 2002), for the third and final fraction (December 18, 2002) the medical physicist entered 17 indexer stop positions with 10.0 mm spacing rather than 2.5 mm spacing and treatment was delivered.

"A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation suggests the patient may have received as much as 200cGy to an unintended site and as much as 60% under dosage to the intended site during delivery of the final fraction. For the entire course of treatment, the calculated dosage through simulation indicates that 1200 cGy rather than 1500 cGy was delivered to the intended site. This represents a twenty percent (20%) under dosage for the overall treatment. A thorough review of the patient chart indicates no abnormal findings during follow up clinical exams and our Radiation Oncology Physicians verify these treatment parameters are within acceptable therapeutic and clinical dosages.

"This patient is currently in active follow-up with her radiation oncologist. This patient was last seen May 5th, 2005 with no evidence of complications or clinical abnormalities. As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical, complications are anticipated or expected.

"Event 'E' occurred on August 7, 2003, involved an HDR brachytherapy which also involved a GYN cylinder application.

"In this case, an 85 year old female, was treated with Nucletron High Dose Rate (HDR) brachytherapy remote after loader for cervical cancer. The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a 2.00 cm diameter vaginal cylinder. For an active length of 6.0 cm using a 4.74 Ci iridium-1.92 source. The treatment plan called for 13 indexer step positions at 5.Omm spacing. In the delivery of the first fraction, on August 7, 2003, the medical physicist entered 13 indexer step positions with 2.5mm spacing rather than 5.0mm spacing and treatment was delivered. The delivery of the second and third fractions, August 21 and September 4, 2003, the written directive was followed accurately and treatment occurred without incident.

"A simulated plan was calculated on August 23, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulation suggests that for the initial treatment fraction, the patient may have received as much as 60% over dosage to the proximal portion of the intended site and as much as 44% under dosage to the distal portion of the intended site. The calculated dosage through simulation indicates that 800 cGy was delivered to the proximal portion of the intended treatment site and approximately 280 cGy was delivered to the distal portion of the intended treatment site.

"In accordance with the written directive, the intended site was to receive a dosage of 500 cGy for three fractions for a total of 1500 cGy throughout the course of treatment. The calculated simulation reveals the proximal site received 1800 cGy (20% over dosage) and the distal site received 1280 cGy (15% under dosage) over the course of the three treatments. A. thorough review of the patient chart indicates no abnormal findings during follow up clinical exams and our Radiation. Oncology Physicians verify these treatment parameters are within acceptable therapeutic and clinical dosages.

"This patient is currently in active follow-up with her radiation oncologist. This patient was last seen August 15, 2005 with no evidence of complications or clinical abnormalities.

"As a result of this review and discovery, St. Vincent Hospital will notify the referring physician and the patient of this event. No further clinical complications are anticipated or expected,

"It is believed that the conditions and practices which contributed to the five medical events listed above were identified during the course of investigating the previous medical event of April, 2004. It is further believed that St. Vincent Hospital has implemented corrective action since the event of April, 2004 that has eliminated (or significantly reduced the risk of) recurrence of these conditions/practices."