| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
10/08/2008 - 10/09/2008 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 44522 | Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 09/25/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: [CDT]
Last Update Date: 10/08/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)
| Event Text MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE
"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.
"As the result of these ongoing reviews, possible medical events were discovered on September 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.
"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)
"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients are under review by medical experts.
"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.
"Additional Information
"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.
"Address of permittee involved in this event: VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.
"VHA permit number of permittee involved in event: Permit No. 23-08786-01."
* * * UPDATE AT 1945 ON 10/8/2008 FROM EDWIN LEIDHOLDT TO MARK ABRAMOVITZ * * *
"This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number.
"A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event."
Notified the R3DO (Lara), FSME (Einberg), and ILTAB (via e-mail).
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. |
| General Information or Other | Event Number: 44535 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: METCO
Region: 4
City: HOUSTON State: TX
County:
License #: L-03018
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN | Notification Date: 10/03/2008
Notification Time: 10:58 [ET]
Event Date: 09/29/2008
Event Time: 13:00 [CDT]
Last Update Date: 10/03/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RUSS BYWATER (R4)
ANNA BRADFORD (FSME)
| Event Text AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO EXTREMITIES
A radiographer working for METCO was performing radiography operations at CB & I Fabricators in Houston TX. He was moving the radiography camera (a SPEC 150 with a 85 curie Ir-192 source) from one location to another. He removed the nipple off the front of the camera to test the guide tube and his dosimetry started alarming. He observed that the source had come out of the camera about 1/2 inch. At the same time, he inadvertently dropped the camera plug. He picked up the plug and unsuccessfully made two attempts to push the source back in with the plug. He then left the front of the camera and went around and turned the crank and got the source back into the shielded position and then inserted the plug. He then notified appropriate personnel.
METCO sent his dosimetry off and the results came back with a whole body exposure of 946 millirem on October 1. The RSO discussed the details of the event with the radiographer and reenacted the event to attempt to estimate the radiographer's hand exposure because to the close proximity of the source to the hand during the event. Based on the time and distance of the source to the hand, it was estimated that the exposure to the radiographer's right hand may be somewhere between 66 and 282 rem. METCO has called in a consultant to get a more accurate assessment of the exposure to the hand.
The radiographer's work for the rest of the year has been suspended. His hand does not exhibit any eurythemia. No information is available on whether blood work or medical study will be obtained.
Texas will wait for the licensee's final report before it completes and independent investigation of the event.
Texas Report I-8569 |
| General Information or Other | Event Number: 44536 | Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL
Region: 1
City: BURLINGTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: HOWIE CROUCH | Notification Date: 10/03/2008
Notification Time: 11:40 [ET]
Event Date: 10/03/2008
Event Time: [EDT]
Last Update Date: 10/03/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN WHITE (R1)
ANDREW MAUER (FSME)
SCOTT SHAEFFER (R2)
STEVE ORTH (R3)
RUSS BYWATER (R4)
JOHN JANKOVICH (FSME)
| Event Text AGREEMENT STATE REPORT - DEFECTIVE COMPONENT THAT COULD POTENTIALLY CAUSE A SUBSTANTIAL SAFETY HAZARD
The following information was received from the State of Massachusetts via email:
"Prompted by a reported event, Event Number 44434, QSA Global conducted an investigation of a Model 660B camera. QSA Global concluded that the root cause of the event was a defective component on the pigtail of the camera, and has determined that more cameras contain these defective components which could contribute to future events. "
"This defect could give the user the false impression that the source is connected to the drive cable when there is only a partial connection. The operations manual does require that the user check the connection prior to use and when this is done, there is no problem. However if the user does not do a check of the connection, it may not be secure and may cause the source to disconnect in the guide tube.
"The defective component was reported to the State of Massachusetts under Massachusetts code 105 CMR 120.142(B)(2)(a). The defective component is a female source connector, QSA part number 55042-1. This defect was only found in lot 0731300805. QSA sold six Co-60 sources [Model 424-14] and 659 Ir-192 [Model 424-9] sources that utilized connectors from this lot. One Co-60 source will be returned to QSA for evaluation due to a source retrieval event.
"[QSA Global] Corrective Actions: Customers who had received the other five Co-60 source wires from the suspected lot were contacted and arrangements were made to make a field inspection of these sources by QSA Global staff for the potential defect. Any defective source wires would be recommended to the customer for return and replacement by QSA Global.
"Customers who had received one of the 659 Ir-192 source wires that contained the suspected lot were notified and advised of this potential condition. These customers were provided with [a] notification which re-enforces the need to ensure a solid connection between the drive cable and the source prior to making any source exposures. The customer notification letter includes inspections the customer should make to determine if their source may contain this defect and advises the customer to contact QSA Global if a source is suspected of being defective to arrange for source replacement.
"It was decided that the supplier of the defective lot would be removed from the approved supplier list pending further evaluation of their production processes. This will prevent their use as a supplier for components (including Class A components) until their evaluation and re-approval at a later date." |
| General Information or Other | Event Number: 44543 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FLINT HILLS RESOURCES LP
Region: 4
City: ODESSA State: TX
County:
License #: L00547
Agreement: Y
Docket:
NRC Notified By: BOB FREE
HQ OPS Officer: VINCE KLCO | Notification Date: 10/06/2008
Notification Time: 12:52 [ET]
Event Date: 10/06/2008
Event Time: [CDT]
Last Update Date: 10/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DALE POWERS (R4)
ANNA BRADFORD (FSME)
| Event Text TEXAS AGREEMENT STATE REPORT- SOURCE RETRACTOR FAILED TO FUNCTION
The following information was received from the State of Texas via e-mail:
"While servicing the level gauge [Ohmart Model A2102, Cs-137], an Ohmart technician discovered that the source retractor failed to function. The source is extended into a polymer vessel and is functioning normally while source is extended. Ohmart will recover the source and remove it from service. The licensee will arrange for disposal and discontinue use of the source."
Texas Report I-8570. | |