| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
10/26/2010 - 10/27/2010 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 46319 | Rep Org: COMMUNITY HOSPITAL
Licensee: COMMUNITY HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 130600901
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: VINCE KLCO | Notification Date: 10/08/2010
Notification Time: 09:57 [ET]
Event Date: 10/06/2010
Event Time: [EDT]
Last Update Date: 10/26/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
DAVE PASSEHL (R3DO)
ANGELA MCINTOSH (FSME)
| Event Text DELIVERED DOSE POTENTIALLY DIFFERENT THAN THE PRESCRIBED DOSE
During a brachytherapy treatment, the patient breast received an incorrect entry of the catheter position from a treatment planning system. Because of this, the prescribed dose was 340 centi-Gray at 1 centimeter from the tumor cavity while the actual dose received was 680 centi-Gray at 1 centimeter from the tumor cavity.
The physician notified the patient of the potential dose difference. Based on physician review, it was determined that there was no affect on the patient.
The reason for the potential dose difference was due to a missed change of a program default in the software program of the radiation treatment planning system. A new check step has been added to the Community Hospital procedure in order to correct the issue.
* * * UPDATE AT 1550 EDT ON 10/26/10 FROM ANDREA BROWNE TO S. SANDIN * * *
The licensee is updating this report to confirm that upon further evaluation this is a medical event.
Notified R3DO (Skokowski) and FSME (Burgess).
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: 46351 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: INTERNATIONAL PAPER COMPANY
Region: 4
City: QUEEN CITY State: TX
County:
License #: 01686
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: JOE O'HARA | Notification Date: 10/21/2010
Notification Time: 17:58 [ET]
Event Date: 10/21/2010
Event Time: [CDT]
Last Update Date: 10/21/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
VIVIAN CAMPBELL (R4DO)
KEITH McCONNELL (FSME)
| Event Text AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER INOPERABLE
The following was received from the State of Texas via e-mail:
"On October 21, 2010, the Agency [State of Texas] received a 'Notice of reciprocity' from Berthold Technologies. The notice stated that a Berthold Technologies service representative would be replacing the shutters on two gauges at the licensee's (International Paper Company) facility on October 22, 2010. The Agency contacted the licensee and asked to speak with the Radiation Safety Officer (RSO). The Agency was forwarded to the RSO's voicemail box and left a message. The Agency then contacted one of the licensee's employees whose information was obtained from the 'Notice of Reciprocity.' The employee then reported that the licensee had experienced a shutter failure.
"The licensee stated that on Monday, October 18, 2010, another licensee properly authorized by the Agency [State of Texas] to remove the gauges came to the licensee's facility to remove the gauge from the pipe it was fixed to. The gauge was manufactured by Berthold Technologies (Model: LB7440; Serial Number: 1335) and it houses a 30 milliCurie Cesium (Cs) 137 source (Serial Number: 1335- 5-89). The gauge was removed so that the licensee could perform maintenance on the pipe. The licensee stated that the shutter was hard to turn at that time, but the shutter properly closed prior to the authorized person removing the gauge. On Wednesday, October 20, 2010, the authorized person returned to reattach the gauge and attempted to open the shutter, and the shutter would not open. The licensee then stated that they contacted Berthold Technologies to repair the shutter that failed, as well as another shutter on different gauge that was difficult to operate. The shutters are scheduled to be repaired on Friday, October 22, 2010. The RSO was later contacted and he agreed to submit a written report to the Agency within thirty days."
TX Incident No. I-8794 |
| General Information or Other | Event Number: 46356 | Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: NORTHERN TECHNOLOGIES INC.
Region: 4
City: FARGO State: ND
County: CASS
License #: 33-32112-01
Agreement: Y
Docket:
NRC Notified By: DAN HARMAN
HQ OPS Officer: VINCE KLCO | Notification Date: 10/23/2010
Notification Time: 14:07 [ET]
Event Date: 10/21/2010
Event Time: 09:12 [MDT]
Last Update Date: 10/23/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
VIVIAN CAMPBELL (R4DO)
KEITH McCONNELL (FSME)
| Event Text AGREEMENT STATE REPORT - DAMAGE TO TROXLER PORTABLE DENSITY GAUGE
A Troxler portable density gauge was run over by a forklift at a construction site. The source rod was retrieved into the gauge by the RSO. The damaged gauge was surveyed and then the gauge was removed for transport to the company office. The construction site was surveyed to ensure both sources were in the gauge.
The licensee is reviewing their procedures to determine what can be done to reduce the risk of this type of incident happening again.
The density gauge is a Model 3430 Troxler with a nominal 8 mCi Cs-137 gamma source and a 40 mCi Am-241:Be neutron source.
North Dakota Incident #: ND10005 |
| General Information or Other | Event Number: 46357 | Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: QUALITY INSPECTION AND TESTING INC.
Region: 4
City: VERNAL State: UT
County:
License #: LA11238L01
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: PETE SNYDER | Notification Date: 10/24/2010
Notification Time: 11:34 [ET]
Event Date: 10/24/2010
Event Time: 06:00 [MDT]
Last Update Date: 10/24/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
VIVIAN CAMPBELL (R4DO)
TIM MCCARTIN (NMSS)
KEITH McCONNELL (FSME)
| Event Text AGREEMENT STATE REPORT - RADIOGRAPHER TRUCK IN ROLLOVER ACCIDENT
A radiographer from Quality Inspection and Testing, Inc was involved in a single vehicle accident 18 miles west of Vernal, Utah on highway 40. According to witnesses, the truck rolled numerous times. The state police arrived, secured the highway, contacted state radiation control, and surveyed the area. The results of the survey indicated no spread of contamination or radiation levels above background. The SPEC Model 150 radiography camera S/N 1195 containing 40 Curies of Ir-192 was undamaged and placed into the custody of another representative of Quality Inspection and Testing Inc., who arrived on the scene at the request of the state. The driver survived the accident.
The radiography company is a Louisiana licensee with reciprocity in the State of Utah. |
| Other Nuclear Material | Event Number: 46363 | Rep Org: EVONIK DEGGUSSA CORP
Licensee: EVONIK DEGGUSSA CORP
Region: 3
City: LAFAYETTE State: IN
County: TIPPECANOE
License #: GL
Agreement: N
Docket:
NRC Notified By: EMMA YORK
HQ OPS Officer: VINCE KLCO | Notification Date: 10/26/2010
Notification Time: 11:50 [ET]
Event Date: 10/06/2010
Event Time: 10:00 [EDT]
Last Update Date: 10/26/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
RICHARD SKOKOWSKI (R3DO)
MICHELE BURGESS (FSME)
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text IMPROPERLY DISPOSED OF TRITIUM SIGNS
Notified by the licensee that two tritium exit signs were improperly disposed of as trash. The signs were manufactured on April/1999 and the tritium gas was in sealed tubes. The sign manufacturer was NRD-LLC\Penteco and the original source strength was 25 Ci for each sign.
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Other Nuclear Material | Event Number: 46365 | Rep Org: CONSTRUCTION TESTING AND ENGINEERIN
Licensee: CONSTRUCTION TESTING AND ENGINEERING
Region: 1
City: MANASSAS State: VA
County:
License #: 45-25554-01
Agreement: Y
Docket:
NRC Notified By: HASSAN TSAJIK
HQ OPS Officer: STEVE SANDIN | Notification Date: 10/26/2010
Notification Time: 16:30 [ET]
Event Date: 10/26/2010
Event Time: 16:15 [EDT]
Last Update Date: 10/26/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
JOHN CARUSO (R1DO)
CHRISTEPHER MCKENNEY (FSME)
ILTAB via email ()
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text TROXLER MOISTURE DENSITY GAUGE STOLEN
At approximately 1615 EDT on 10/26/10, a vehicle containing a Troxler Moisture Density Gauge, Model #3440, S/N 34482, with 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen at 1800 Alabama Ave, SE, DC. The RSO reported the theft to the DC Police who are on-scene.
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | |