Event Notification Report for December 15, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/14/2003 - 12/15/2003
General Information or Other
Event Number: 40395
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GE COMPANY VALLECITOS NUCLEAR CENTER
Region: 4
City: SUNOL State: CA
County:
License #: 0017-01
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER (EMAIL)
HQ OPS Officer: GERRY WAIG
Licensee: GE COMPANY VALLECITOS NUCLEAR CENTER
Region: 4
City: SUNOL State: CA
County:
License #: 0017-01
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER (EMAIL)
HQ OPS Officer: GERRY WAIG
Notification Date: 12/16/2003
Notification Time: 19:28 [ET]
Event Date: 12/15/2003
Event Time: 00:00 [PST]
Last Update Date: 12/22/2003
Notification Time: 19:28 [ET]
Event Date: 12/15/2003
Event Time: 00:00 [PST]
Last Update Date: 12/22/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)
THOMAS DECKER (R2)
CHRISTOPHER CAHILL (R1)
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)
THOMAS DECKER (R2)
CHRISTOPHER CAHILL (R1)
Xe-133 SOURCE LOST DURING SHIPMENT
"On December 16, 2003, GE Vallecitos contacted RHB-Sacramento office to report that a shipment of 2.1 Ci [Curies] of Xe-133 to the University of Alabama has not arrived at its destination. On the same day, RHB-Berkeley office contacted the GE Vallecitos RSO, C.W. Bassett and the EHS leader, D.W. Turner and learned the following:
On December 12, 2003, GE Vallecitos sent a shipment of 2.1 Ci of Xe-133 to the University of Alabama via Fedex. On December 15, 2003,one of the Vallecitos technicians noticed that the shipment had not arrived at its destination in Alabama. They contacted Fedex immediately [name deleted] and the tracking database indicated that the shipment supposedly left Oakland Friday. As of December 16, 2003, Fedex was unable to locate the final destination of the shipment. GE Vallecitos had contacted the University of Alabama and confirmed that they have not received the Xe-133 shipment. Per RSO, the current estimated activity (as of 12/16/03) of the Xe-133 shipment is 1.2 Ci [Curies].
* * * UPDATE 1115 ET 12/22/03 FROM R. GREGOR TO J. ROTTON * * *
The following information was received via email:
"This lost shipment was found Friday 12/19/03 at the Fed Ex warehouse facility in Memphis, TN. It has been shipped to it's original destination, the University of Alabama."
Notified R1DO (R. Lorson), R2DO (T. Decker), R4DO (L. Smith), NMSS EO (F. Brown, Bill Reamer)
"On December 16, 2003, GE Vallecitos contacted RHB-Sacramento office to report that a shipment of 2.1 Ci [Curies] of Xe-133 to the University of Alabama has not arrived at its destination. On the same day, RHB-Berkeley office contacted the GE Vallecitos RSO, C.W. Bassett and the EHS leader, D.W. Turner and learned the following:
On December 12, 2003, GE Vallecitos sent a shipment of 2.1 Ci of Xe-133 to the University of Alabama via Fedex. On December 15, 2003,one of the Vallecitos technicians noticed that the shipment had not arrived at its destination in Alabama. They contacted Fedex immediately [name deleted] and the tracking database indicated that the shipment supposedly left Oakland Friday. As of December 16, 2003, Fedex was unable to locate the final destination of the shipment. GE Vallecitos had contacted the University of Alabama and confirmed that they have not received the Xe-133 shipment. Per RSO, the current estimated activity (as of 12/16/03) of the Xe-133 shipment is 1.2 Ci [Curies].
* * * UPDATE 1115 ET 12/22/03 FROM R. GREGOR TO J. ROTTON * * *
The following information was received via email:
"This lost shipment was found Friday 12/19/03 at the Fed Ex warehouse facility in Memphis, TN. It has been shipped to it's original destination, the University of Alabama."
Notified R1DO (R. Lorson), R2DO (T. Decker), R4DO (L. Smith), NMSS EO (F. Brown, Bill Reamer)
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 40549
Rep Org: ST. MARY HOSPITAL
Licensee: ST. MARY HOSPITAL
Region: 1
City: HOBOKEN State: NJ
County:
License #: 2901024-01
Agreement: N
Docket:
NRC Notified By: IRA GARELICK
HQ OPS Officer: ERIC THOMAS
Licensee: ST. MARY HOSPITAL
Region: 1
City: HOBOKEN State: NJ
County:
License #: 2901024-01
Agreement: N
Docket:
NRC Notified By: IRA GARELICK
HQ OPS Officer: ERIC THOMAS
Notification Date: 02/26/2004
Notification Time: 15:43 [ET]
Event Date: 12/15/2003
Event Time: 12:00 [EST]
Last Update Date: 03/09/2004
Notification Time: 15:43 [ET]
Event Date: 12/15/2003
Event Time: 12:00 [EST]
Last Update Date: 03/09/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MOHAMED SHANBAKY (R1)
CHARLIE MILLER (NMSS)
MOHAMED SHANBAKY (R1)
CHARLIE MILLER (NMSS)
MEDICAL EVENT
During a Health Physics audit, while reviewing seed implantation cases, the auditor was reviewing a procedure performed on a patient on 2/13/04. The procedure involved an I-125 seed implantation that delivered 5000 Rad to the patient's prostate. The auditor saw a notation in the record that a previous implantation on 12/15/03 had also delivered 5000 Rad to the same patient's prostate.
When the auditor pulled the record for the 12/15/03 implantation, he discovered that the intended dose from the procedure was 10,000 Rad. He proceeded to call Radiation Medicine Center, the licensee who performed both procedures (License # 2902023-06). Radiation Medicine Center stated that, when evaluating the patient in mid-January, they discovered, via CT scan and dosimetry, that the patient had only received 5000 Rad during the first procedure, and that is why the second procedure was performed on 2/13/04.
The auditor is reporting the implantation from 12/15/03 as a Medical Event.
* * * UPDATE ON 03/09/04 @ 0956 BY IRA GARELICK TO C GOULD * * * RETRACTION
The licensee is retracting this event on the basis that further investigation along with consultation and a site visit with Reg 1 NRC personnel determined the implant went as planned. There was some tissue shrinkage resulting in cold spots which were adequately treated in the second implant on 02/13/04.
Notified Reg 1 RDO(Cobey) and NMSS EO(Psyk)
During a Health Physics audit, while reviewing seed implantation cases, the auditor was reviewing a procedure performed on a patient on 2/13/04. The procedure involved an I-125 seed implantation that delivered 5000 Rad to the patient's prostate. The auditor saw a notation in the record that a previous implantation on 12/15/03 had also delivered 5000 Rad to the same patient's prostate.
When the auditor pulled the record for the 12/15/03 implantation, he discovered that the intended dose from the procedure was 10,000 Rad. He proceeded to call Radiation Medicine Center, the licensee who performed both procedures (License # 2902023-06). Radiation Medicine Center stated that, when evaluating the patient in mid-January, they discovered, via CT scan and dosimetry, that the patient had only received 5000 Rad during the first procedure, and that is why the second procedure was performed on 2/13/04.
The auditor is reporting the implantation from 12/15/03 as a Medical Event.
* * * UPDATE ON 03/09/04 @ 0956 BY IRA GARELICK TO C GOULD * * * RETRACTION
The licensee is retracting this event on the basis that further investigation along with consultation and a site visit with Reg 1 NRC personnel determined the implant went as planned. There was some tissue shrinkage resulting in cold spots which were adequately treated in the second implant on 02/13/04.
Notified Reg 1 RDO(Cobey) and NMSS EO(Psyk)