Event Notification Report for October 26, 2004

LOST RADIOACTIVE MATERIAL

RSO for the VA Medical Center, New Orleans, LA was notified at 0900 CDT on 10/27/04 of a missing shipment of I-125 (10 millicuries) that had been received by that facility on 10/26/04. The RSO is conducting an investigation into the missing radioactive material.


* * * UPDATE AT 1500 ON 11/10/04 M. SIMMONS TO W. GOTT * * *

"The radioactive material was I-125 as sodium iodide, liquid form, shipped in a shielded vial containing 10 millicuries in a volume of less than 1 milliliter. The RAM was to be used in a biomedical research lab.

"The permittee investigated the loss and concluded the radioactive material most likely ended up in a local landfill.

"The permittee notified the local landfill operations staff of the event. The permittee and landfill operations staff performed radiation surveys of the landfill. The radiation surveys did not locate the missing radioactive material.

"The NHPP performed a reactive inspection one week after the loss was discovered.

"The initial inspection results confirm the radioactive material is most likely buried at the local landfill and is not recoverable. According to witnesses, the probable cause of the event is the shipping box was not correctly labeled as containing radioactivity."

Notified NMSS (Moore), R3DO (Ring), and R4DO (Gody).

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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FAILURE OF SAFETY SYSTEM CAUSING UNFAVORABLE GEOMETRY

The licensee reported a transfer of low concentration HEU solution from favorable to unfavorable geometry was initiated upon sampling data that was not representative of the solution. The solution has been determined to be above the transfer concentration limit. Verification of HEU concentration is an administrative "item relied on for safety" (IROFS) for the accident sequence. The remaining IROFS for the accident sequence is an inline radiation detector that automatically closes redundant block valves. This system performed as designed. The system was placed in a safe shutdown condition and the solution remains in a favorable geometry.

Mass is controlled in the unfavorable geometry tank by limiting the volume and concentration of transfers into it. The failed control is administrative sampling and verifying the concentration is below the limit. The licensee states the solution will be reprocessed to lower concentration prior to discharge.

The licensee has informed the NRC Resident Inspector.

* * * UPDATE ON 05/11/08 BY J KOZAL * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.

RANDOM FITNESS FOR DUTY TEST

Illegal drug use was detected during a random drug test of a non-licensed employee. The employee's access to the plant has been terminated. Contact the HOO for additional details.

The NRC Resident Inspector was notified by the licensee.

AGREEMENT STATE REPORT - MEDICAL EVENT

"This event involved an HDR brachytherapy unit [Varian Medical Systems, Inc. Model GammaMed plus, serial number E159; with sealed source Model GammaMed 232, serial number 24-07-4445-004-082504-11622-71 (connector serial number D24E445)]. The female patients larynx cancer treatment plan called for four HDR brachytherapy treatments. On October 26, 2004, two HDR brachytherapy treatments were given. Before the third treatment was to be given, on October 27, 2004, an error was discovered. The prescribing physician stopped the treatment until dosimetry information was completed. The third treatment was not given. The error was caused because a circular tool was used to mark the treatment site. The diameter of the circle was used when the radius should have been applied. As a result, the area treated was 2 cm away from the defined locus instead of 1 cm. The total source length treated was 11 cm, (approximately 1 cm diameter cylinder surrounding the brachytherapy source placed inside a tracheotomy tube). The prescribed dose was 500 cGy (centiGray) to the entire 11 cm length. The worse case patient dose scenario was that the patient received 2,756 cGy at one dwell position out of 23 dwell positions along the 11 cm treatment length. The dose delivered would have been 551% greater than the prescribed dose at the position respective to the worst-case scenario. The licensee does not anticipate any adverse health affects to the patient. The Utah Division of Radiation Control is currently investigating this event."