Event Notification Report for January 17, 2005

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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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LOSS OF FIRE MONITORING CAPABILITY

The following information was received by the licensee via facsimile:

I. Event Description

"On Monday, January 17, 2005, at approximately 0545, Security personnel manning the Central Alarm Station notified the Emergency Team captain [Redacted] that they were unable to detect any information from the facility fire protection system and the system operability was in question. Compensatory measures were put in place: the e-team patrolled the facility with a special emphasis placed on radiologically controlled areas. The system was restored at 0956."

II. Evaluation of the Event

"10 CFR 70.50(b)(2) states that the NRC must be notified of an event within 24 hours followed by a 30-day written report if the following condition is met:

"An event in which equipment that meets all of the following three conditions is disabled or fails to function as designed: [10CFR70.50(b)(2)]

"(1) The equipment is required by regulation or license condition to prevent releases exceeding regulatory limits, to prevent exposures to radiation and radioactive material exceeding regulatory limits, or to mitigate the consequences of an accident; and

"(2) The equipment is required to be available and operable when it is disabled or fails to function; and

"(3) No redundant equipment is available and operable to perform the required safety function.

"License SNM-42, Chapter 1, Section 1.9.2 requires that: "Fire detectors be installed and maintained in controlled areas. These detectors will alarm in the continuously manned NPD security alarm station." The system malfunction in the Central Alarm Station prevented them from being continuously monitored.

"Evaluations have been performed to determine that the system is not an IROFS and that regulatory limits will not be exceeded by [DELETED]. While SARs 15.9, 15.10, and 15.11 currently list the smoke detectors as IROFS, an evaluation was performed in December, 2004 which determined that these systems were not required to be IROFS and they are in the process of being removed from the ISA Summary.

"The equipment was required to be available and operable when it failed to function. Also, redundant equipment was not available; however, compensatory measures were utilized. The emergency team was dispatched to patrol the facility and monitor for local alarms and system activations. Special emphasis was placed on controlled areas. Compensatory measures were in place within 15 minutes of notification of the system loss.

III. Notification Requirements

"The event is reportable due to:

"Although the fire system monitoring is not an IROFS, it is required by the license to mitigate the consequences of an event in a controlled area. Also, it was required to be functional when the communications loss occurred and a redundant system was not available to perform the required safety function. Based on this, notification is required to the NRC within 24 hours followed by a 30-day written report.

IV. Status of Corrective Actions:

"The equipment has been returned to service and is functioning. An investigation of the event is underway."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 05/11/08 BY H. Crouch * * *

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.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

MEDICAL MISADMINISTRATION - WRONG TREATMENT SITE

The State provided the following NMED information:

"On 1/18/05, the licensee reported to the Agency a teletherapy misadministration that occurred on 1/17/05. The situation was described as 'the treatment field was displaced by six cm when the therapist set the central axis of the field at the tattoo marking the bottom of the field'. An area of 15 cm x 6 cm (treatment site) received dose when the plan called for that tissue to receive no dose. The dose was one day's treatment of 180 cGy. The treatment monitor units and energy were correct, the error was entirely an issue of field placement."

The Regulation Code cited is 105 CFR 120.502 (4) (a). The intended dose to the patient was 180 cGy, however, only 90 cGy was given to the wrong treatment site (15 cm x 6 cm area). Per the treating physician, no corrective action is needed. The hospital retrained staff to ensure confirming proper positioning of therapy prior to treatment.

"Event type Description: MD2 - Wrong Treatment Site.

"Cause description: The therapist did not correctly align the treatment field with the patient's treatment alignment tattoo."

"The Agency considers this event closed."

* * * UPDATE FROM STATE (TONY CARPENITO) TO M. RIPLEY AT 0953 EST 04/04/05 * * *

The following information was provided by the State via facsimile (State text in quotes):

"The device used to deliver the radiation treatment was a LINEAR ACCELERATOR."

Notified R1 DO (Noggle) and NMSS EO (T. Essig)

* * * RETRACTION FROM STATE (TONY CARPENITO) TO M. RIPLEY AT 1130 EST 04/04/05 * * *

Based on a discussion with the NMSS EO (T. Essig) and the State (T. Carpenito), this notification is retracted because the device used to deliver the radiation treatment is not regulated by NRC.

Notified R1 DO (Noggle) and NMSS EO (T. Essig)

MEDICAL EVENT INVOLVING DELIVERED DOSE LESS THAN THE PRESCRIBED DOSE

During a review of patient's records, the licensee identified a patient who received a delivered dose of 6,885 Centigray vice the prescribed dose of 8,196 Centigray using an ovoid applicator. The incident occurred on 1/17/05 and was discovered following a similar incident reported on 03/30/06 (see EN #42453). Both the referring physician and patient have been informed. There is indication or requirement for additional treatment at this time. The licensee discussed this incident with R3 (Gattone).

* * * UPDATE AT 11:44 ON 4/4/2006 FROM JEFF MASON TO ABRAMOVITZ * * *

The doses are being revised by the System RSO as:
prescribed: 2500 centigray
actual dose: 1203 centigray

Notified NMSS (Morell) and the R3DO (Stone).

CONFIRMED POSITIVE FITNESS FOR DUTY TEST OF LICENSED OPERATOR

The licensee reported a confirmed positive fitness for duty test for drugs [random] of a licensed operator. The individual's unescorted access has been revoked. A work performance investigation is underway.

The licensee has notified the NRC Resident Inspector and will be notifying the New Jersey Bureau of Nuclear Engineering. Contact the Headquarters Operations Officer for additional details.

NORTH CAROLINA AGREEMENT STATE REPORT - DAMAGED TROXLER

The following information was reported by facsimile.

The North Carolina Department of Environment and Natural Resources reported a damaged Troxler moisture density gage during construction activities in Reidsville, NC. The NC Radiation Protection Section dispatched a health physicist to the site, the health physicist secured the damaged gage on site and conducted radiation exposure surveys to access the status of the radioactive sources. All indications and surveys support that no radiological damage occurred to those workers involved and no damage was incurred to the environment.

Damage to the gage resulted in a potential loss of shielding. If the gage is mishandled the source rod will pull out. The gage was secured and the sliding block was closed.

Stakeholders and responsible parties were contacted and are arranging to have the gage appropriately transferred to the manufacturer for further evaluation.

Troxler Model # 3430, S/N 34504

Radiological Information:
Cs-137 10 milliCi S/N 77-1449
Am/Be 40 milliCi S/N 47-29961

Survey Results:
Background: 20 microR/hr
three inches from gage: 8 milliR/hr
After gage removed: 20 microR/hr (no indication of contamination)

NC Incident Report: 05-01 The license number was not provided.