Event Notification Report for March 07, 2007

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

The gauge was used at a jobsite at 35050 Halls Road, Clewiston, Florida on a Seminole Indian Reservation. After being used on the jobsite, the gauge was placed in a storage trailer. The gauge is a Model 3411B Troxler soil moisture density gauge, serial number 13563. The gauge contained a 8 millicurie Cs-137 source and a 40 millicurie Am-241:Be source.

"Device was used Friday 03/02/07 and placed in a storage trailer. It was noticed missing when the trailer was opened 03/07/07 [in the morning]. The trailer had not been broken into. The Seminole Reservation authorities are investigating. Licensee will submit a written report. [State of] Florida will investigate within the limits of its authority.

FL Incident Number: FL07-039

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.

AGREEMENT STATE REPORT- MEDICAL EVENT - UNDERDOSE TO PATIENT

During a series of fractional medical treatments given to the patient on 2/13/07 through 2/20/07, a dose of 24000 centigray was administered to the dose area of the patient instead of the 31092 centigray prescribed dose. The isotope used was Iridium-192. The source strength was unknown at the time of the report.

"The HDR misadministration was the result of a failure to correct for the proper length of the type of connector used in the procedure. The error resulted in a dose more than 20% below the prescribed dose. The error in the procedure was identified during the review process following the conclusion of the last dose fraction."

The length of the connector differed from the correct length by 1.4 centimeters. The prescribing physician said that the patient will likely have a skin reaction to the treatment that will heal with time.

"The [Colorado Health] Department's inspector is scheduled to conduct an inspection at the Penrose Hospital on Monday, March 12, 2007. He was briefed with the known details of the misadministration at this date and will look further into this matter."

The state expects to provide additional information at a later date.

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.

HPCI DECLARED INOPERABLE FOLLOWING SURVEILLANCE TESTING

"While Performing HPCI ATTS Panel, 1H11-P927, Functional Test & Calibration Surveillance (57SV-SUV-013-1S) For Ambient Torus Temperature High, The HPCI System Isolated. The Functional Test & Calibration Was Complete. The Isolation Was Reset. Following Return Of The Test Switch To Normal, HPCI Isolation Trip Logic 'A' Initiated & Closed 1E41-F002. HPCI Isolation Valve F002/F003 Alarm Annunciated When The Isolation Valve Started Closing & The HPCI Turbine Trip Solenoid Energized. I&C Investigating Time Delay Relay For Possible Cause."

HPCI has been declared inoperable placing Unit 1 in TS LCO A/S 3.5.1.c - 14 days to restore. The licensee informed the NRC Resident Inspector.

EMERGENCY DIESEL GENERATOR AUTOSTART ON LOSS OF "B" RESERVE STATION SERVICE TRANSFORMER

"The Unit-2 H Emergency Diesel Generator (EDG) automatically started on a Degraded Voltage/Under Voltage (DV/UV) signal due to the loss of the 'B' Reserve Station Service Transformer (RSST). The Unit-2 H Emergency Diesel Generator is supplying the Unit-2 H 4160 Volt Bus. Both Unit 1 and Unit 2 were stabilized using the appropriate abnormal procedures.

"During the event, the Unit 2 'B' Main Feed Water Pump motor, 2-FW-P-1B1, was noted to be running with the other motor, 2-FW-P-1B2, not running. The Unit 2 'B' Main Feed Water Pump was subsequently placed in Pull-to-Lock. Investigation continues as to the cause of the loss of the 'B' Reserve Station Service Transformer and the start of the Unit 2 'B' Main Feed Water Pump motor.

The licensee notified the NRC Resident Inspector.

LOST TROXLER MOISTURE DENSITY GAUGE

This event was entered per the request of NRC Region 1

On the morning of 3/7/07 the reporting company noticed that a Troxler Moisture Density Gauge (Model 3411B, Serial Number 13563) was missing. The gauge was used Friday 3/2/07 at a jobsite at 35050 Halls Road, Clewiston, Florida and placed in a storage trailer. The jobsite was on a Seminole Indian Reservation.

The trailer had not been broken into. The Seminole Reservation authorities are investigating. The licensee will submit a written report.

This report was originally reported to the state of Florida, see event # 43219 reported on 3/7/07, since the reporting company was a Florida Licensee (License Number 3424-1). The reporting company also called the NRC on 3/7/07 at 15:18 regarding this same event.


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.

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"A brachytherapy misadministration involving a 31year old female patient with a history of vaginal cancer was reported to NYS DOH BERP on 3/9/07.

"The patient was successfully treated to 5590 cGy to the target volume using external beam (IMRT) therapy and she was to receive 2500-3000 cGy via interstitial brachytherapy with both Cesium-137 and lridium-192 (seeds in ribbons) sources.

"The medical physicist developed a treatment plan as directed by the authorized user/ radiation oncologist using a commercial treatment planning software application. Eleven ribbons with 8 seeds each and an activity of 1.855 mgRaEq per Ir-192 [3.19 mCi] seed were ordered from Best Industries. Hospital owned Cs-137 sources were selected for use. The medical physicist verified source strength of all sources. The oncologist reviewed and approved the plan. He prescribed a total dose of 2500 cGy to be delivered to the 50 cGy-isodose line for a total treatment time of 50 hours.

"At 2:30 PM on 3/6/07 the sources were placed into the patient. A Syed template was used to place the ribbons and the Cs-137 sources were loaded into a tandem applicator.

"On 3/7/07, late in the morning, the medical physicist performed a manual check of the treatment plan calculations and identified a significant discrepancy - the hand calculations indicated a significantly higher dose rate than what was generated from the treatment planning software. An investigation ensued, which included consultation with the TPS vendor's application specialist. After several hours of investigation it was determined that the original treatment plan was in error, and at 5:30 PM on 3/7/07, after 27 of the intended 50 hour treatment time, the radiation oncologist decided to remove the sources [from the patient].

"Instead of the intended 2500cGy, the patient received an estimated dose of 4590 cGy and the anterior rectal dose was approximately 7300 cGy.

"The licensee provided a written report as required, and DOH staff performed an on-site investigation on 3/21/2007.

"Cause and contributing factors:

"1. The primary error was the use of an inappropriate Dose Rate Factor in the TPS. The value used corresponded to the DRF for Air Kerma however the source strength entered was in MgRaEq. The physicist should have changed the units of source strength or entered the correct DRF.

"2. Changing the units of activity in the TPS does not generate a prompt for a new Dose Rate Constant.

"3. During the physics review it was determined that acceptance testing of this treatment planning software did not include Iridium-192. The acceptance testing covered Cesium -137 and Iodine -125 seeds which where the only materials being used at the time. If this testing had been performed the physicist would have been more likely to recognize that the treatment planning system does not automatically select the correct dose rate factor when the source strength units are changed.

"4. There was no check of the preplan before the seeds arrived although there was sufficient time (sources ordered 2/27/07). The plan was approved on 3/6/07.

"5. Neither the physicist nor the radiation oncologist had prepared a treatment with Ir-192 in six years and the physicist had not used this particular TPS for Ir-192 implants. It would have been prudent to have an additional review or outside review in order to verify there were no oversights or errors.

"6. The double check was not done until after the day after sources had been implanted. Again while the physicist was observing the minimum requirements of Part 16 it would have been prudent to perform a check of the calculations either prior to the implant or immediately thereafter.

"Corrective action: The policy and procedures have been changed to require a check of calculations for any single fraction brachytherapy treatment to be performed and approved prior to initiation of treatment.

"Patient condition and follow-up: The radiation oncologist disclosed that the patient is at risk for radiation cystitis, rectal proctitis and more importantly, fistula formation between the rectum and the vagina. The patient will be monitored closely over the next year by both her gynecologic oncologist and the radiation oncologist. The patient is currently being treated with broad spectrum antibiotics along with daily treatments in a hyperbaric oxygen chamber."

NY Event No: NYS-DOH 07-001

* * * UPDATE ON 4/16/2007 AT 1112 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN * * *

This event has been reviewed and determined to be a reportable medical event.

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.