Event Notification Report for June 25, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/24/2007 - 06/25/2007
EVENT NUMBERS
43444434454344143482
Other Nuclear Material
Event Number: 43444
Rep Org: SOIL & MATERIALS ENGINEERING, INC.
Licensee: SOIL & MATERIALS ENGINEERING, INC.
Region: 3
City: PLYMOUTH State: MI
County:
License #: 21-17158-02
Agreement: N
Docket: 30-19574
NRC Notified By: FRANK HENDERSON
HQ OPS Officer: STEVE SANDIN
Licensee: SOIL & MATERIALS ENGINEERING, INC.
Region: 3
City: PLYMOUTH State: MI
County:
License #: 21-17158-02
Agreement: N
Docket: 30-19574
NRC Notified By: FRANK HENDERSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/25/2007
Notification Time: 18:00 [ET]
Event Date: 06/25/2007
Event Time: 15:00 [EDT]
Last Update Date: 06/25/2007
Notification Time: 18:00 [ET]
Event Date: 06/25/2007
Event Time: 15:00 [EDT]
Last Update Date: 06/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X 30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X 30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMNES CAMERON (R3)
JACK DAVIS (FSME)
JAMNES CAMERON (R3)
JACK DAVIS (FSME)
TROXLER MOISURE DENSITY GAUGE SOURCE FOUND MISSING AFTER FIELD USE
A Troxler Moisture Density Gauge, Model 3430 S/N 22053, was evaluated in the shop after use at a temporary jobsite two hours earlier today in Royal Oak, MI. At the time the Authorized User (AU) attributed the inconsistent G-M readings to survey instrument error. However, further evaluation in the shop noted that the Cs-137 source (8 mCi) connected to the extendable source rod was missing. The licensee is enroute to the temporary jobsite in an effort to locate and recover the missing source.
* * * UPDATE AT 2000 EDT ON 6/25/07 FROM FRANK HENDERSON TO S. SANDIN * * *
The licensee located and recovered the missing source. The source, shielded in a portable container of sand, is enroute to their facility in Plymouth, MI where the licensee will contact Troxler Labs for assistance.
Established conference call between R3 (Shear, Gattone) and the licensee (Henderson).
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.
A Troxler Moisture Density Gauge, Model 3430 S/N 22053, was evaluated in the shop after use at a temporary jobsite two hours earlier today in Royal Oak, MI. At the time the Authorized User (AU) attributed the inconsistent G-M readings to survey instrument error. However, further evaluation in the shop noted that the Cs-137 source (8 mCi) connected to the extendable source rod was missing. The licensee is enroute to the temporary jobsite in an effort to locate and recover the missing source.
* * * UPDATE AT 2000 EDT ON 6/25/07 FROM FRANK HENDERSON TO S. SANDIN * * *
The licensee located and recovered the missing source. The source, shielded in a portable container of sand, is enroute to their facility in Plymouth, MI where the licensee will contact Troxler Labs for assistance.
Established conference call between R3 (Shear, Gattone) and the licensee (Henderson).
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.
General Information or Other
Event Number: 43445
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PROVIDENCE MEDFORD MEDICAL CENTER
Region: 4
City: MEDFORD State: OR
County:
License #: ORE-91035
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JEFF ROTTON
Licensee: PROVIDENCE MEDFORD MEDICAL CENTER
Region: 4
City: MEDFORD State: OR
County:
License #: ORE-91035
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/26/2007
Notification Time: 19:12 [ET]
Event Date: 06/25/2007
Event Time: 00:00 [PDT]
Last Update Date: 06/26/2007
Notification Time: 19:12 [ET]
Event Date: 06/25/2007
Event Time: 00:00 [PDT]
Last Update Date: 06/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4)
EDWIN HACKETT (FSME)
GREG PICK (R4)
EDWIN HACKETT (FSME)
OREGON AGREEMENT STATE REPORT - UNDERDOSE DUE TO EQUIPMENT MALFUNCTION
"On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated.
"Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment.
"Dosimetry reconstruction of the delivered dose indicates that 17.8% of the prescribed dose was delivered. Physician will reconstruct new treatment plan. Treatment Details: The patient was receiving HDR treatment #2 to a Miami vaginal cylinder with tandem. This apparatus is connected to the HDR After loader (with radioactive wire) with 7 separate connecting tubes, one for each treatment channel. During connection, bloody fluid was noted on one of the connectors, cleaned, and the tube connected. The treatment was initiated, but after that tube was treated, the device's computer indicated the wire positioning was not reproducible (error code 18 - Wire drift detected) and the treatment was paused. The QA positioning test was run and within acceptable limits. The treatment was continued, but the device again indicated positioning errors. The treatment was discontinued without being fully completed.
"Protective caps covering the tubes were removed in surgery instead of waiting until the patient arrived in the department, a typical procedure that had not caused an incident in the past. In the future, it is prudent to leave them connected until the patient is ready to be connected to the treatment device. Two lessons learned from this experience: For HDR cases using a tandem, the tandem channel should be treated first, since the prescribed dose is more influenced by tandem dose than by ovoids or vaginal cylinder. The protective caps on the applicator should be left on as long as possible to reduce or preclude any fluid in the closed system.
"Device: Varian VariSource High Dose Rate After loader, S/N#: 600379, SS&D #: CA-0661-D-103-S,
Source: Alpha - Omega Model #: VS 2000, SS&D #: CA-1080-S-102-S, S/N #: 02-01-0588-001-041907-10089-97, Activity: 10.089 Ci on 4/19/07"
* * * UPDATE AT 0844 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *
"This event (EN43443) 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.
"On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated.
"Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment.
"Dosimetry reconstruction of the delivered dose indicates that 17.8% of the prescribed dose was delivered. Physician will reconstruct new treatment plan. Treatment Details: The patient was receiving HDR treatment #2 to a Miami vaginal cylinder with tandem. This apparatus is connected to the HDR After loader (with radioactive wire) with 7 separate connecting tubes, one for each treatment channel. During connection, bloody fluid was noted on one of the connectors, cleaned, and the tube connected. The treatment was initiated, but after that tube was treated, the device's computer indicated the wire positioning was not reproducible (error code 18 - Wire drift detected) and the treatment was paused. The QA positioning test was run and within acceptable limits. The treatment was continued, but the device again indicated positioning errors. The treatment was discontinued without being fully completed.
"Protective caps covering the tubes were removed in surgery instead of waiting until the patient arrived in the department, a typical procedure that had not caused an incident in the past. In the future, it is prudent to leave them connected until the patient is ready to be connected to the treatment device. Two lessons learned from this experience: For HDR cases using a tandem, the tandem channel should be treated first, since the prescribed dose is more influenced by tandem dose than by ovoids or vaginal cylinder. The protective caps on the applicator should be left on as long as possible to reduce or preclude any fluid in the closed system.
"Device: Varian VariSource High Dose Rate After loader, S/N#: 600379, SS&D #: CA-0661-D-103-S,
Source: Alpha - Omega Model #: VS 2000, SS&D #: CA-1080-S-102-S, S/N #: 02-01-0588-001-041907-10089-97, Activity: 10.089 Ci on 4/19/07"
* * * UPDATE AT 0844 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *
"This event (EN43443) 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.
Other Nuclear Material
Event Number: 43441
Rep Org: BLAZOSKY ASSOCIATES, INC
Licensee: BLAZOSKY ASSOCIATES, INC
Region: 1
City: PORT MATILDA State: PA
County: CENTRE
License #: 37-28507-01
Agreement: N
Docket:
NRC Notified By: JAMES DOTTS, RSO
HQ OPS Officer: JOHN KNOKE
Licensee: BLAZOSKY ASSOCIATES, INC
Region: 1
City: PORT MATILDA State: PA
County: CENTRE
License #: 37-28507-01
Agreement: N
Docket:
NRC Notified By: JAMES DOTTS, RSO
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/25/2007
Notification Time: 10:02 [ET]
Event Date: 06/25/2007
Event Time: 09:40 [EDT]
Last Update Date: 06/25/2007
Notification Time: 10:02 [ET]
Event Date: 06/25/2007
Event Time: 09:40 [EDT]
Last Update Date: 06/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)
RAY POWELL (R1)
CINDY FLANNERY (FSME)
DAMAGED TROXLER MOISTURE DENSITY GAUGE
The Radiation Safety Officer (RSO) of Blazosky Associates, Inc. called to report a damaged Troxler gauge. The damage occurred at the ERPA site on 06/25/07 as a pickup truck backed over the gauge. At the time the gauge was retracted and not actively in-use. The employee at the site called the RSO.
The employee visually examined the gauge and saw that the sources were intact and the shutter still closed. No leakage was found. The RSO will conduct a leak test and radiation check and return the instrument to Troxler.
The gauge is a Troxler Model 3440, Serial Number 29883. Sources were 8 mCi of Cs-137 and 40 mCi of Am-241/Be.
The Radiation Safety Officer (RSO) of Blazosky Associates, Inc. called to report a damaged Troxler gauge. The damage occurred at the ERPA site on 06/25/07 as a pickup truck backed over the gauge. At the time the gauge was retracted and not actively in-use. The employee at the site called the RSO.
The employee visually examined the gauge and saw that the sources were intact and the shutter still closed. No leakage was found. The RSO will conduct a leak test and radiation check and return the instrument to Troxler.
The gauge is a Troxler Model 3440, Serial Number 29883. Sources were 8 mCi of Cs-137 and 40 mCi of Am-241/Be.
General Information or Other
Event Number: 43482
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: OHMSTEDE
Region: 4
City: SULPHUR State: LA
County:
License #: LA-5694-L01A
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOE O'HARA
Licensee: OHMSTEDE
Region: 4
City: SULPHUR State: LA
County:
License #: LA-5694-L01A
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOE O'HARA
Notification Date: 07/12/2007
Notification Time: 07:53 [ET]
Event Date: 06/25/2007
Event Time: 00:00 [CDT]
Last Update Date: 07/12/2007
Notification Time: 07:53 [ET]
Event Date: 06/25/2007
Event Time: 00:00 [CDT]
Last Update Date: 07/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VINCENT GADDY (R4)
MICHELE BURGESS (FSME)
VINCENT GADDY (R4)
MICHELE BURGESS (FSME)
AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA
The licensee provided the following information via facsimile:
"Agreement State Agency: Louisiana Department of Environmental Quality
"Event Report ID No.: LA070020
License No.: LA-5694-L0IA
"Licensee: Ohmstede
"Event date and Time: June 25, 2007
"Event Location: Sulphur, LA
Event type: Equipment
Notifications: LA DEQ
"Event description: Ohmstede sent an Amersham 660B camera serial number B1072 to QSA Global for a source exchange. Before a new source was put into the camera, QSA Global discovered that the camera had a cracked S tube. The camera has been removed from operation and is in storage."
The licensee provided the following information via facsimile:
"Agreement State Agency: Louisiana Department of Environmental Quality
"Event Report ID No.: LA070020
License No.: LA-5694-L0IA
"Licensee: Ohmstede
"Event date and Time: June 25, 2007
"Event Location: Sulphur, LA
Event type: Equipment
Notifications: LA DEQ
"Event description: Ohmstede sent an Amersham 660B camera serial number B1072 to QSA Global for a source exchange. Before a new source was put into the camera, QSA Global discovered that the camera had a cracked S tube. The camera has been removed from operation and is in storage."