Event Notification Report for March 10, 2008

NEBRASKA AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The State of Nebraska Department of Health & Human Services, Radiation Control Program, Radioactive Materials Branch reported that a radiographer employed by Team Industrial Services, Inc. was potentially overexposed while performing radiography at a Nebraska City, NE facility. Team Industrial Services, Inc. is performing work in Nebraska under reciprocity of their Illinois license.

On March 7, 2008, while at the job site, the radiographer noticed that his direct-reading pocket dosimeter was off-scale. He reported this to the regional Team Industrial Services RSO and stated that he believed he just bumped the dosimeter to cause the off-scale condition. The RSO directed him to send his TLD to Landauer Laboratories for processing.

On March 10, 2008, Landauer informed the RSO that the TLD indicated that the radiographer received 7.753 REM Deep Dose Equivalent.

The Team Industrial RSO notified his corporate RSO, who then notified the State of Nebraska. The radiographer has been restricted from radiation areas while Team Industrial and the State of Nebraska investigates this incident.

* * * UPDATE RECEIVED VIA E-MAIL FROM HOWARD SHUMAN TO JOE O'HARA AT 1530 ON 4/11//08 * * *

"On March 11, 2008, the Corporate RSO for Team Industrial Services, Inc. called to report that one of their industrial radiographers had received an exposure of 7.753 rems to their dosimetry badge while conducting radiographic operations, under reciprocity, at a construction site in Nebraska City, NE.

"The dates that the radiographer had performed radiography were the evening of March 4, 2008 and the early morning of March 5, 2008. At the time the radiographer noted that his pencil dosimeter had gone off-scale. He did not notify the FRSO in the licensee's Illinois office until March 7, 2008 at which time his dosimetry badge was sent off to Landauer for emergency processing. Landauer verbally reported the findings to Team Industrial on March 10, 2008.

"During the subsequent investigation of the incident, the radiographer admitted that he had performed radiography alone at the temporary jobsite alone. Four possible scenarios were developed during the investigation. First, he had received the exposure because the confined space in which the exposures were made caused the radiographer and assistant to be in a 200-300 Mr/hr field. This was discounted because the assistant only had 30 mrem on her pencil dosimeter and badge readings were 137 mrem for February and 4 mrem for March (both sent in for emergency processing).

"The second scenario involved the statement by the radiographer that he had dropped his dosimetry badge near the camera and guide tube and that he may have "bumped" his pencil dosimeter. Calculations could not substantiate the exposure to the badge. In addition, it was too coincidental that both the dropped badge and "bumped" pencil dosimeter happened at the same time.

"The third scenario was that this was an intentional exposure of the badge. Intensive questioning by the State of Nebraska inspectors and Team management could not substantiate this scenario.

"The last and most probable scenario was that the radiographer did not fully retract the source following a radiography shot and failed to properly conduct a complete survey around the camera and guide tube before repositioning the guide tube for the next radiography shot.

"There is no evidence to discount any of the above scenarios so the investigation is considered to be inconclusive.

"A complete investigation report is in process. Violations have been identified and will be included in the final report with the response from the licensee."

Notified R4DO(Deese) and FSME(Kock)

DAMAGED TROXLER MOISTURE DENSITY GAUGE

The RSO reported that while the technician was performing a soil test, a piece of construction equipment backed over the gauge. The incident occurred at the "Bodo tract" on the corner of Station Rd. and Con-Chester Pike (Rt. 322). The current status of the gauge is that the source rod is still in the test position. The technician has cordoned off the area awaiting the arrival of the RSO. The extent of damage to the gauge is unknown at this time.

The gauge is a Troxler model 3440 containing 40 mCi of Am-Be and 8 mCi Cs-137.

The RSO has notified Region 1 NRC (Gordon) and will be updating this report once the event is assessed.

* * * UPDATE FROM MICHAEL SOWERS TO HOWIE CROUCH @ 1752 EDT ON 03/10/08 * * *

The licensee RSO was able to retract the source back into the shield, however the shield has broken away from the gauge. Area radiation surveys did not indicate any contamination in the incident area. The licensee has transported the gauge back to their facility and will be conducting a leak test sample to send to Troxler.

Notified R1DO (Lorson) and FSME EO (Flanders).

HPCI INOPERABLE

"During performance of the quarterly high pressure coolant injection (HPCI) Surveillance Test, a technical specification step could not be completed due to observed system water flow and discharge pressure oscillations. These oscillations are presently under investigation. The tech spec step involved establishing flow conditions at a certain discharge pressure. The problem is either with the test return system or the control system. A formal troubleshooting plan is being developed to determine the root cause and corrective action required to re-establish operability of the HPCI system. The system remains inoperable due to the problem found during testing. If the problem is found to be caused by the control system, then it could have potentially impacted the ability of the HPCI system to mitigate the consequences of an accident."

HPCI is currently in a 14 day Tech Spec 3.5.1.h LCO.

The licensee notified the NRC Resident Inspector. The licensee will be notifying the Minnesota Duty Officer.

* * * UPDATE FROM MARK KRUSE TO JASON KOZAL ON 4/22/08 AT 1631 * * *

"Monticello is retracting the event reported based on further reviews of the event which found that the issue did not impact HPCI operability. A problem was identified with the test return valve CV-3503 which is not a safety-related component. The stations formal troubleshooting team has identified the cause for the degradation and corrective actions will be tracked in the station's corrective action program."

The licensee will notify the NRC Resident Inspector. Notified R3DO (Cameron).

AGREEMENT STATE REPORT - MEDICAL EVENT - PATIENT RECEIVED LESS THAN THE PRESCRIBED DOSE

"The Kentucky Radiation Health Branch was notified by the U.S. NRC by email on October 4, 2010 of a possible medical event occurring in the Commonwealth. There was no identification of the licensee involved. After extensive research, the Radiation Health Branch identified the licensee where the alleged medical event occurred. During an inspection of the facility, a review of medical documents identified a medical event involving the therapeutic treatment of prostate cancer with Pd-103 seeds.

"The treatment plan called for 100 Pd-103 seeds with an activity of 1.237 mCi per seed. The pretreatment plan of D90=132.78 Gy. The post treatment plan indicated the prostate received a D90=5.18 Gy. The licensee has not acknowledged a medical event. The patient involved has never been notified by the licensee. He was advised of the misadministration by another physician during a second opinion medical evaluation.

"Violations have been issued to the licensee. [An] evaluation [by the state] is ongoing."

* * * UPDATE FROM MICHELE GREENWELL TO JOE O'HARA AT 0841 ON 12/15/10 * * *

The following update was received from the Commonwealth via fax:

"The written directive had a prescribed dose for Pd-103, 100 Gy, act/seed 1.6 U, number of seeds 100."

Notified R1DO(Holody) and FSME(Villamar).

* * * UPDATE FROM MICHELE GREENWELL TO MARK ABRAMOVITZ ON 7/1/2011 AT 1353 EDT * * *

The Commonwealth of Kentucky performed an inspection of Our Lady of Bellefonte Hospital on 11/30/2010 and found 35 additional cases of medical misadministration during prostate seed implantation by one doctor. The date of the misadministration occurred from 10/3/2001 to 2/24/2009. No written directive for the dose prescribed or delivered was found for 14 of the cases with the remainder of the cases not having the post implant dose recorded. There was no post CT scan on 17 cases, and D90 doses ranged from 0% to 162% of the prescribed dose. The physician was notified on all of these cases however, none of the patients were notified.

Notified the R1DO (Welling) and FSME (Jackson).

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.