Event Notification Report for July 14, 2008

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DOSE LESS THAN PRESCRIBED DOSE

The following report was received from the State of Wisconsin via facsimile:

"On 7/14/2008, a patient was simulated and treatment planning performed for High Dose Rate (Ir-192) partial breast irradiation to the right breast using a Contura (SenoRx) balloon. The authorized user prescribed a dose of 3.65 Gy per fraction x 9 fractions for a total dose of 32.85 Gy to the Planning Target Volume. After the planning was done, the length of each of the five catheters was measured by the Nucletron Source Position Simulator. The readings were found to be 1154 each. The treatment file in the High Dose Rate treatment console was modified from its default value of 1500 to 1154 and patient was treated. The patient was treated in the High Dose Rate machine located in Room 'A'.

"On 7/15/08, the patient was scheduled to be treated in the High Dose Rate machine located in Room 'B'. Since the sources are different in activity, total time check was performed, at which time, the medical physicists also compared the measured lengths with a second patient under treatment with the Contura balloon in Room 'B'. At this point they noted the difference in the measured lengths between the two cases. The medical physicist checked the Source Position Simulator and noticed that there was an obstruction at the 1154 reading. The review of the actual delivered dose during the first fraction revealed that the source did not enter the patient's body and thus the negative impact was mitigated. A small region of the skin surface received some radiation dose, but the clinical impact is insignificant. The incident was immediately reported to the primary Radiation Oncologist and the Authorized User. The licensee states that no long-term, permanent side effects are anticipated as a result of the medical event.

"Due to the licensee's investigation of the Source Position Simulator revealing that a welded junction in the cable of this measuring device was kinked, it was immediately replaced with a new one. The licensee has also developed a new Quality Assurance form which will be exclusively used for Contura balloons and which incorporates the expected length for the five catheters. Department of Health Services (DHS) staff have been dispatched to investigate this incident."

Wisconsin Report Number: WI080017

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.

AGREEMENT STATE REPORT - CRUSHED MOISTURE DENSITY GAUGE

"Approximately 02:35 a.m. on 7-14-08, an employee who coordinates nuclear gauge use with W. G. Yates & Sons Construction Company notified MEMA that a Troxler 4640-B thin lift density gauge had been crushed by an 18-wheeler truck when the truck drove through the cone barrier. The Gauge contents were scattered over a 10 ft X 10 ft area in the middle of highway 49 South, Richland, Mississippi. MEMA then notified [redacted] Director of Radiological Health at approximately 3:03 a.m.

"[The director] picked up the gauge parts off Highway 49 South and packed them in the original shipping container with dirt. Surveys were conducted of the accident scene revealing only background readings after the gauge parts were put back into the gauge box. At 4:10 a.m., [the director] reported to MEMA the contents of the crushed gauge and that one lane of traffic was open on Highway 49 South in Richland, Mississippi. Confiscation of the gauge by the Division of Radiological Health was reported to MEMA at 4:38 a.m., when [the director] was leaving the accident site.

"[The director] returned with the gauge to Radiological Health at approximately 8:30 a.m., on 7-14-08. Pictures of the crushed gauge were taken by [a Senior Health Physicist of the] Division of Radiological Health. Then the gauge was surveyed and placed in a lead storage cask. Surveys revealed 600 Mr/hr at 6 in from the gauge source rod.

"The RSO for W. G. Yates & Sons Construction Company was contacted by [the director] and asked to give a report on how the accident happened. The report issued to the Mississippi State Department of Health / Division of Radiological Health was received 7-15-08. In summary, the RSO said work was being performed on two of the three South bound lanes of Highway 49 South. The center and right hand lanes of Highway 49 South were blocked off with cones. The RSO said one employee on site walked away from his profiler machine which was in the center lane of Highway 49 South to ask another employee about the measurements from the thin lift density gauge, also located in the center lane of Highway 49 South. Standing approximately 5 feet from the gauge, they witnessed an 18 wheeler veer from the left hand lane and travel to the center lane crossing the cone barrier. The driver of the 18-wheeler veered further to the right of the profile machine which was in the center lane of the highway. One employee's truck was parked in the right hand lane while he was taking readings from the profile machine. Upon approaching the employees truck, the 18-wheeler veered back into the center lane from the right hand lane and crushed the thin lift density gauge. Both employees were uninjured.

"Upon further review of the accident, the authorized user for the thin lift density gauge was trained and certificates are on file with the Division of Radiological Health. The gauge was also last leak tested on 11/1/07. The RSO said three employees with W. G. Yates & Sons Construction company who were involved in the accident have had there badges sent in for processing.

"Accident site surveys revealed the source was still in the gauge. Additional site surveys revealed only background readings. The gauge was confiscated by DRH.

"Isotope(s): Cesium-137;
"Activity: 8 mCi."

This is Mississippi Event Number MS08008.

ITEM RELIED ON FOR SAFETY (IROFS) DISCOVERED INOPERABLE

"NOX (nitrogen dioxide, nitric oxide, etc) detection is IROFS BUND-17 for the LEU [Low Enriched Uranium] portion of the BPF facility. This IROFS is one of the two controls used to prevent chemical occupational exposure to NOX emissions due to the U-natural dissolution operation. The NOX detector alarms prior to exceeding 5 ppm NOX to allow operations to perform monitoring and/or evacuation actions. On July 11, 2008, it was identified that the calibration gas used to functionally test the NOX detector has expired. The calibration expiration date was September 2007. The prior functional test of the NOX detector was performed on January 11, 2008. Due to use of expired calibration gas, it was determined that the NOX detector (IROFS BPF-43) has been in a degraded condition since the last functional test (January 2008).

"A 2nd IROFS is credited in the NOX accident sequence but, with degradation of IROFS BUND-17, the performance criteria of 10 CFR 70.61 were not met.

"No actual emissions have been identified.

"The event occurred due to a degraded management measure, specifically a periodic function test. Improved calibration verifications have recently been implemented; this improved check identified the problem of the expired calibration gas."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1241 EDT ON 8/5/08 FROM E.A. SENTER TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"On July 14, 2008, NFS made a 24-hour report (NRC Event No. 44345) to the operations center based on 10CFR70, Appendix A, Paragraph (a)(2). 10CFR70, Appendix A, Paragraph (a)(2) requires a 24-hour report for loss or degradation of an item relied on for safety (IROFS) that results in failure to meet the performance requirement of Sec. 70.61. The report was made due to expired calibration gas being used to functionally test the IROFS BUND-17 Nox (nitrogen dioxide, nitric oxide, etc) detector.

"After calibrating the detector with in-date calibration gas, it was determined that the NOX detector was actually set to alarm at a much more conservative part per million reading than the normal alarm setting. Therefore there was no degradation of the IROFS BUND-17, but rather an increased level of protection had been applied since the last functional test in January 2008. Based on this information, it is requested that this event report be retracted."

Notified R2DO (Hooper), NMSS (Tschiltz) and Fuels OUO Gp via email.