Event Notification Report for December 10, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/09/2008 - 12/10/2008
EVENT NUMBERS
44712457084471046273
General Information or Other
Event Number: 44712
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: COMMUNITY REGIONAL MEDICAL CENTER
Region: 3
City: LORAIN State: OH
County:
License #: 02120480002
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOE O'HARA
Licensee: COMMUNITY REGIONAL MEDICAL CENTER
Region: 3
City: LORAIN State: OH
County:
License #: 02120480002
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOE O'HARA
Notification Date: 12/11/2008
Notification Time: 08:34 [ET]
Event Date: 12/10/2008
Event Time: 14:00 [EST]
Last Update Date: 12/11/2008
Notification Time: 08:34 [ET]
Event Date: 12/10/2008
Event Time: 14:00 [EST]
Last Update Date: 12/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTINE LIPA (R3)
TERRY REIS (FSME)
CHRISTINE LIPA (R3)
TERRY REIS (FSME)
DETECTABLE CESIUM CONTAMINATION FOUND IN SOURCE SAFE DRAWER
A contractor removed cesium sources from a source safe located in a storage area. The sources were removed, packaged, shipped without incident. Surveys were conducted in the safe, and the survey in the lower safe drawer revealed contamination levels greater than 5000 dpm per 100 square centimeters. The lower drawer of the safe has not been used during this recent storage and transfer of sources. The licensee reported to the state that they believed it was "legacy" contamination. Individuals involved in the source transfer were surveyed. No contamination was found. The storage area and passageway to and from the storage area were surveyed. No contamination was found. The licensee has secured the safe and the contaminated area. The area is secured and posted with "no access" signs. The state will follow up with their licensee once a decontamination service completes the decontamination of the affected areas and is ready to release the area for general use.
The state notified Region 3 (Jim Lynch).
A contractor removed cesium sources from a source safe located in a storage area. The sources were removed, packaged, shipped without incident. Surveys were conducted in the safe, and the survey in the lower safe drawer revealed contamination levels greater than 5000 dpm per 100 square centimeters. The lower drawer of the safe has not been used during this recent storage and transfer of sources. The licensee reported to the state that they believed it was "legacy" contamination. Individuals involved in the source transfer were surveyed. No contamination was found. The storage area and passageway to and from the storage area were surveyed. No contamination was found. The licensee has secured the safe and the contaminated area. The area is secured and posted with "no access" signs. The state will follow up with their licensee once a decontamination service completes the decontamination of the affected areas and is ready to release the area for general use.
The state notified Region 3 (Jim Lynch).
General Information or Other
Event Number: 45708
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L-00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L-00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/18/2010
Notification Time: 10:58 [ET]
Event Date: 12/10/2008
Event Time: 00:00 [CST]
Last Update Date: 02/18/2010
Notification Time: 10:58 [ET]
Event Date: 12/10/2008
Event Time: 00:00 [CST]
Last Update Date: 02/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - SOURCE STUCK IN CATHETER TUBE
The following information was obtained from NMED:
"The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence."
The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report.
Texas Report Number: I-8590
The following information was obtained from NMED:
"The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence."
The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report.
Texas Report Number: I-8590
Power Reactor
Event Number: 44710
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: STEVE SANDIN
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/10/2008
Notification Time: 14:35 [ET]
Event Date: 12/10/2008
Event Time: 10:37 [EST]
Last Update Date: 12/10/2008
Notification Time: 14:35 [ET]
Event Date: 12/10/2008
Event Time: 10:37 [EST]
Last Update Date: 12/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (R1)
RONALD BELLAMY (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION MADE DUE TO MINOR OIL SPILL
"On December 10, 2008 at approximately 8:30 the control room was notified of an oil sheen in the discharge canal. An Operator was dispatched to assess the condition and its significance. At Approximately 1037 hours the CCR [Central Control Room] was informed that an apparent oil sheen had been observed in the Hudson River. The oil is partially contained by a boom in the outfall structure and the amount of oil released to the river is estimated to be less than one gallon. A sample of the material has been collected to determine what type of substance it is. The source of the apparent sheen is unknown and remains under investigation. In accordance with the Indian Point Spill/Release plan a spill or leak from Indian Point causing a visible sheen in the river as a result of a release of a petroleum product requires notification of the New York State Department of Environmental Conservation and the Coast Guard National Response Center. An environmental cleanup vendor has been contacted for assessment and cleanup.
"The NRC resident has been informed."
"On December 10, 2008 at approximately 8:30 the control room was notified of an oil sheen in the discharge canal. An Operator was dispatched to assess the condition and its significance. At Approximately 1037 hours the CCR [Central Control Room] was informed that an apparent oil sheen had been observed in the Hudson River. The oil is partially contained by a boom in the outfall structure and the amount of oil released to the river is estimated to be less than one gallon. A sample of the material has been collected to determine what type of substance it is. The source of the apparent sheen is unknown and remains under investigation. In accordance with the Indian Point Spill/Release plan a spill or leak from Indian Point causing a visible sheen in the river as a result of a release of a petroleum product requires notification of the New York State Department of Environmental Conservation and the Coast Guard National Response Center. An environmental cleanup vendor has been contacted for assessment and cleanup.
"The NRC resident has been informed."
General Information or Other
Event Number: 46273
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TIFFIN MERCY HOSPITAL
Region: 3
City: TIFFIN State: OH
County:
License #: 02120750001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: TIFFIN MERCY HOSPITAL
Region: 3
City: TIFFIN State: OH
County:
License #: 02120750001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/10/2008
Event Time: 00:00 [EDT]
Last Update Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/10/2008
Event Time: 00:00 [EDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)
AGREEMENT STATE REPORT - UNREPORTED MEDICAL PROSTATE THERAPY UNDERDOSE DISCOVERED DURING AUDIT
The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010:
"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [See EN # 46272]
"On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray [104.76 Gray actually delivered] to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose."
Ohio NMED Item # OH100019.
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.
The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010:
"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [See EN # 46272]
"On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray [104.76 Gray actually delivered] to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose."
Ohio NMED Item # OH100019.
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.