Event Notification Report for February 04, 2009

AGREEMENT STATE REPORT INVOLVING A DOSE DELIVERED TO THE WRONG TREATMENT SITE

The following information was received from the State of California via email:

"On February 5, 2009, [the Radiation Safety Officer (RSO) for the] City of Hope/Beckman Research Institute, contacted LA County Radiation Management regarding a misadministration that occurred at approximately 6:00 pm on February 4, 2009. The incident involved HDR treatment of the wrong site.

"Using HDR, a patient was scheduled for groin sarcoma therapy treatment. The treatment planning comprised of administration of approximately 4000 cGy to the tumor. The dose is to be administered in 10 fractions of 400 cGy/fraction; 2 fractions per day for 5 days. Six catheters to be administered/fraction. Per [the RSO], an error was made in the interpretation of the CT data, and therefore, the wrong distance was calculated. On February 4, 2009, the first day of the treatment, the catheters administered went to the body, past the tumor site, then to the outside of the thigh. [The RSO] stated that there was no dose administered to the tumor. All the dose was administered to the skin of the thigh. The patient had two treatments, and received approximately 800 cGy to the skin of the thigh.

"A written report will be submitted by the licensee within 15 days.

"Based on the current report of 800 rad to the wrong treatment site (skin), this medical event does not meet the criteria for an Abnormal Occurrence (see SA-300, Appendix section 6.3.IV)."

CA 5010 Number: 020509

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

SIRENS OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"The Prairie Island Nuclear Generating Plant is making an ENS notification in accordance with 10 CFR 50.72(b)(3)(xiii) due to planned maintenance on the Goodhue County radio repeaters. This maintenance will result in unavailability of 51 of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) for approximately 3 hours. The maintenance is scheduled to occur on the afternoon of 02/04/2009.

"The Goodhue County Sheriff's Office has been notified to implement the established process of back-up route alerting if required.

"Upon completion of the maintenance a cancel test will be performed to verify availability of the Goodhue County sirens and an update to this notification will be provided.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM R. FORTIER TO HOWIE CROUCH @ 1735 EST ON 02/04/09 * * *

The cancel test was performed by the Goodhue County Sheriff's Office to all Goodhue County sirens successfully. All sirens have been returned to service.

The licensee will be notifying the NRC Resident Inspector. Notified R3DO (Ring).

LOST NICKEL-63 SOURCE

"Description of the material involved, including kind, quantity, and chemical and physical form: GE Vapor Tracer 2 detection system (SN 07024933861). Approx. 8 mCi Nickel-63 (#09-3896).

"Description of the circumstances under which the loss occurred: On 29 Jan 09, during a routine semi-annual audit, the Andrews Air Force Base (AAFB) Radiation Safety Officer (RSO) identified the missing device used by the Aerial Port Squadron (APS). The device was used to screen luggage for explosives/narcotics. A review of records indicated the device was sent to the Defense Reutilization and Marketing Service (DRMS) through base supply by the user on 1 Jul 08. On 4 Feb 09, the RSO contacted the USAF Radioisotope Committee (RIC) to report the event. NOTE: The RSO is a member of the Bioenvironmental Engineering (BE) office.

"An investigation shows the APS (user) contacted the BE office on 24 Jan 08 and received instructions for disposing of the device via the DRMS. A technician from the BE office certified the device did not contain any hazardous material and would be suitable for turn-in to the DRMS. On 25 Jan 08, an officer from the BE office (not the RSO) sent a letter to the user affirming the technician's assessment. The technician and officer had no knowledge the device contained radioactive material (RAM). No RAM warning labels were visible on the exterior surface of the device.

"During the investigation of the loss of material, the RSO found the RAM warning label was located under the battery pack and not visible. Being unfamiliar with the device, the technician evaluated it for chemical hazards (and found none) but didn't consider radiological aspects.

"After review of all transfer/receipt and inventory documents over a span of three years, the RSO found no evidence that another event of this type had occurred at AAFB. This is an isolated event. Air Force Instruction 40-201, Managing Radioactive Material in the U.S. Air Force, expressly prohibits GLDs from being sent to the DRMS.

"A statement of disposition, or probable disposition, of the material involved: The investigation by the RSO revealed the device left AAFB and traveled to DRMS at FT Meade, MD and then to the DRMS at Mechanicsburg, PA. It was sold to a de-manufacturing contractor, Global Investment Recovery, where it was shredded for scrap. The scrap was sold through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further.

"Exposures of individuals to radiation, circumstances under which the exposures occurred, and the possible total effective dose equivalent to persons in unrestricted areas: Nickel-63 is a pure beta emitter with a 100 year half life. The ingestion annual limit on intake (ALI) is 9 millicuries (mCi). Ingestion of the source would not exceed the ALI and the committed effective dose equivalent (CEDE) would be less than 5 rem. The (Class D) inhalation ALI is 2 mCi. Using the EPA's inhalation dose conversion factor of 3.1 millirem/microCuries, the CEDE for 8 mCi of Ni-63 (Class D) is 25 rem. The size of the source is approximately that of a pencil eraser. It is unlikely an industrial shredder could have pulverized it to such an extent so as to present an inhalation hazard. The possible total effective dose equivalent to persons in unrestricted areas is presumed to be less than 1% of the ALI.

"Actions that have been taken, or will be taken, to recover the material: The RSO tracked the device from AAFB (1 Jul 08) to the DRMS at Fort Meade, MD and to the DRMS at Mechanicsburg, PA (7 Aug 08). It was shredded by Global Investment Recovery, the DRMS de-manufacturing contractor and sold as scrap through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further.

"Procedures or measures that have been, or will be, adopted to ensure against a recurrence of the loss of material: The RSO has determined the root cause of the event to be inadequate training. The users of the device and the BE office did not, collectively, possess information about GL material. The RSO had not shared his knowledge about the material with the BE office.

"The following corrective measures have been taken: Photographs of GLDs will be taken and provided to the BE staff, the users, base supply and DRMS. If warning labels are considered to be inadequate, new labels will be affixed to GLDs to alert individuals that RAM is present. The RSO, working with BE staff, has initiated awareness training for users of GLDs. Such will be conducted annually. Users will be required to possess binders in which to maintain information about their devices (e.g., safety data sheets, owner's manuals, policy, pictures, inventory, leak test results, contact numbers, etc.).

"The RSO has informed management of the event. Lessons learned will be passed down to targeted audiences. Andrews AFB instructions will be evaluated for gaps in policy and strengthened as necessary. The means for purchasing and transferring GLDs back to the manufacturer will be addressed in detail.

"The RIC Secretariat has contacted the GE Radiation Safety Officer regarding the placement of the radiation warning label. The RIC Secretariat informed Ms. Rachel Browder, NRC Region-IV, about the loss of a GLD on 10 Feb 09."


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source