Event Notification Report for March 05, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/04/2009 - 03/05/2009
Transportation Event
Event Number: 44892
Rep Org: EDLOW INTERNATIONAL
Licensee: NOT APPLICABLE
Region: 1
City: BALTIMORE State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANCHONE OSHINOWO
HQ OPS Officer: JOE O'HARA
Licensee: NOT APPLICABLE
Region: 1
City: BALTIMORE State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANCHONE OSHINOWO
HQ OPS Officer: JOE O'HARA
Notification Date: 03/05/2009
Notification Time: 13:44 [ET]
Event Date: 03/05/2009
Event Time: 13:00 [EST]
Last Update Date: 03/09/2009
Notification Time: 13:44 [ET]
Event Date: 03/05/2009
Event Time: 13:00 [EST]
Last Update Date: 03/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SAM HANSELL (R1)
DANIEL RICH (R2)
MICHAEL TSCHILTZ (NMSS)
ANGELA MCINTOSH (FSME)
SAM HANSELL (R1)
DANIEL RICH (R2)
MICHAEL TSCHILTZ (NMSS)
ANGELA MCINTOSH (FSME)
INDUSTRIAL SHIPPING INCIDENT CONTAINING UF6 (URANIUM HEXAFLUORIDE)
NRC Operations Center was notified by the Vice President for Operations at Edlow International of a marine incident at Dundalk Marine Terminal in Baltimore, MD. While offloading a flat rack containing UX30 protective overpacks with type 30B cylinders containing uranium hexafluoride from the MV Atlantic Conveyor, the rigging gear failed and the rack dropped onto the pier on top of another flat rack containing UX30 type 30B cylinders. There is no indication of a leak or release at this time. There were no injuries. Surveyor is at the scene.
* * * UPDATE FROM FRANCHONE OSHINOWO TO JOE O'HARA AT 1640 EST ON 03/05/09 * * *
Edlow confirms no material spill or damage to the packages. Damage was confined to the flat rack itself. Contrary to what was reported earlier, the mishap occurred onboard the vessel and NOT on the pier. Preliminary indications are that the spreader used to lift the flat rack was not engaged on all four lifting points prior to the lift commencing.
Notified R1DO (Hansell), R2DO(D. Rich), NMSS EO(M. Tschiltz), and FSME EO (McConnell).
* * * UPDATE FROM FRANCHONE OSHINOWO TO PETE SNYDER AT 1055 EST ON 03/06/09 * * *
Upon inspection of the shipping containers on land, Edlow personnel have verified that only cosmetic damage was caused to one flat rack by the mishap. The highest radiation readings on contact with the containers were 0.5 millirem/hour which were within expected levels.
Notified R1DO (Hansell), R2DO (Rich), NMSS EO (Tschiltz), and FSME EO (McIntosh).
* * * UPDATE FROM FRANCHIONE OSHINOWO TO PETE SNYDER AT 1139 EDT ON 03/09/09 * * *
Edlow stated that the information put into the last update above was incorrect. The previous update should have read that there was only cosmetic damage to one overpack however one flatrack was rendered unusable.
Notified R1DO (Dimitriadis), R2DO (Rich), NMSS EO (Tshiltz), and FSME EO (McIntosh).
NRC Operations Center was notified by the Vice President for Operations at Edlow International of a marine incident at Dundalk Marine Terminal in Baltimore, MD. While offloading a flat rack containing UX30 protective overpacks with type 30B cylinders containing uranium hexafluoride from the MV Atlantic Conveyor, the rigging gear failed and the rack dropped onto the pier on top of another flat rack containing UX30 type 30B cylinders. There is no indication of a leak or release at this time. There were no injuries. Surveyor is at the scene.
* * * UPDATE FROM FRANCHONE OSHINOWO TO JOE O'HARA AT 1640 EST ON 03/05/09 * * *
Edlow confirms no material spill or damage to the packages. Damage was confined to the flat rack itself. Contrary to what was reported earlier, the mishap occurred onboard the vessel and NOT on the pier. Preliminary indications are that the spreader used to lift the flat rack was not engaged on all four lifting points prior to the lift commencing.
Notified R1DO (Hansell), R2DO(D. Rich), NMSS EO(M. Tschiltz), and FSME EO (McConnell).
* * * UPDATE FROM FRANCHONE OSHINOWO TO PETE SNYDER AT 1055 EST ON 03/06/09 * * *
Upon inspection of the shipping containers on land, Edlow personnel have verified that only cosmetic damage was caused to one flat rack by the mishap. The highest radiation readings on contact with the containers were 0.5 millirem/hour which were within expected levels.
Notified R1DO (Hansell), R2DO (Rich), NMSS EO (Tschiltz), and FSME EO (McIntosh).
* * * UPDATE FROM FRANCHIONE OSHINOWO TO PETE SNYDER AT 1139 EDT ON 03/09/09 * * *
Edlow stated that the information put into the last update above was incorrect. The previous update should have read that there was only cosmetic damage to one overpack however one flatrack was rendered unusable.
Notified R1DO (Dimitriadis), R2DO (Rich), NMSS EO (Tshiltz), and FSME EO (McIntosh).
General Information or Other
Event Number: 44893
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNIVERSITY OF NORTH CAROLINA HOSPITALS
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF NORTH CAROLINA HOSPITALS
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/06/2009
Notification Time: 10:47 [ET]
Event Date: 03/05/2009
Event Time: 12:00 [EST]
Last Update Date: 03/23/2009
Notification Time: 10:47 [ET]
Event Date: 03/05/2009
Event Time: 12:00 [EST]
Last Update Date: 03/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SAM HANSELL (R1)
KEITH McCONNELL (FSME)
SAM HANSELL (R1)
KEITH McCONNELL (FSME)
UNDERDOSE TO PATIENT DIFFERS >20% OF INTENDED DOSE
The following was provided by the state via e-mail:
"Incident is a Medical Event per 15A NCAC 11.0364(a)(1)(A) where the EDE [effective dose equivalent] exceeds 5 Rem, and the total dose delivered differs from the prescribed dose by 20% or more.
"[This incident] occurred during the use of Y-90 TheraSpheres. It appears that the TheraSpheres became stuck in the source vial, and the entire dose could not be administered to the patient. This resulted in a 26.4% underdose to the patient. The licensee is investigating why the Medical Event occurred. The Agency [NCDENR] has requested that the licensee submit the source vial lot or batch number in the report to assist in the determination if it may have been a manufacturing error."
* * * UPDATE FROM JAMES ALBRIGHT TO JOE O'HARA VIA E-MAIL ON 3/20/09 AT 1715 * * *
"We were unable to obtain complete administration of the Y-90 TheraSphere dosage even after repeated flushes of thee dosage vial. The unadministered dosage appeared to remain in the dosage vial. Proper administration protocol was followed, and included four flushes of the vial. Two attempts were made to agitate and remove the remaining material by inverting the vial. The inversions were not completely successful at removing the remaining dosage.
"The decision was made to stop the administration after four flushes since the previous inversion and flush did not lower the dosimeter readings (a dosimeter is mounted on the delivery device which serves as an indicator of relative activity remaining in the dosage vial).
"The prescribed dosage was 44,7 mCi. It was estimated that [about] 32.9 mCi of the prescribed dosage was administered (73.6%). The intended dose to the right lobe of the liver was 120 Gy. The actual delivered dose to the right lobe was [about] 88.3 Gy. Although the other lobe of the liver (left) will be treated, there are no plans at this time to treat the right lobe again.
"MDS Nordion is conducting an investigation of this event. If deemed necessary upon completion of their investigation, supplemental procedures or recommendations will be provided to prevent further events of this type. Manufacturer representatives will be on-site on March 19, 2009 for further evaluation and follow-up. The TheraSphere dosage lot number was 9990019."
Notified R1DO (J. Dwyer) and FSME EO (L. Camper)
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.
The following was provided by the state via e-mail:
"Incident is a Medical Event per 15A NCAC 11.0364(a)(1)(A) where the EDE [effective dose equivalent] exceeds 5 Rem, and the total dose delivered differs from the prescribed dose by 20% or more.
"[This incident] occurred during the use of Y-90 TheraSpheres. It appears that the TheraSpheres became stuck in the source vial, and the entire dose could not be administered to the patient. This resulted in a 26.4% underdose to the patient. The licensee is investigating why the Medical Event occurred. The Agency [NCDENR] has requested that the licensee submit the source vial lot or batch number in the report to assist in the determination if it may have been a manufacturing error."
* * * UPDATE FROM JAMES ALBRIGHT TO JOE O'HARA VIA E-MAIL ON 3/20/09 AT 1715 * * *
"We were unable to obtain complete administration of the Y-90 TheraSphere dosage even after repeated flushes of thee dosage vial. The unadministered dosage appeared to remain in the dosage vial. Proper administration protocol was followed, and included four flushes of the vial. Two attempts were made to agitate and remove the remaining material by inverting the vial. The inversions were not completely successful at removing the remaining dosage.
"The decision was made to stop the administration after four flushes since the previous inversion and flush did not lower the dosimeter readings (a dosimeter is mounted on the delivery device which serves as an indicator of relative activity remaining in the dosage vial).
"The prescribed dosage was 44,7 mCi. It was estimated that [about] 32.9 mCi of the prescribed dosage was administered (73.6%). The intended dose to the right lobe of the liver was 120 Gy. The actual delivered dose to the right lobe was [about] 88.3 Gy. Although the other lobe of the liver (left) will be treated, there are no plans at this time to treat the right lobe again.
"MDS Nordion is conducting an investigation of this event. If deemed necessary upon completion of their investigation, supplemental procedures or recommendations will be provided to prevent further events of this type. Manufacturer representatives will be on-site on March 19, 2009 for further evaluation and follow-up. The TheraSphere dosage lot number was 9990019."
Notified R1DO (J. Dwyer) and FSME EO (L. Camper)
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.
General Information or Other
Event Number: 44902
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: ABILENE State: TX
County:
License #: 04590
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: ABILENE State: TX
County:
License #: 04590
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/12/2009
Notification Time: 15:15 [ET]
Event Date: 03/05/2009
Event Time: 16:45 [CDT]
Last Update Date: 06/05/2009
Notification Time: 15:15 [ET]
Event Date: 03/05/2009
Event Time: 16:45 [CDT]
Last Update Date: 06/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS FARNHOLTZ (R4)
ANDREW MAUER (FSME)
THOMAS FARNHOLTZ (R4)
ANDREW MAUER (FSME)
SOURCE DISCONNECT FROM RADIOGRAPHY CAMERA DRIVE CABLE
The Agency (State) was notified (at 1645 CDT) by the licensees RSO that they had a source disconnect and that the source was later retracted. The event involved an INC IR-100 camera containing a 94 curie Ir-192 source. The source was in use for about one week, about 6 jobs. A local Texas inspector went to the site to investigate the event.
The licensee later notified the Agency (State) that in this case, the connector crimped fitted on the source pig tail had separated from the source drive cable. The two individuals who returned the source to the camera housing received 425 millirem by self reading dosimeter for one worker, and between 750 and 800 millirem calculated for the other worker. The RSO stated that neither worker exceeded the annual DDE limit. TLD's for the workers involved have been sent to their processor and the results should be back on 3/9/09. The State of California has been informed of the event.
On March 13, 2009, the RSO notified the Agency (State) that the radiography camera had been packaged and will be returned to the manufacturer today.
Texas Incident # I-8614
UPDATE FROM ART TUCKER VIA EMAIL TO JOHN KNOKE AT 1237 0N 04/14/09
"[The State] received exposure reports for two workers involved in the source retrieval. The support individual received 299 millirem DDE, and the individual who actually retrieved the source received 502 millirem DDE, and 425 millirem calculated to the hand."
Notified FSME (Angela McIntosh) and R4DO (Jack Whitten)
* * * UPDATE ON 06/05/2009 AT 1015 FROM ART TUCKER TO VINCE KLCO * * *
Report received via e-mail:
"The [State of Texas] received the following information from the manufacturer of the source device:
"[The] license, Industrial Nuclear Company [INC], was notified by Desert Industrial X-ray that there had been a source disconnect of 97 curies, source S/N-N597 on March 5, 2009. Source and connector was received at Industrial Nuclear Co, Inc on March 13, 2009.
"Upon inspection of source connector [on] S/N- N597 that was received from Desert Industrial X-ray, INC found no evidence [of] physical damage. The cable appeared to have some stretching but not any more than would be expected after the pull test.
"Dimensions were performed on all previous inspected source assembly components and found to be within design limits.
"All INC source connector assemblies in inventory (from the same manufacturing date) were re-load tested and all passed. INC has to date never had a Source Connector come off in pre-inspection or after it was put in use. INC has not been able to discover just how this might have happened. In the report the licensee stated the connector crimp failed. INC has tried to recreate this event but [has] had no success in doing so. The licensee said the source had been in use for one week [and] if the source connector crimp was bad it should had failed on the first day.
"The licensee has not reported any additional problems associated with their exposure devices."
Notified R4DO (Lantz) and FSME EO (McIntosh)
The Agency (State) was notified (at 1645 CDT) by the licensees RSO that they had a source disconnect and that the source was later retracted. The event involved an INC IR-100 camera containing a 94 curie Ir-192 source. The source was in use for about one week, about 6 jobs. A local Texas inspector went to the site to investigate the event.
The licensee later notified the Agency (State) that in this case, the connector crimped fitted on the source pig tail had separated from the source drive cable. The two individuals who returned the source to the camera housing received 425 millirem by self reading dosimeter for one worker, and between 750 and 800 millirem calculated for the other worker. The RSO stated that neither worker exceeded the annual DDE limit. TLD's for the workers involved have been sent to their processor and the results should be back on 3/9/09. The State of California has been informed of the event.
On March 13, 2009, the RSO notified the Agency (State) that the radiography camera had been packaged and will be returned to the manufacturer today.
Texas Incident # I-8614
UPDATE FROM ART TUCKER VIA EMAIL TO JOHN KNOKE AT 1237 0N 04/14/09
"[The State] received exposure reports for two workers involved in the source retrieval. The support individual received 299 millirem DDE, and the individual who actually retrieved the source received 502 millirem DDE, and 425 millirem calculated to the hand."
Notified FSME (Angela McIntosh) and R4DO (Jack Whitten)
* * * UPDATE ON 06/05/2009 AT 1015 FROM ART TUCKER TO VINCE KLCO * * *
Report received via e-mail:
"The [State of Texas] received the following information from the manufacturer of the source device:
"[The] license, Industrial Nuclear Company [INC], was notified by Desert Industrial X-ray that there had been a source disconnect of 97 curies, source S/N-N597 on March 5, 2009. Source and connector was received at Industrial Nuclear Co, Inc on March 13, 2009.
"Upon inspection of source connector [on] S/N- N597 that was received from Desert Industrial X-ray, INC found no evidence [of] physical damage. The cable appeared to have some stretching but not any more than would be expected after the pull test.
"Dimensions were performed on all previous inspected source assembly components and found to be within design limits.
"All INC source connector assemblies in inventory (from the same manufacturing date) were re-load tested and all passed. INC has to date never had a Source Connector come off in pre-inspection or after it was put in use. INC has not been able to discover just how this might have happened. In the report the licensee stated the connector crimp failed. INC has tried to recreate this event but [has] had no success in doing so. The licensee said the source had been in use for one week [and] if the source connector crimp was bad it should had failed on the first day.
"The licensee has not reported any additional problems associated with their exposure devices."
Notified R4DO (Lantz) and FSME EO (McIntosh)