Event Notification Report for November 30, 2010

AGREEMENT STATE REPORT - BADGE EXPOSURE EXCEEDING 5 REM ANNUAL DOSE LIMIT

The following was received from the State of Oregon via email:

"Oregon Radiation Protection Services was notified by phone on January 19, 2011 at 1119 PDT, a representative of Good Samaritan Regional Medical Center, of a whole body (collar) badge report for the wear period of November 1-30, 2010 that exceeded the 5 rem dose limit. The monthly badge report was received by the licensee sometime after December 28, 2010 for an authorized user showing monthly/quarterly/annual dose as follows:

"Monthly (Nov 2010):
DDE, LDE = 5230 mrem
SDE = 5032 mrem

"Quarterly (4Q2010):
DDE, LDE = 5290 mrem
SDE = 5091 mrem

"Annual (2010) and Lifetime (hired in 2010):
DDE, LDE = 5376 mrem
SDE = 5175 mrem

"The vendor (Landauer) performed a second read of the dosimeter that agreed with the reported doses above and stated that the imaging indicated an 'irregular exposure.' The authorized user stored his badge and ring in a 'cubby' along with his lab jacket.

"On January 24th, the licensee emailed Oregon RPS with results from the licensee's investigation stating that the badge user was a student on rotation to the nuclear medicine dept. for the month of November. The user's previous WB badge results were 'normal' and no other nuclear medicine worker received a high dose reading during November. The student was '100% supervised' and is described as 'very conscientious about spills or drops.' Regardless, the licensee determined after eliminating several factors, that contamination was the most probably factor since the collar badge result was higher than the user's finger ring (4480 mrem SDE November, 5220 mrem SDE for 2010) and 'irregular exposure' noted by the dosimetry vendor. It remains unknown what isotope caused the overexposure and any Tc-99m has decayed to background. Surveys of the cubby and lab jacket were performed with negative results. In addition, the licensee stated that no 'large' iodine doses were administered for November. Remedial actions were not noted on the report.

"On July 16, 2013, a review was performed of this incident and it was discovered that it was not reported to the US NRC HOO as per the NRC's Reporting Material Events (SA-300), Appendix A. The specific requirement is 10 CFR 20.2203(a) which states, in part, that radiation doses that exceed the regulatory requirements (5 rem) are to be reported (30 day requirement). The licensee was e-mailed for any remedial actions taken after this event.

"On July 19, the licensee responded by e-mail stating that without a definitive cause for the overexposure, no change in procedure was instituted except heightened awareness of badge placement/location. The report was written and submitted via e-mail to the HOO on this same date.

"Oregon Radiation Protection Services noted on the Incident report that US NRC Operations Center was to be notified but this was not done."

State Event Number: OR-11-0004

LOSS OF POWER TO INSTRUMENTATION IN THE OPERATING UNITS OF THE FEED MATERIALS BUILDING

"Description of the Event: This report is performed pursuant to 10 CFR 40.60(b)(2) reporting requirements.

"On Tuesday, November 30, 2010, at approximately 0500, the failure of F-Substation caused a loss of instrumentation in operating units in the Feed Materials Building. At 0505, various weight, temperature and pressure indications were not available.

"Due to the loss of power to a load cell component, the UF6 Vaporizer weight exceeded the administrative limit. During the power loss the vessel's weight measurement was not available to the operator.

"At 0538, power was restored and instrumentation readings returned to normal. The loss of the Vaporizer weight control did not have any safety consequences.

"Isotope, Quantities and Chemical Form: No material release.

"Personnel Radiation Exposure Date (if applicable): No additional exposure to radiation or radioactive materials."

The licensee will inform the NRC Region II Office.

* * * RETRACTION FROM MICHAEL GREENO TO JOE O'HARA AT 1659 ON 12/20/10 * * *

"On December 1, 2010, Honeywell Metropolis Works made notification of Event #46444 to the NRC Operations Center. This November 30, 2010 incident occurred due to the loss of power to a load cell component. During the power loss the weight measurement was not available to the operator, and the UF6 Vaporizer weight exceeded the administrative limit.

"This twenty-four hour report was made following 10 CFR 40.60(b)(2) reporting requirements:

"Each licensee shall notify the NRC within 24 hours after the discovery of any of the following events involving licensed material: ...

"(2) An event in which equipment is disabled or fails to function as designed when:
(i) The equipment is required by regulation or license condition to prevent releases exceeding regulatory limits, to prevent exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the consequences of an accident;
(ii) The equipment is required to be available and operable when it is disabled or fails to function; and
(iii) No redundant equipment is available and operable to perform the required safety function.

"As determined by Honeywell's safety analysis, potential UF6 release may occur due to failure to control process resulting in process vessel failure. UF6 Vaporizer load cells, which are identified in the safety analysis as a safety feature to control the total weight in this vessel, were not operable during the incident. However, load cells are not the only component designed to perform the equivalent safety function - to prevent UF6 Vaporizer failure. Thus, UF6 Vaporizer failure due to over-pressurization is prevented by the existing relief system which is designed to relieve at a pressure below the maximum allowable working pressure. This Vaporizer relief system was available and operable during the event.

"As a result of these additional considerations, Honeywell determined that the redundant equipment (Vaporizer relief system) was available and operable to perform the required safety function (Vaporizer failure prevention), and therefore the initially reported incident (# 46444) does not meet the reporting requirement (iii). Since this incident does not constitute a reportable event, Honeywell requests to withdraw its event notification #46444."

Notified R2DO(Henson) and NMSS EO(Davis)

AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSES

This information was emailed by the state as follows:

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. During a recent routine inspection, DHS determined that in response to the Information Notice, this licensee was reviewing medical records of several patients who may have received doses during prostate brachytherapy that were less than intended. On November 30, 2010, the licensee's Radiation Safety Officer reported the preliminary identification of one medical event. On December 20, 2010, the licensee's 15-day written report included information on this event, plus an additional two medical events. The doses delivered are D90 values based on CT scans performed thirty days post-surgery.

Treatment Date Isotope Prescription Dose Delivered Percentage
6/17/2008 Pd-103 125 Gy to prostate 97.4 Gy to prostate 77.9%
8/24/2009 I-125 145 Gy to prostate 107.9 Gy to prostate 74.4%
9/02/2009 I-125 145 Gy t0 prostate 93.05 Gy to prostate 64.2%


"The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patients and referring physicians. The licensee stated that the events occurred due to clinical limitations of the interstitial prostate brachytherapy implant technique. The licensee made process improvements (i.e. planning to D90 of 115% of the prescribed dose) which have resulted in unproved dosimetric coverage. DHS inspectors performed a reactive inspection and will follow up on the next inspection."

Event Report ID No.: WI100018


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.