Event Notification Report for December 10, 2010

MEDICAL EVENT - TREATMENT AREA DIFFERENT FROM THE PRESCRIBED AREA

A High Dose Rate brachytherapy treatment with a 5.11 Ci source of Ir-192 was performed on a patient for vaginal cancer. The prescribed procedure was for a tube be inserted into the vaginal area for 120 cm, however, the treatment length of insertion was 132 cm. This was an out-patient procedure, so the patient went home after her treatment. The physician will be notifying the patient of the 12 cm insertion error.

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.

* * * UPDATE AT 1610 EST ON 12/15/2010 FROM BRETT MILLER TO MARK ABRAMOVITZ * * *

The brachytherapy exposure was received by four patients with the 12 cm insertion error. Three patients received three fractions each and the fourth received five fractions. The physicians have been notified except for the fourth patient's physician who will be notified.

Notified the R3DO (Kazak) and FSME (O'Sullivan).

STRUCTURAL STEEL BEAM FAULTS

The following information was received by facsimile:

"Several W16 x 67 [structural steel] beams have been discovered with a longitudinal crack in the web of the beam. The crack appears to run intermittently down the entire length of the beam. Each of the beams were found to be from the same heat (22536130).

"Procurement was notified and indicated that [Hirschfeld] purchased 15- 50 feet beams with this heat number. The location of all pieces of this heat were located. It was determined that some were in [the Hirschfeld] shop, some were at the fireproofer and three pieces had been delivered to the site [Eunice, NM] but were not erected. Arrangements have been [made] to have all pieces returned to [the Hirschfeld] facility. Customer, Baker Concrete Construction (National Enrichment Facility, Eunice, NM) has been notified as has the supplier of the steel, Gerdau Ameristeel, Midlothian, TX."

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LOCKING DEVICE FAILURE RESULTING IN PERSONNEL EXPOSURE

"On December 17, 2010, the Agency [Texas Department of Health Services] was notified by the licensee that on December 10, 2010, the locking device on QSA model 880 camera containing 97 curies of Iridium (Ir) 192 failed to activate. The radiography crew (group A) had completed operations at one site near Lufkin, Texas, and was moving to a new location at the same site. The radiography camera with the cranking device and guide tube still attached were placed in the dark room of the radiographers' truck. The licensee stated that a survey was conducted to verify the source was in the fully shielded, locked position. As the radiographer was driving to the new location, he passed about 5 feet from another group of radiographers (group B) from the same licensee. As group A passed by group B, group B's dosimeters alarmed. Group B stopped group A and told them that their alarms had gone off. Group A went to the camera, picked up the crank for the camera, and found that the source had moved from the locked position approximately one quarter of a turn. The radiographer cranked the source back to the fully shielded position and secured the camera for transportation.

"The radiographers did not inform the licensee of the event until December 16, 2010. At that time, the licensee began an investigation of the event, including reenactments of the event to determine how much dose the radiographers had received. During the investigation, it was discovered that both radiographer's self reading pocket dosimeters had been read after the camera was secured and were reading off scale. The licensee determined that radiographers 'A' were eight feet from the source while they were driving and would have been exposed to the source for approximately 10 minutes. A dose estimate of 1,700 millirem was made for both individuals. The thermoluminescent dosimeters for radiographers 'A' have been sent to the processor for reading. The licensee stated they expected the readings by late Monday December 20. The licensee stated that several pieces of radiography film were lying on the seat of the truck when the event occurred. The film was developed and indicated that it had been exposed to approximately 1,700 millirem. The licensee stated that neither radiographer would have received enough exposure to exceed any limit. The licensee stated that no member of the general public was exposed to any radiation as a result of this event.

"The licensee has not inspected the camera. The licensee stated that the camera is out of service and is currently stored in their storage facility. Additional information has been requested of the licensee. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #I-8803

* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA E-MAIL AT 1203 EST ON 1/18/11 * * *

"On December 23, 2010, the Agency [Texas Department of Health Services] performed an on-site investigation at the licensee's facility. The investigation determined that the camera did not fail to operate properly, but that the operator failed to fully retract and lock the source in place."

* * * RETRACTION RECEIVED VIA EMAIL FROM A. TUCKER TO J. SHOEMAKER AT 0856 EST ON 2/1/11 * * *

"This event was initially reported as a failure of the locking device on a radiography camera. The investigation into the event determined that it was caused by operator error and not a failure of the equipment to operate as designed."

Notified R4DO(Howell) and FSME(McIntosh).