Event Notification Report for January 26, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/25/2011 - 01/26/2011
Agreement State
Event Number: 46579
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County: MIDDLESEX
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: JOHN SHOEMAKER
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County: MIDDLESEX
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSH DAEHLER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/01/2011
Notification Time: 10:07 [ET]
Event Date: 01/26/2011
Event Time: 00:00 [EST]
Last Update Date: 02/04/2011
Notification Time: 10:07 [ET]
Event Date: 01/26/2011
Event Time: 00:00 [EST]
Last Update Date: 02/04/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)
JAMES DWYER (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT
The following Agreement State Report was received via fax:
"The Radiation Safety Officer of QSA Global, Inc. reported the following information on February 2, 2011, to the Massachusetts Radiation Control Program:
"On Wednesday, January 26, 2011, QSA shipped a radioactive [High Dose Rate] HDR source to Memorial Hospital SW Cancer Center in Houston, TX. It was scheduled to deliver on Friday, January 28. On Monday, January 31, the [common carrier] tracking website still showed it as 'At destination sort facility' in Houston, TX. [The common carrier] was called to track the package, and we [QSA Global, Inc.] were told that it was actually still in Memphis, TN. A trace was requested. The [common carrier] trace number is [redacted]. [The common carrier] said they would inform us with any new information. As of this morning, Tuesday, February 1, there was no news, so [the common carrier] was called. We were informed that the package was indeed LOST. We gave [the common carrier] a physical description of the package, and informed them of the importance of locating this package due to the fact that it was radioactive. They will call with any results.
"The specifics of the package are as follows:
Isotope - Ir-192
Activity - 10.951 Ci / 405.2. GBq
Container s/n - 81C6
Source s/n - D36C-6084
Surface reading - 26.0 mr/hr
Transport Index - 0.4"
* * * UPDATE VIA FAX FROM JOHN SUMARES TO DONALD NORWOOD AT 1417 EST ON 2/4/2011 * * *
"On February 3, 2011, the licensee notified the Agency [Massachusetts Radiation Control Program] that the missing / lost shipment was found. The licensee reported that the shipment was never actually lost. It had been delivered to the hospital on 1/27/11 under a different air way bill number and the licensee was not aware of the new number. On February 4, 2011, the Agency asked the licensee for the new air way bill number, received the new number from the licensee, and used the [common carrier] tracking system to confirm the shipment was received on January 27, 2011."
Notified R1DO (Dwyer) and FSME EO (Villamar).
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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
The following Agreement State Report was received via fax:
"The Radiation Safety Officer of QSA Global, Inc. reported the following information on February 2, 2011, to the Massachusetts Radiation Control Program:
"On Wednesday, January 26, 2011, QSA shipped a radioactive [High Dose Rate] HDR source to Memorial Hospital SW Cancer Center in Houston, TX. It was scheduled to deliver on Friday, January 28. On Monday, January 31, the [common carrier] tracking website still showed it as 'At destination sort facility' in Houston, TX. [The common carrier] was called to track the package, and we [QSA Global, Inc.] were told that it was actually still in Memphis, TN. A trace was requested. The [common carrier] trace number is [redacted]. [The common carrier] said they would inform us with any new information. As of this morning, Tuesday, February 1, there was no news, so [the common carrier] was called. We were informed that the package was indeed LOST. We gave [the common carrier] a physical description of the package, and informed them of the importance of locating this package due to the fact that it was radioactive. They will call with any results.
"The specifics of the package are as follows:
Isotope - Ir-192
Activity - 10.951 Ci / 405.2. GBq
Container s/n - 81C6
Source s/n - D36C-6084
Surface reading - 26.0 mr/hr
Transport Index - 0.4"
* * * UPDATE VIA FAX FROM JOHN SUMARES TO DONALD NORWOOD AT 1417 EST ON 2/4/2011 * * *
"On February 3, 2011, the licensee notified the Agency [Massachusetts Radiation Control Program] that the missing / lost shipment was found. The licensee reported that the shipment was never actually lost. It had been delivered to the hospital on 1/27/11 under a different air way bill number and the licensee was not aware of the new number. On February 4, 2011, the Agency asked the licensee for the new air way bill number, received the new number from the licensee, and used the [common carrier] tracking system to confirm the shipment was received on January 27, 2011."
Notified R1DO (Dwyer) and FSME EO (Villamar).
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
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
Agreement State
Event Number: 46574
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSON CLINIC, LTD
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: GUNDERSON CLINIC, LTD
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/27/2011
Notification Time: 15:43 [ET]
Event Date: 01/26/2011
Event Time: 00:00 [CST]
Last Update Date: 01/27/2011
Notification Time: 15:43 [ET]
Event Date: 01/26/2011
Event Time: 00:00 [CST]
Last Update Date: 01/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANN MARIE STONE (R3DO)
RICHARD TURTIL (FSME)
ANN MARIE STONE (R3DO)
RICHARD TURTIL (FSME)
AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MEDICAL UNDERDOSE
The following report was received via fax:
"On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS [Wisconsin Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients.
"Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%.
"Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%.
"Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%.
"DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report."
Wisconsin Report Number: WI110003
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 report was received via fax:
"On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS [Wisconsin Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients.
"Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%.
"Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%.
"Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%.
"DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report."
Wisconsin Report Number: WI110003
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.
Power Reactor
Event Number: 46571
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LEWIS A. ROUSE
HQ OPS Officer: STEVE SANDIN
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LEWIS A. ROUSE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/26/2011
Notification Time: 09:36 [ET]
Event Date: 01/26/2011
Event Time: 08:30 [EST]
Last Update Date: 01/26/2011
Notification Time: 09:36 [ET]
Event Date: 01/26/2011
Event Time: 08:30 [EST]
Last Update Date: 01/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (R2DO)
MARVIN SYKES (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SUPPORT CENTER UNAVAILABLE DUE TO PLANNED MAINTENANCE
"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance being performed on TSC support systems. Alternate facilities are available to provide emergency response functions and actions are proceeding to return the TSC to FUNCTIONAL status with high priority. A 10CFR50.54 (q) evaluation has been performed for this planned maintenance activity.
"The NRC Resident Inspector has been notified."
* * * UPDATE AT 2245 EST ON 1/26/11 FROM WESLEY GRANT TO MARK ABRAMOVITZ * * *
TSC maintenance has been completed and testing was performed. The TSC has been returned to service.
The licensee will inform the NRC Resident Inspector.
Notified the R2DO (Desai).
"A condition is being reported per Technical Requirements Manual 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance being performed on TSC support systems. Alternate facilities are available to provide emergency response functions and actions are proceeding to return the TSC to FUNCTIONAL status with high priority. A 10CFR50.54 (q) evaluation has been performed for this planned maintenance activity.
"The NRC Resident Inspector has been notified."
* * * UPDATE AT 2245 EST ON 1/26/11 FROM WESLEY GRANT TO MARK ABRAMOVITZ * * *
TSC maintenance has been completed and testing was performed. The TSC has been returned to service.
The licensee will inform the NRC Resident Inspector.
Notified the R2DO (Desai).