Event Notification Report for February 10, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/09/2011 - 02/10/2011
Fuel Cycle Facility
Event Number: 46608
Facility: NUCLEAR FUEL SERVICES INC.
Region: 2 State: TN
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
NRC Notified By: RIK DROKE
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: TN
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
NRC Notified By: RIK DROKE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/11/2011
Notification Time: 13:42 [ET]
Event Date: 02/10/2011
Event Time: 17:02 [EST]
Last Update Date: 02/11/2011
Notification Time: 13:42 [ET]
Event Date: 02/10/2011
Event Time: 17:02 [EST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
GERALD MCCOY (R2DO)
DAVID PSTRAK (NMSS)
FUELS OUO GRP EMAIL
GERALD MCCOY (R2DO)
DAVID PSTRAK (NMSS)
FUELS OUO GRP EMAIL
MATERIAL CONTROL AND ACCOUNTABILITY (MC&A) ALARM RESOLUTION
"10 CFR 74.57 (f) (2) requires notification within 24 hours that an MC&A alarm resolution procedure has been initiated. In the solvent extraction area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There is no indication that a material loss has occurred.
"There were no actual or potential safety consequences to workers, the public, or the environment."
The licensee has notified NRC Region 2 and the NRC Resident Inspector.
"10 CFR 74.57 (f) (2) requires notification within 24 hours that an MC&A alarm resolution procedure has been initiated. In the solvent extraction area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There is no indication that a material loss has occurred.
"There were no actual or potential safety consequences to workers, the public, or the environment."
The licensee has notified NRC Region 2 and the NRC Resident Inspector.
Agreement State
Event Number: 46609
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: MERCY MEDICAL CENTER
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #: 0339157HDR
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: PETE SNYDER
Licensee: MERCY MEDICAL CENTER
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #: 0339157HDR
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2011
Notification Time: 13:39 [ET]
Event Date: 02/10/2011
Event Time: 00:00 [CST]
Last Update Date: 02/11/2011
Notification Time: 13:39 [ET]
Event Date: 02/10/2011
Event Time: 00:00 [CST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ERIC DUNCAN (R3DO)
KEITH McCONNELL (FSME)
ERIC DUNCAN (R3DO)
KEITH McCONNELL (FSME)
AGREEMENT STATE REPORT - LEAKING MAMOSITE BALLOON CATHETER POSSIBLY AFFECTED DOSE
The State of Iowa reported the following via email:
"The licensee reported a potential medical event that had occurred on Thursday, February 10, 2011.
"A patient was under going breast cancer treatment using a Nucletron Corporation Micro Selection High Dose Rate Afterloader (HDR). The HDR contained a 5.2 curie Iridium-192 sealed source. The patient was scheduled to receive a total dose of 3400 cGy in ten (10) fractions of 340 cGy each over a five day period. The licensee performs a CT scan on the patient before each fraction to confirm the positioning of the balloon catheter.
"On the morning of Thursday, February 10, 2011 the patient arrived for the seventh fraction. The licensee's CT scanner was not operable at the time so the Authorized User (AU) (Radiation Oncologist) imaged the patient using ultrasound. The AU noticed at the time that the patient had some drainage from the surgical incision but the results of the ultrasound appeared [to show] that the balloon catheter was correctly placed. The patient then received the seventh fraction. When the patient returned for the eighth fraction in the afternoon of the 10th the licensee's CT scanner was operable. This scan showed that the balloon catheter had completely leaked out all of the fluid. The AU and Medical Physicist made the decision to not perform the eighth fraction due to the possibility that the patient may have received a double dose (680 cGy) during the previous fraction.
"The patient, referring physician and surgeon were then notified. The surgeon removed the leaking balloon catheter and replaced it with a new catheter. The patient completed fraction nine on the morning of Friday, February 11, 2011 and is scheduled for fraction ten and treatment completion in the afternoon of the 11th.
"The AU and Medical Physicist do not believe that this event will result in any adverse complications to the health of the patient. The licensee will continue to investigate this event and provide a written report to IDPH within 15 days of the occurrence."
Iowa Item Number: IA110001
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 State of Iowa reported the following via email:
"The licensee reported a potential medical event that had occurred on Thursday, February 10, 2011.
"A patient was under going breast cancer treatment using a Nucletron Corporation Micro Selection High Dose Rate Afterloader (HDR). The HDR contained a 5.2 curie Iridium-192 sealed source. The patient was scheduled to receive a total dose of 3400 cGy in ten (10) fractions of 340 cGy each over a five day period. The licensee performs a CT scan on the patient before each fraction to confirm the positioning of the balloon catheter.
"On the morning of Thursday, February 10, 2011 the patient arrived for the seventh fraction. The licensee's CT scanner was not operable at the time so the Authorized User (AU) (Radiation Oncologist) imaged the patient using ultrasound. The AU noticed at the time that the patient had some drainage from the surgical incision but the results of the ultrasound appeared [to show] that the balloon catheter was correctly placed. The patient then received the seventh fraction. When the patient returned for the eighth fraction in the afternoon of the 10th the licensee's CT scanner was operable. This scan showed that the balloon catheter had completely leaked out all of the fluid. The AU and Medical Physicist made the decision to not perform the eighth fraction due to the possibility that the patient may have received a double dose (680 cGy) during the previous fraction.
"The patient, referring physician and surgeon were then notified. The surgeon removed the leaking balloon catheter and replaced it with a new catheter. The patient completed fraction nine on the morning of Friday, February 11, 2011 and is scheduled for fraction ten and treatment completion in the afternoon of the 11th.
"The AU and Medical Physicist do not believe that this event will result in any adverse complications to the health of the patient. The licensee will continue to investigate this event and provide a written report to IDPH within 15 days of the occurrence."
Iowa Item Number: IA110001
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.