Event Notification Report for January 05, 2012

MEDICAL UNDEREXPOSURE TO TARGET AREA USING HIGH DOSE RATE AFTERLOADER DEVICE

The licensee reported that a patient received only about 10% of the required dose to the target area during a treatment for esophageal cancer. The prescribed dose for the esophageal region was 700 centigray. The area was being treated with a Varian High Dose Rate Brachytherapy Afterloader device using a 6.344 Curie Ir-192 source. The location of the source is normally tracked by a radiographically opaque image near the source. In this case, the end of the catheter also appeared somewhat radiographically opaque and was mistaken for the source location. Consequently, the source was mispositioned about 4 cm back from the intended target area resulting in the underexposure.

The physician and patient have been notified and no health effects are anticipated from the area that was unintentionally exposed due to the mispositioning of the source.

* * * UPDATE AT 1345 EST ON 01/18/12 FROM KARI CANN TO S. SANDIN * * *

The licensee is continuing their review of this incident and have determined that the source may have been mispositioned by as much as 29 cm back from the intended target area. This may have resulted in excessive exposure to portions of the upper neck and back of the patient. A physician has scheduled an anatomical examination of the patient tomorrow to assess if there are any adverse effects related to the treatment. NRC Region IV Inspectors are currently on-site.

Notified R4DO (Pick) and FSME (McIntosh).

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.

AGREEMENT STATE REPORT INVOLVING CONTAMINATION FROM A SUSPECTED BROKEN EXIT SIGN

The following information was provided by the Commonwealth of Massachusetts via email:

"Large area swipes reading up to 14,000 DPM H-3 were found in the loading dock area. No cause is known. Activity is distributed evenly on the floor and walls so airborne deposition is suspected. Current theorized cause is a broken exit sign.

"Licensee has evacuated unnecessary personnel from loading dock and is trying to find the extent of contamination.

"Since a broken exit sign could cause a release over 5 ALI, immediate notification was given to NRC over the phone."
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AGREEMENT STATE REPORT INVOLVING DETECTION OF CONTAMINATED MATERIAL

The following information was received from the State of California via email:

"Two [2] packages set off radiation alarms at Truckee, CA truck scales. Both packages indicated Cobalt 60. One package read 5.7 mr/hr and the other indicated 6.1 mr/hr using a Victoreen 450 CHP. The packages were enroute to Bed Bath and Beyond in Santa Clara and San Jose.

"The shipment was authorized to proceed in a separate trailer to the Sacramento [the shippers] yard at 8200 Elder Creek Road where the shipment will be secured awaiting RHB inspector to determine the contents and disposition of the material. Surveys were requested of the CHP to document ALARA during this shipment.

"Shipment contained four Model DR9M Dual Ridge Metal Boutique (Kleenex box holders). Contact reading 6.5 mr/hr, One foot 0.85 mr/hr with a Victoreen 450P ion chamber."

The shipment originated in India with a port of entry at Newark, NJ and was shipped via common carrier to its final destination in California.

CA 5010 #: 010512

AGREEMENT STATE REPORT INVOLVING A FIXED GAUGE WITH A STUCK SHUTTER

The following information was received from the State of Texas via email:

"On January 6, 2012 the Agency [Texas Department of Health] was notified by the licensee that while conducting routine maintenance check, the shutter on an Ohmart/Vega model SH-F2 was found stuck in the open position. The gauge contains 375 millicuries of cesium - 137. Open is the normal operating position for the gauge. The gauge does not pose an increased exposure hazard to the general public or to their workers. The licensee is contacting the manufacturer for repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-8917

SODIUM HYPOCHLORITE LEAK RESULTED IN AIRBORNE CONCENTRATIONS POTENTIALLY DANGEROUS TO LIFE AND HEALTH

"A section of piping between sodium hypochlorite tanks[tanks 121 and 122] broke and resulted in a unisolable leak in one of the tanks. The spill was contained within the berm of the chlorine house.

"The spill resulted in airborne concentrations exceeding Immediately Dangerous to Life and Health (IDLH) conditions in the chlorine house, which is contiguous to the plant screen house.

"Alert declared based upon HA3.1 - Report or detection of toxic gases within or contiguous to Table H-1 areas in concentrations that may result in an atmosphere Immediately Dangerous to Life and Health (IDLH)."

The licensee will remain in the Alert until IDLH conditions have been terminated. An offsite HAZMAT team has been notified and is expected to be on-site today at 0630 CST to clean up the spill.

The licensee will notify the Resident Inspectors.

* * * UPDATE FROM JOHN DUBOSE TO VINCE KLCO AT 0932 EST ON 1/5/2021 * * *

The licensee reports that the HAZMAT contractor has arrived on-site. Licensee personnel are preparing a clearance for the sodium hypochlorite system in order to support HAZMAT contractor work. The licensee will notify the NRC Resident Inspector.

Notified the R3DO (Valos)

* * * UPDATE FROM DARRELL LAPCINSKI TO CHARLES TEAL AT 1634 EST ON 1/5/2012 * * *

"The Alert declaration due to HA3.1, Report or detection of toxic gases within or contiguous to Table H-1 areas in concentrations that may result in an atmosphere Immediately Dangerous to Life and Health (IDHL):

"Prairie Island terminated from the Alert declaration at 1408 CST on Jan 5, 2012.

"The following additional conditions were established prior to termination:

1. The permanent berm containing the sodium hypochlorite released by 121 Sodium Hypochlorite Tank piping break was pumped down.
2. Clean-up and remediation of the affected area is in progress.
3. Inspection of the unaffected sodium hypochlorite tank piping has been conducted to ensure satisfactory integrity.

"NRC Resident has been informed."

Notified NRR EO (Ruland), R3DO (Valos), IRD (Morris), DHS (Beach), FEMA (Blankenship), DOE (Jackson), USDA (Timmons), and HHS (Fajardo).

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

At 10:45 a.m. today, 1/05/12, the [NJ] Bureau of Environmental Radiation (BER) received a call from the RSO for Nova QA Consulting to report that one of his inspector's car was stolen in front of the client's facility in Orange, NJ this morning between 09:30 and 10:00 a.m. In the locked car was a Troxler Model 4640 serial #2375 with less than 9 mCi of Cs-137. His inspector called the Orange police and the RSO is also in communication with the Orange police. At 11:05 a.m. the RSO said that he will call Trenton Dispatch. Trenton Dispatch called the BER at 11:25 a.m.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - MEDICAL RADIATION TREATMENT EXPOSURE TO WRONG TREATMENT SITE

The following report was received from the State of North Carolina via email:

"A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192.

"The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected.

"The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered.

"The patient was informed of the event, and received a correct third treatment as well as external beam therapy.

"Additional information will be provided as it is provided by the licensee."

The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up.

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.

TEXAS AGREEMENT STATE REPORT - POTENTIAL PROSTATE THERAPY UNDERDOSE

"On November 16, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that a potential medical event occurred. On January 5, 2012, a patient received an Iodine-125 prostate seed implant of 63 seeds (0.475 mCi/seed). The implant was completed as planned and verification films were taken and confirmed that the implant appeared normal and no concerns were expressed during or immediately after the implant procedure. In late August or early September, a post plan was created for evaluation. 63 seeds were localized by a staff physicist and sometime after or during the post plan analysis, the staff physicist noticed the seed placement appeared inconsistent with the pre-plan. The staff physicist informally notified the Chief Physicist and a Senior Radiation Oncologist who each viewed the plan and concluded that further evaluation was needed. The implant appeared shifted inferior to the prostate. The final determination is that all of the parameters of the implant (activity per seed, total activity, seed distribution, etc.) were all consistent with the pre-plan except that the center of the seed distribution and the center of the prostate were separated by a couple of centimeters and the most inferior seed was approximately 3.5 cm inferior to the apex of the prostate. The licensee has been contacted to report prescribed dose, actual dose, and percent of dose received. Additional information will be provided IAW SA-300."

Texas Incident# I-9014

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.