Event Notification Report for June 03, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/02/2013 - 06/03/2013
Agreement State
Event Number: 49089
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: State: TX
County: HOUSTON
License #: 00457
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Licensee: THE METHODIST HOSPITAL
Region: 4
City: State: TX
County: HOUSTON
License #: 00457
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/04/2013
Notification Time: 13:33 [ET]
Event Date: 06/03/2013
Event Time: 00:00 [CDT]
Last Update Date: 06/14/2013
Notification Time: 13:33 [ET]
Event Date: 06/03/2013
Event Time: 00:00 [CDT]
Last Update Date: 06/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4DO)
FSME EVENT RESOURCE (EMAI)
BLAIR SPITZBERG (R4DO)
FSME EVENT RESOURCE (EMAI)
AGREEMENT STATE REPORT - SOURCE RETRACTION FAILURE
The following was received from the State of Texas via email:
"On June 3, 2013, the Agency [State of Texas] was notified by the licensee that on June 3, 2013, a medical event had occurred. The licensee reported a source retraction failure with a Novoste Beta-Cath intravascular brachytherapy system containing a 45.1 mCi strontium - 90 source. When the treatment was completed, upon source retraction, the source got stuck in another area of the blood vessel roughly 5 cm away from the treatment site for 1 minute.
"The unintended absorbed dose to that area of the vessel is in the range of 5-6 Gy. The source open in air time was roughly 3 seconds from being retracted from the patient before being secured in a bail out box. Personnel exposure issues or concerns are not expected, however, dosimeters will be assessed. A technical representative was notified and during the next several days will inspect the system and assist in packaging the system for return shipment back to the manufacturer. Additional information will be provided as it is received in accordance with SA-300."
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 FROM CHRIS MOORE TO PETE SNYDER AT 1118 EDT ON 6/14/13 * * *
The following updated information was provided from the State of Texas via email:
"The Methodist Hospital reported an equipment failure that involved a source retraction during an intravascular brachytherapy treatment performed on 6/3/2013. The intravascular brachytherapy system (Best Vascular Beta-Cath A1000 series) contained a 1.67 GBq (45.1 mCi) Sr-90 source. When the treatment was completed and upon source retraction, the source became stuck in another area of the blood vessel approximately 5 cm from the treatment site for one minute. The unintended absorbed dose to the area of the aortic arch was approximately 40 cGy at 10 mm on the wall of the arch. A technical representative was notified and will inspect the system within the next several days and assist in packaging the system for return to the manufacturer."
The State of Texas determined that this event is no longer classified a medical event and has been updated to equipment failure.
Notified R4DO (Gepford) and FSME Events Resource email.
Texas Incident #: I-9088
The following was received from the State of Texas via email:
"On June 3, 2013, the Agency [State of Texas] was notified by the licensee that on June 3, 2013, a medical event had occurred. The licensee reported a source retraction failure with a Novoste Beta-Cath intravascular brachytherapy system containing a 45.1 mCi strontium - 90 source. When the treatment was completed, upon source retraction, the source got stuck in another area of the blood vessel roughly 5 cm away from the treatment site for 1 minute.
"The unintended absorbed dose to that area of the vessel is in the range of 5-6 Gy. The source open in air time was roughly 3 seconds from being retracted from the patient before being secured in a bail out box. Personnel exposure issues or concerns are not expected, however, dosimeters will be assessed. A technical representative was notified and during the next several days will inspect the system and assist in packaging the system for return shipment back to the manufacturer. Additional information will be provided as it is received in accordance with SA-300."
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 FROM CHRIS MOORE TO PETE SNYDER AT 1118 EDT ON 6/14/13 * * *
The following updated information was provided from the State of Texas via email:
"The Methodist Hospital reported an equipment failure that involved a source retraction during an intravascular brachytherapy treatment performed on 6/3/2013. The intravascular brachytherapy system (Best Vascular Beta-Cath A1000 series) contained a 1.67 GBq (45.1 mCi) Sr-90 source. When the treatment was completed and upon source retraction, the source became stuck in another area of the blood vessel approximately 5 cm from the treatment site for one minute. The unintended absorbed dose to the area of the aortic arch was approximately 40 cGy at 10 mm on the wall of the arch. A technical representative was notified and will inspect the system within the next several days and assist in packaging the system for return to the manufacturer."
The State of Texas determined that this event is no longer classified a medical event and has been updated to equipment failure.
Notified R4DO (Gepford) and FSME Events Resource email.
Texas Incident #: I-9088
Fuel Cycle Facility
Event Number: 49087
Facility: HONEYWELL INTERNATIONAL, INC.
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: MARK ABEL
HQ OPS Officer: CHARLES TEAL
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: MARK ABEL
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/03/2013
Notification Time: 13:47 [ET]
Event Date: 06/03/2013
Event Time: 10:25 [CDT]
Last Update Date: 06/03/2013
Notification Time: 13:47 [ET]
Event Date: 06/03/2013
Event Time: 10:25 [CDT]
Last Update Date: 06/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
BRIAN BONSER (R2DO)
PETER HABIGHORST (NMSS)
BRIAN BONSER (R2DO)
PETER HABIGHORST (NMSS)
UNPLANNED MEDICAL TREATMENT
"An employee reported to the dispensary this morning with a finger laceration [at approximately] 1025 CDT. The plant nurse administered first aid and decided to send the employee to an offsite medical facility. A whole body survey of the employee in his plant clothing was performed; the maximum amount of contamination was present on his right boot, 55,039 dpm/100 cm2. Prior to leaving the Restricted Area, the employee removed all plant clothing, changed into his personal clothing, and was re-surveyed. The employee was free of contamination upon release."
The licensee notified NRC RII (Gibson).
"An employee reported to the dispensary this morning with a finger laceration [at approximately] 1025 CDT. The plant nurse administered first aid and decided to send the employee to an offsite medical facility. A whole body survey of the employee in his plant clothing was performed; the maximum amount of contamination was present on his right boot, 55,039 dpm/100 cm2. Prior to leaving the Restricted Area, the employee removed all plant clothing, changed into his personal clothing, and was re-surveyed. The employee was free of contamination upon release."
The licensee notified NRC RII (Gibson).