Event Notification Report for October 10, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/09/2013 - 10/10/2013
EVENT NUMBERS
494314943949424494254942649427
Agreement State
Event Number: 49431
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. MARY'S HOSPITAL AND MEDICAL CENTER
Region: 4
City: MONTROSE State: CO
County:
License #: CO-014-03
Agreement: Y
Docket:
NRC Notified By: JAMES H. GRICE
HQ OPS Officer: DONG HWA PARK
Licensee: ST. MARY'S HOSPITAL AND MEDICAL CENTER
Region: 4
City: MONTROSE State: CO
County:
License #: CO-014-03
Agreement: Y
Docket:
NRC Notified By: JAMES H. GRICE
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/11/2013
Notification Time: 17:38 [ET]
Event Date: 10/10/2013
Event Time: 00:00 [MDT]
Last Update Date: 10/11/2013
Notification Time: 17:38 [ET]
Event Date: 10/10/2013
Event Time: 00:00 [MDT]
Last Update Date: 10/11/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
PAMELA HENDERSON (FSME)
MICHAEL HAY (R4DO)
PAMELA HENDERSON (FSME)
AGREEMENT STATE REPORT - POTENTIAL DOSE FROM DECEASED PATIENT WITH PREVIOUSLY ADMINISTERED IODINE-131
The following was received from the State of Colorado via email:
"CDPHE [Colorado Department of Public Health and Environment] received telephone notification on 10/11/13 at approximately 2:00 p.m. of a deceased patient who had been administered 150 mCi of I-131 approximately 10-14 hours prior to his death. A male patient, 35 years of age, was administered 150 mCi of I-131 at St. Mary's Hospital and Medical Center on Wednesday October 9, 2013. The RSO at St. Mary's was notified on Thursday that the patient had passed at some point in the night of the 9th. County EMTs as well as staff from the county coroner's office were called to the scene and examined the body prior to the confirmation of death and the transport of the body to the Montrose Memorial Hospital in Montrose, Colorado.
"Section 7.22 of the Colorado Regulations require that the licensee shall notify the Department [Colorado Department of Public Health and Environment] by telephone immediately upon discovery that a patient or human research subject containing radioactive material has died, and it is possible that any individual could receive exposures in excess of 4.14 as a result of the deceased's body.
"At this time, the licensee has consulted with and performed contamination surveys of all of the members of the public who have come into contact with the deceased and has situated the body in a secluded portion of the morgue with lead aprons to reduce any potential exposure. The preliminary estimates on dose indicate that the highest dose would have been to the driver of the vehicle which was used to move the body and that dose is estimated to be 30 mrem. The pathology staff at the hospital would like to perform an autopsy since the patient was 35 years of age and was not expected to pass based on medical history.
"The Department [Colorado Department of Public Health and Environment] will keep communications open as details of the autopsy schedule are finalized and provide guidance on best practices and ALARA techniques for handling of the body.
"The licensee will submit a written report with more detail within thirty days. No other details are available at this time."
The following was received from the State of Colorado via email:
"CDPHE [Colorado Department of Public Health and Environment] received telephone notification on 10/11/13 at approximately 2:00 p.m. of a deceased patient who had been administered 150 mCi of I-131 approximately 10-14 hours prior to his death. A male patient, 35 years of age, was administered 150 mCi of I-131 at St. Mary's Hospital and Medical Center on Wednesday October 9, 2013. The RSO at St. Mary's was notified on Thursday that the patient had passed at some point in the night of the 9th. County EMTs as well as staff from the county coroner's office were called to the scene and examined the body prior to the confirmation of death and the transport of the body to the Montrose Memorial Hospital in Montrose, Colorado.
"Section 7.22 of the Colorado Regulations require that the licensee shall notify the Department [Colorado Department of Public Health and Environment] by telephone immediately upon discovery that a patient or human research subject containing radioactive material has died, and it is possible that any individual could receive exposures in excess of 4.14 as a result of the deceased's body.
"At this time, the licensee has consulted with and performed contamination surveys of all of the members of the public who have come into contact with the deceased and has situated the body in a secluded portion of the morgue with lead aprons to reduce any potential exposure. The preliminary estimates on dose indicate that the highest dose would have been to the driver of the vehicle which was used to move the body and that dose is estimated to be 30 mrem. The pathology staff at the hospital would like to perform an autopsy since the patient was 35 years of age and was not expected to pass based on medical history.
"The Department [Colorado Department of Public Health and Environment] will keep communications open as details of the autopsy schedule are finalized and provide guidance on best practices and ALARA techniques for handling of the body.
"The licensee will submit a written report with more detail within thirty days. No other details are available at this time."
Agreement State
Event Number: 49439
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA DEPARTMENT OF TRANSPORTATION
Region: 4
City: State: OK
County: WOODWARD
License #: OK-15794-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BILL HUFFMAN
Licensee: OKLAHOMA DEPARTMENT OF TRANSPORTATION
Region: 4
City: State: OK
County: WOODWARD
License #: OK-15794-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/14/2013
Notification Time: 15:16 [ET]
Event Date: 10/10/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/14/2013
Notification Time: 15:16 [ET]
Event Date: 10/10/2013
Event Time: 00:00 [CDT]
Last Update Date: 10/14/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
PAMELA HENDERSON (FSME)
FSME EVENTS RESOURCE (E-MA)
MICHAEL HAY (R4DO)
PAMELA HENDERSON (FSME)
FSME EVENTS RESOURCE (E-MA)
AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE
The following report was received from the Oklahoma Department of Environmental Quality via e-mail:
"On Oct. 10 we were informed by the Oklahoma Dept. of Transportation that one of their Troxler Model 3440 gauges (S/N 32291) had been run over at a road construction site on Hwy 412 east of Woodward, OK. The Radiation Safety Officer responded to the site that day, recovered the gauge and transported it back to their facility in Oklahoma City. Department of Environmental Quality staff inspected the gauge the next day. Although the source rod had been completely snapped off, it did not appear that either of the sealed sources had been damaged."
The following report was received from the Oklahoma Department of Environmental Quality via e-mail:
"On Oct. 10 we were informed by the Oklahoma Dept. of Transportation that one of their Troxler Model 3440 gauges (S/N 32291) had been run over at a road construction site on Hwy 412 east of Woodward, OK. The Radiation Safety Officer responded to the site that day, recovered the gauge and transported it back to their facility in Oklahoma City. Department of Environmental Quality staff inspected the gauge the next day. Although the source rod had been completely snapped off, it did not appear that either of the sealed sources had been damaged."
Power Reactor
Event Number: 49424
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAN GENEVA
HQ OPS Officer: JOHN SHOEMAKER
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAN GENEVA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/10/2013
Notification Time: 07:25 [ET]
Event Date: 10/10/2013
Event Time: 05:38 [EDT]
Last Update Date: 10/10/2013
Notification Time: 07:25 [ET]
Event Date: 10/10/2013
Event Time: 05:38 [EDT]
Last Update Date: 10/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
J LILLIENDAHL (R1DO)
J LILLIENDAHL (R1DO)
| 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 |
OFFSITE NOTIFICATION DUE TO SINGLE SIREN ACTIVATION
"At 0538 [EDT on 10/10/13], Calvert Cliffs was notified by Calvert Control Center, that a siren in the Calvert County Area was activated. [It was] determined to be siren C-15 on Lloyd Bowen Road. This is 1 of 73 sirens.
"Per [procedure] CNG-NL-1.01-1004 this is a verbal report to Calvert Control Center.
"This event is reportable as a 4 hour non emergency notification 10CFR50.72(b)(2)(xi) as: any event resulting in notification to other government agencies that has or will be made."
Heavy rains in the area are believed to have caused the siren activation. Maintenance personal have been dispatched to repair the siren.
The licensee has notified the NRC Resident Inspector.
"At 0538 [EDT on 10/10/13], Calvert Cliffs was notified by Calvert Control Center, that a siren in the Calvert County Area was activated. [It was] determined to be siren C-15 on Lloyd Bowen Road. This is 1 of 73 sirens.
"Per [procedure] CNG-NL-1.01-1004 this is a verbal report to Calvert Control Center.
"This event is reportable as a 4 hour non emergency notification 10CFR50.72(b)(2)(xi) as: any event resulting in notification to other government agencies that has or will be made."
Heavy rains in the area are believed to have caused the siren activation. Maintenance personal have been dispatched to repair the siren.
The licensee has notified the NRC Resident Inspector.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 49425
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: MATT HUMMER
HQ OPS Officer: DONG HWA PARK
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: MATT HUMMER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/10/2013
Notification Time: 14:08 [ET]
Event Date: 10/10/2013
Event Time: 08:09 [PDT]
Last Update Date: 10/18/2013
Notification Time: 14:08 [ET]
Event Date: 10/10/2013
Event Time: 08:09 [PDT]
Last Update Date: 10/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL HAY (R4DO)
MICHAEL HAY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOW PRESSURE CORE SPRAY DECLARED INOPERABLE
"At 0809 PDT on 10/10/2013, after starting Standby Service Water (SW) pumps, Columbia Generating Station (Columbia) received a flow low alarm for the Low Pressure Containment Spray (LPCS) pump motor cooling water. The flow indicator SW-FIS-19 was reported too low to support pump function. The LPCS system was declared inoperable, and the appropriate Technical Specification action statement was entered. The cause of the low flow alarm has not been determined. This event is reportable under criterion 10 CFR 50.72(b)(3)(v)(D) 'Any Event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (D) Mitigate the consequences of an accident.'
"Columbia is continuing to troubleshoot and repair as appropriate to restore the SW flow to the LPCS pump.
"The licensee has notified the NRC Resident Inspector."
* * * UPDATE ON 10/11/13 AT 1653 EDT FROM MATT HUMMER TO DONG PARK * * *
"Subsequent to receipt of the low flow alarm, flushing of the flow indicating switch sensing lines was conducted. It has been determined that the instrument sensing lines are partially blocked providing a flow indication that is slow to respond to actual flow conditions. The flow is currently reading normally. The LPCS pump was declared operable on 10/10/13 at 1447 PDT. The initial notification incorrectly stated 'Low Pressure Containment Spray (LPCS)', the correct description is 'Low Pressure Core Spray (LPCS)'."
The licensee has notified the NRC Resident Inspector.
Notified R4DO (Hay).
* * * RETRACTION FROM DAVID HOLICK TO JOHN SHOEMAKER AT 2030 EDT ON 10/18/13 * * *
"Subsequent evaluation of this event found there was no actual low flow condition to the LPCS bearing cooler. A flow scan on the SW outlet line from the LPCS pump bearing cooler was conducted on 10/12/13 which confirmed the actual flow conditions were reading normally. The problem resides in the installed flow indication switch. Since there was no actual low flow condition to the LPCS bearing cooler, the LPCS pump could perform its safety function to mitigate an accident. Therefore, this event notification is being retracted."
Notified R4DO (Azua). The licensee has notified the NRC Resident Inspector.
"At 0809 PDT on 10/10/2013, after starting Standby Service Water (SW) pumps, Columbia Generating Station (Columbia) received a flow low alarm for the Low Pressure Containment Spray (LPCS) pump motor cooling water. The flow indicator SW-FIS-19 was reported too low to support pump function. The LPCS system was declared inoperable, and the appropriate Technical Specification action statement was entered. The cause of the low flow alarm has not been determined. This event is reportable under criterion 10 CFR 50.72(b)(3)(v)(D) 'Any Event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (D) Mitigate the consequences of an accident.'
"Columbia is continuing to troubleshoot and repair as appropriate to restore the SW flow to the LPCS pump.
"The licensee has notified the NRC Resident Inspector."
* * * UPDATE ON 10/11/13 AT 1653 EDT FROM MATT HUMMER TO DONG PARK * * *
"Subsequent to receipt of the low flow alarm, flushing of the flow indicating switch sensing lines was conducted. It has been determined that the instrument sensing lines are partially blocked providing a flow indication that is slow to respond to actual flow conditions. The flow is currently reading normally. The LPCS pump was declared operable on 10/10/13 at 1447 PDT. The initial notification incorrectly stated 'Low Pressure Containment Spray (LPCS)', the correct description is 'Low Pressure Core Spray (LPCS)'."
The licensee has notified the NRC Resident Inspector.
Notified R4DO (Hay).
* * * RETRACTION FROM DAVID HOLICK TO JOHN SHOEMAKER AT 2030 EDT ON 10/18/13 * * *
"Subsequent evaluation of this event found there was no actual low flow condition to the LPCS bearing cooler. A flow scan on the SW outlet line from the LPCS pump bearing cooler was conducted on 10/12/13 which confirmed the actual flow conditions were reading normally. The problem resides in the installed flow indication switch. Since there was no actual low flow condition to the LPCS bearing cooler, the LPCS pump could perform its safety function to mitigate an accident. Therefore, this event notification is being retracted."
Notified R4DO (Azua). The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 49426
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RODGER ELLINGWOOD
HQ OPS Officer: CHARLES TEAL
Region: 2 State: SC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RODGER ELLINGWOOD
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/10/2013
Notification Time: 15:19 [ET]
Event Date: 10/10/2013
Event Time: 15:19 [EDT]
Last Update Date: 10/10/2013
Notification Time: 15:19 [ET]
Event Date: 10/10/2013
Event Time: 15:19 [EDT]
Last Update Date: 10/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MALCOLM WIDMANN (R2DO)
PART 21 GROUP (EMAI)
MALCOLM WIDMANN (R2DO)
PART 21 GROUP (EMAI)
| 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 | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
INCOMPLETE BRAZING OF CONTACTS FOR DIESEL GENERATOR CONTROL RELAY
"On August 5, 2013, annunciators were received for diesel generator (DG) 2B low lube oil inlet and outlet temperature. Investigation revealed that a control relay in motor control center cubicle 2EMXF F02D was not operating as expected. A work order was generated to replace the relay. While working the work order, a relay contact pad was found resting next to the relay. An inspection of the relay revealed that the contact pad came from the backside of the left movable contact. With the relay coil in the energized state and the contact pad missing, the relay contact would not engage. This prevented the lube oil heaters from energizing.
"The failed relay was sent to the Duke Energy Metallurgy Laboratory. It was observed that the gold brazing material was miniscule where the pad should have been attached. The laboratory observed the same brazing issue with the adjacent relay contact pads that were still attached on the failed relay. The material could barely be seen under the pads: it should have protruded out the edges for good brazing. It was determined that the overseas manufacturer of the relays had insufficiently bonded the relay contact pads to the movable contact arms for at least one known batch of relays.
"The failed relay is a Cutler-Hammer relay, Model Number 9575H3A000. The failed relay had been installed on July 30, 2013 to replace obsolete relay Model Number 9575H2612A. The replacement relay type was purchased by Duke Energy as a commercial grade item and dedicated for use in safety related applications. The failed relay batch number is 1111AF. Similar relays had been installed in the DG lube oil sump tank heater and the DG jacket water heater applications for DGs 2A and 2B. Duke Energy concluded that for these two installed applications, no substantial safety hazard existed, as DGs 2A and 2B were determined to be operable. (The heaters operate while the DGs are in standby to maintain required lube oil and jacket water temperature. Failure of these heaters to automatically start would be detected by alarms and the DGs could be started to maintain temperature. The heaters do not operate when the DGs are running.) However, because similar affected relays were in inventory, they theoretically could have been utilized in other safety related applications (even though they were not actually utilized in any other safety related applications). The most significant safety related applications where the affected relays could have been utilized were in circuitry associated with safety related ventilation system fans. Had they been utilized in these systems, a failure could have prevented the affected ventilation system fan from starting on an actuation signal. Catawba's evaluation that concluded that this issue could have resulted in a substantial safety hazard was completed on October 7, 2013. However, there was no actual impact to public health or safety. The required company officer notification was made on October 9, 2013.
"Catawba is the only Duke Energy site that had the affected relays. In addition, none of the affected relays were sold or transferred to other utilities by Duke Energy. Notifications will he made to the Catawba NRC Resident Inspector and to the required state and local agencies."
The licensee will also be notifying North and South Carolina State, York, Gaston, and Mecklenburg Counties.
"On August 5, 2013, annunciators were received for diesel generator (DG) 2B low lube oil inlet and outlet temperature. Investigation revealed that a control relay in motor control center cubicle 2EMXF F02D was not operating as expected. A work order was generated to replace the relay. While working the work order, a relay contact pad was found resting next to the relay. An inspection of the relay revealed that the contact pad came from the backside of the left movable contact. With the relay coil in the energized state and the contact pad missing, the relay contact would not engage. This prevented the lube oil heaters from energizing.
"The failed relay was sent to the Duke Energy Metallurgy Laboratory. It was observed that the gold brazing material was miniscule where the pad should have been attached. The laboratory observed the same brazing issue with the adjacent relay contact pads that were still attached on the failed relay. The material could barely be seen under the pads: it should have protruded out the edges for good brazing. It was determined that the overseas manufacturer of the relays had insufficiently bonded the relay contact pads to the movable contact arms for at least one known batch of relays.
"The failed relay is a Cutler-Hammer relay, Model Number 9575H3A000. The failed relay had been installed on July 30, 2013 to replace obsolete relay Model Number 9575H2612A. The replacement relay type was purchased by Duke Energy as a commercial grade item and dedicated for use in safety related applications. The failed relay batch number is 1111AF. Similar relays had been installed in the DG lube oil sump tank heater and the DG jacket water heater applications for DGs 2A and 2B. Duke Energy concluded that for these two installed applications, no substantial safety hazard existed, as DGs 2A and 2B were determined to be operable. (The heaters operate while the DGs are in standby to maintain required lube oil and jacket water temperature. Failure of these heaters to automatically start would be detected by alarms and the DGs could be started to maintain temperature. The heaters do not operate when the DGs are running.) However, because similar affected relays were in inventory, they theoretically could have been utilized in other safety related applications (even though they were not actually utilized in any other safety related applications). The most significant safety related applications where the affected relays could have been utilized were in circuitry associated with safety related ventilation system fans. Had they been utilized in these systems, a failure could have prevented the affected ventilation system fan from starting on an actuation signal. Catawba's evaluation that concluded that this issue could have resulted in a substantial safety hazard was completed on October 7, 2013. However, there was no actual impact to public health or safety. The required company officer notification was made on October 9, 2013.
"Catawba is the only Duke Energy site that had the affected relays. In addition, none of the affected relays were sold or transferred to other utilities by Duke Energy. Notifications will he made to the Catawba NRC Resident Inspector and to the required state and local agencies."
The licensee will also be notifying North and South Carolina State, York, Gaston, and Mecklenburg Counties.
Agreement State
Event Number: 49427
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: BAPTIST HEALTH MADISONVILLE
Region: 1
City: MADISONVILLE State: KY
County:
License #: 202-141-26
Agreement: Y
Docket:
NRC Notified By: ERIC PERRY
HQ OPS Officer: DONG HWA PARK
Licensee: BAPTIST HEALTH MADISONVILLE
Region: 1
City: MADISONVILLE State: KY
County:
License #: 202-141-26
Agreement: Y
Docket:
NRC Notified By: ERIC PERRY
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/10/2013
Notification Time: 15:38 [ET]
Event Date: 10/10/2013
Event Time: 09:30 [CDT]
Last Update Date: 10/10/2013
Notification Time: 15:38 [ET]
Event Date: 10/10/2013
Event Time: 09:30 [CDT]
Last Update Date: 10/10/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JON LILLIENDAHL (R1DO)
FSME EVENTS RESOURCE (EMAI)
JON LILLIENDAHL (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING POSSIBLE EQUIPMENT MALFUNCTION
The following was received from the Commonwealth of Kentucky via email:
"Licensee notified the Radiation Health Branch on October 10, 2013 at 0930 EDT of the possible event. The RSO, reported the following: A vaginal applicator using Cs-137 was found to be dislodged from the patient this morning. The RSO reported that the patient is paralyzed and would not have recognized the specific time that the applicator became dislodged. At this time, (1035 EDT) the RSO has received an email which requested him to provide all required notification information included in 902 KAR 100:072 section 15, has been provided a web link to the regulation, and has been provided with an information form to complete regarding the possible medical event. The RSO indicated he would provide the requested information to the Investigator by return email. The licensee is currently conducting an investigation into this matter to determine dose estimates for the patient and if there was an equipment failure."
KY Event Report ID No: KY130004
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 was received from the Commonwealth of Kentucky via email:
"Licensee notified the Radiation Health Branch on October 10, 2013 at 0930 EDT of the possible event. The RSO, reported the following: A vaginal applicator using Cs-137 was found to be dislodged from the patient this morning. The RSO reported that the patient is paralyzed and would not have recognized the specific time that the applicator became dislodged. At this time, (1035 EDT) the RSO has received an email which requested him to provide all required notification information included in 902 KAR 100:072 section 15, has been provided a web link to the regulation, and has been provided with an information form to complete regarding the possible medical event. The RSO indicated he would provide the requested information to the Investigator by return email. The licensee is currently conducting an investigation into this matter to determine dose estimates for the patient and if there was an equipment failure."
KY Event Report ID No: KY130004
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.