Event Notification Report for December 27, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/26/2013 - 12/27/2013
Agreement State
Event Number: 49680
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DEL-TIN FIBER, LLC
Region: 4
City: EL DORADO State: AR
County:
License #: ARK-0874-0312
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: DONG HWA PARK
Licensee: DEL-TIN FIBER, LLC
Region: 4
City: EL DORADO State: AR
County:
License #: ARK-0874-0312
Agreement: Y
Docket:
NRC Notified By: TAMMY KRIESEL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/30/2013
Notification Time: 12:04 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [CST]
Last Update Date: 02/06/2014
Notification Time: 12:04 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [CST]
Last Update Date: 02/06/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
FSME EVENTS RESOURCE (EMAI)
GEOFFREY MILLER (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE
The following information was received via email from Arkansas Department of Health:
"The licensee notified the [Arkansas] Department [of Health] on December 27, 2013 via email that a Ronan source holder model SA1-F37 shutter failed. The source holder serial number is M4785, and the source contains 100 mCi of Cesium-137. The problem was discovered during shutter checks. [According to the licensee], it appears the shutter handle is spinning on the shaft that rotates [to] open [and] close the shutter. [This] may be a result of a sheared pin that connects the handle to the shaft. Per the RSO, the gauge is still in use, and there have been no exposures to employees or members of the public. The RSO has notified applicable facility personnel.
"The licensee indicated the manufacturer was contacted on December 27, 2013 and repairs should be performed the week of January 6th-13th.
"The State of Arkansas is awaiting a written report after repairs. The State's event number is ARK-2013-013."
* * * UPDATE AT 0844 EST ON 02/06/14 FROM TAMMY KRIESEL TO S. SANDIN VIA EMAIL * * *
"The following updates and closes Event Number 49680.
"The manufacturer, Ronan Engineering Company, sent a report to the Arkansas Department of Health dated January 9, 2014 and received on February 5, 2014 indicating repair was completed. The root cause was a top rubber seal had 'dry rotted and allowed contaminates to seep into the shutter cavity. Over time, contaminates built up to a point of binding up the shutter.' The damaged seal was replaced and the source holder was reassembled. On January 16, 2014 a routine inspection was conducted at the facility. At the time of inspection, the gauge was functioning properly.
"The Department [Arkansas Department of Health] considers this event closed."
Notified R4DO (Azua) and FSME Events Resource (email).
The following information was received via email from Arkansas Department of Health:
"The licensee notified the [Arkansas] Department [of Health] on December 27, 2013 via email that a Ronan source holder model SA1-F37 shutter failed. The source holder serial number is M4785, and the source contains 100 mCi of Cesium-137. The problem was discovered during shutter checks. [According to the licensee], it appears the shutter handle is spinning on the shaft that rotates [to] open [and] close the shutter. [This] may be a result of a sheared pin that connects the handle to the shaft. Per the RSO, the gauge is still in use, and there have been no exposures to employees or members of the public. The RSO has notified applicable facility personnel.
"The licensee indicated the manufacturer was contacted on December 27, 2013 and repairs should be performed the week of January 6th-13th.
"The State of Arkansas is awaiting a written report after repairs. The State's event number is ARK-2013-013."
* * * UPDATE AT 0844 EST ON 02/06/14 FROM TAMMY KRIESEL TO S. SANDIN VIA EMAIL * * *
"The following updates and closes Event Number 49680.
"The manufacturer, Ronan Engineering Company, sent a report to the Arkansas Department of Health dated January 9, 2014 and received on February 5, 2014 indicating repair was completed. The root cause was a top rubber seal had 'dry rotted and allowed contaminates to seep into the shutter cavity. Over time, contaminates built up to a point of binding up the shutter.' The damaged seal was replaced and the source holder was reassembled. On January 16, 2014 a routine inspection was conducted at the facility. At the time of inspection, the gauge was functioning properly.
"The Department [Arkansas Department of Health] considers this event closed."
Notified R4DO (Azua) and FSME Events Resource (email).
Agreement State
Event Number: 49686
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: DONG HWA PARK
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/31/2013
Notification Time: 16:35 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [EST]
Last Update Date: 12/31/2013
Notification Time: 16:35 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [EST]
Last Update Date: 12/31/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - NUCLEAR MEDICINE ADMINISTERED TO WRONG PATIENT
The following Agreement State Report was received via facsimile:
"Notifications: York Hospital [a PA DEP licensee] left a voice message on Friday, December 27, 2013 after business hours; the voice message was reviewed by the South Central Regional Office on Monday, December 30, 2013. This is an immediate reporting event under 35.3045(a)(2)(iii).
"Event Description: On Friday, December 27, 2013 a nuclear medicine technologist at York Hospital injected the wrong patient with 500 microcuries (microCi) of indium-111 (ln-111) Oxine leukocyte (ln-111 Oxine WBC or ln-111 WBC). This was to be part of a radiolabeling leukocyte component procedure for another patient that was in an adjacent room. The nuclear medicine technologist noticed swelling at the injection site and notified a nurse. Physicians and patient were informed of the incident on December 27th. Additional information regarding the dimensions of the tissue volume affected by the extravasation has become available from non-nuclear imaging performed subsequent to the ln-111 WBC injection. The shallow dose to the skin was estimated to be approximately 210 rad (2.1 Gy).
"In addition, a request has been made for approval to conduct follow-up whole body imaging of the residual ln-111 in the patient's body, towards providing additional information utilizable in refining further the shallow and whole body dose estimate.
"CAUSE OF THE EVENT: Human error. The nuclear medicine technologist did not check the patient's wrist-band, nor did they correlate the name and birth date provided verbally from the wrong patient, as to being not the appropriate patient for the ln-111 WBC injection.
"ACTIONS: A reactive inspection by the PA DEP South Central Region took place on Monday, December 30th. The nuclear medicine technologist was immediately placed on administration leave by the licensee. Further investigations by PA DEP and the licensee are underway."
PA Event Report ID No: PA130030
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 Agreement State Report was received via facsimile:
"Notifications: York Hospital [a PA DEP licensee] left a voice message on Friday, December 27, 2013 after business hours; the voice message was reviewed by the South Central Regional Office on Monday, December 30, 2013. This is an immediate reporting event under 35.3045(a)(2)(iii).
"Event Description: On Friday, December 27, 2013 a nuclear medicine technologist at York Hospital injected the wrong patient with 500 microcuries (microCi) of indium-111 (ln-111) Oxine leukocyte (ln-111 Oxine WBC or ln-111 WBC). This was to be part of a radiolabeling leukocyte component procedure for another patient that was in an adjacent room. The nuclear medicine technologist noticed swelling at the injection site and notified a nurse. Physicians and patient were informed of the incident on December 27th. Additional information regarding the dimensions of the tissue volume affected by the extravasation has become available from non-nuclear imaging performed subsequent to the ln-111 WBC injection. The shallow dose to the skin was estimated to be approximately 210 rad (2.1 Gy).
"In addition, a request has been made for approval to conduct follow-up whole body imaging of the residual ln-111 in the patient's body, towards providing additional information utilizable in refining further the shallow and whole body dose estimate.
"CAUSE OF THE EVENT: Human error. The nuclear medicine technologist did not check the patient's wrist-band, nor did they correlate the name and birth date provided verbally from the wrong patient, as to being not the appropriate patient for the ln-111 WBC injection.
"ACTIONS: A reactive inspection by the PA DEP South Central Region took place on Monday, December 30th. The nuclear medicine technologist was immediately placed on administration leave by the licensee. Further investigations by PA DEP and the licensee are underway."
PA Event Report ID No: PA130030
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
Event Number: 49683
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: STERIS ISOMEDIX SERVICES, INC.
Region: 1
City: CHESTER State: NY
County:
License #: C2583
Agreement: Y
Docket:
NRC Notified By: ROBERT. DANSEREAU
HQ OPS Officer: VINCE KLCO
Licensee: STERIS ISOMEDIX SERVICES, INC.
Region: 1
City: CHESTER State: NY
County:
License #: C2583
Agreement: Y
Docket:
NRC Notified By: ROBERT. DANSEREAU
HQ OPS Officer: VINCE KLCO
Notification Date: 12/31/2013
Notification Time: 10:37 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [EST]
Last Update Date: 12/31/2013
Notification Time: 10:37 [ET]
Event Date: 12/27/2013
Event Time: 00:00 [EST]
Last Update Date: 12/31/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)
RAY MCKINLEY (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT- IRRADIATOR MALFUNCTION
The following information was received by facsimile:
"The Radiation Safety Officer reported a source rack travel event that occurred the evening of December 27, 2013. After an irradiation run, the 3 source racks in a panoramic irradiator were lowered into the pool; source rack 3 was completely lowered but source racks 2 and 1 only lowered 8 and 6 feet, respectively, below the water line causing a travel fault. MDS Nordion was immediately notified and provided guidance to Steris Isomedix staff. The highest exposure rate at the surface of the pool was 18 mR/hr. After investigation, it was determined that the pool water skimmer basket dislodged and became stuck behind source rack 1; source rack 1 pushed into source rack 2 which pushed into source rack 3. The basket was freed from the source rack using remote manipulation tools around [0100] on December 28. The highest worker exposure (from a pocket dosimeter) was less than 1 mrem. A full written report of this event including corrective actions will be submitted to the Department [New York State Department of Health]." ú
New York Event: NY-13-07
The following information was received by facsimile:
"The Radiation Safety Officer reported a source rack travel event that occurred the evening of December 27, 2013. After an irradiation run, the 3 source racks in a panoramic irradiator were lowered into the pool; source rack 3 was completely lowered but source racks 2 and 1 only lowered 8 and 6 feet, respectively, below the water line causing a travel fault. MDS Nordion was immediately notified and provided guidance to Steris Isomedix staff. The highest exposure rate at the surface of the pool was 18 mR/hr. After investigation, it was determined that the pool water skimmer basket dislodged and became stuck behind source rack 1; source rack 1 pushed into source rack 2 which pushed into source rack 3. The basket was freed from the source rack using remote manipulation tools around [0100] on December 28. The highest worker exposure (from a pocket dosimeter) was less than 1 mrem. A full written report of this event including corrective actions will be submitted to the Department [New York State Department of Health]." ú
New York Event: NY-13-07