Event Notification Report for November 21, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/20/2014 - 11/21/2014
Agreement State
Event Number: 50634
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: WICHITA FALLS State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: JOHN SHOEMAKER
Licensee: DESERT NDT LLC
Region: 4
City: WICHITA FALLS State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/22/2014
Notification Time: 10:07 [ET]
Event Date: 11/21/2014
Event Time: 00:00 [CST]
Last Update Date: 11/22/2014
Notification Time: 10:07 [ET]
Event Date: 11/21/2014
Event Time: 00:00 [CST]
Last Update Date: 11/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BOB HAGAR (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
BOB HAGAR (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA FAILED TO OPERATE PROPERLY
The following was received via email from the State of Texas:
"On November 21, 2014, the Agency [Texas Department of State Health Services] was notified by the licensee that an INC IR100 radiography camera, serial #4386, with an iridium-192 source, model 32, serial #W957, activity - 1554 GBq (42 Ci) failed to operate properly at a field site. The technician had an indication that the source was fully inside the camera when the flag indicator changed, however they were unable to disconnect the drive cable from the pig tail. The pig tail was not fully inside the camera. The licensee's RSO [Radiation Safety Officer] responded to the scene to inspect and retrieve the source. [The RSO] moved the source to another camera. The [RSO determined the] locking mechanism had worn out on the camera. No individual received any significant additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Report: # I 9255
The following was received via email from the State of Texas:
"On November 21, 2014, the Agency [Texas Department of State Health Services] was notified by the licensee that an INC IR100 radiography camera, serial #4386, with an iridium-192 source, model 32, serial #W957, activity - 1554 GBq (42 Ci) failed to operate properly at a field site. The technician had an indication that the source was fully inside the camera when the flag indicator changed, however they were unable to disconnect the drive cable from the pig tail. The pig tail was not fully inside the camera. The licensee's RSO [Radiation Safety Officer] responded to the scene to inspect and retrieve the source. [The RSO] moved the source to another camera. The [RSO determined the] locking mechanism had worn out on the camera. No individual received any significant additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Report: # I 9255
Agreement State
Event Number: 50818
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RESURRECTION MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01034-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Licensee: RESURRECTION MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01034-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/13/2015
Notification Time: 10:43 [ET]
Event Date: 11/21/2014
Event Time: 00:00 [CST]
Last Update Date: 02/13/2015
Notification Time: 10:43 [ET]
Event Date: 11/21/2014
Event Time: 00:00 [CST]
Last Update Date: 02/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PATTY PELKE (R3DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
PATRICIA MILLIGAN (EMAI)
PATTY PELKE (R3DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
PATRICIA MILLIGAN (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING HIGH DOSE RATE AFTERLOADER
The following information was obtained from the State of Illinois via email:
"Licensee reported that while following up with a patient who had undergone radiation treatments following surgical removal of a breast tumor, redness, pain and swelling were occurring near the catheter insertion site. It was determined that the intended dose had been delivered with the connector end of the applicator interface identified as the reference location instead of the tip of the applicator as planned in the treatment. As a result, the 10 fractions of 340 cGy each were offset by over 4 cm for all the dwell positions within the applicator. The treatments were conducted with a strut adjusted volume implant (SAVI) applicator following an accelerated partial breast irradiation treatment regime. The catheter insertion site is estimated as having received a dose of over 13,000 R. The patient received medical treatment for the damaged tissue which would not heal. The Agency [Illinois Emergency Management Agency] is conducting an investigation into the matter to determine if the event is isolated or if other similar treatments may have had associated errors. Additional precautions have been taken by the licensee to prevent future occurrences including changing treatment planning systems, implementing additional quality assurance procedures and involving additional personnel to verify plans before treatment commences.
"This event was reported to the US NRC Operations Center on February 13, 2015 and assigned event number 50818.
"This item remains open pending additional investigation results."
The HDR source was 6.95 Ci of Ir-192. As a result of the damage to the tissue, a mastectomy was performed.
IL Report Number: IL15001
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 information was obtained from the State of Illinois via email:
"Licensee reported that while following up with a patient who had undergone radiation treatments following surgical removal of a breast tumor, redness, pain and swelling were occurring near the catheter insertion site. It was determined that the intended dose had been delivered with the connector end of the applicator interface identified as the reference location instead of the tip of the applicator as planned in the treatment. As a result, the 10 fractions of 340 cGy each were offset by over 4 cm for all the dwell positions within the applicator. The treatments were conducted with a strut adjusted volume implant (SAVI) applicator following an accelerated partial breast irradiation treatment regime. The catheter insertion site is estimated as having received a dose of over 13,000 R. The patient received medical treatment for the damaged tissue which would not heal. The Agency [Illinois Emergency Management Agency] is conducting an investigation into the matter to determine if the event is isolated or if other similar treatments may have had associated errors. Additional precautions have been taken by the licensee to prevent future occurrences including changing treatment planning systems, implementing additional quality assurance procedures and involving additional personnel to verify plans before treatment commences.
"This event was reported to the US NRC Operations Center on February 13, 2015 and assigned event number 50818.
"This item remains open pending additional investigation results."
The HDR source was 6.95 Ci of Ir-192. As a result of the damage to the tissue, a mastectomy was performed.
IL Report Number: IL15001
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.