Event Notification Report for March 16, 2016

TEXAS AGREEMENT STATE REPORT - PACKAGE CONTAINING SOURCES LOST THEN FOUND

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

"The Agency [Texas Department of State Health Services] was notified by a manager for a common carrier of radioactive material that a package had fallen out of the transport vehicle. The package was found by a member of the public on a highway [when he] swerved to miss hitting the package. The person collected the package and called the number on the package. The number was to the manufacturer of the source. The radiation safety officer (RSO) for the company met the member of the public to collect the package. The RSO completed a survey of the package and performed leak testing. The container was a type B package containing two Ir-192 sources, SN29629G and 29630G, joint activity of 8,188.8Gbq (>100 curies each) with transport index of 1.2. The package outer shipping box was damaged although the type B container was in good condition and was not leaking. The sources are currently at the manufacturer's location in storage. The sources were enroute to the manufacturer's Baton Rouge location when the container fell out of the transport vehicle onto the freeway. The details of the time frame the member of the public had the package in their possession is being confirmed and details of the time the package was on the freeway is being acquired. Investigation into this event is ongoing and details will be provided in accordance with SA 300 guidelines."

Texas Incident No.: I-9387

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE DAMAGED ON A CONSTRUCTION SITE

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

"At approximately 1315 [EDT] on 3/16/16, ODH [Ohio Department of Health] was notified that a licensee had a nuclear density gauge run over on a construction site. The incident occurred at about 0730 that morning. The licensee's technician instructed site personnel to stay 20 feet from the damaged gauge and contacted the RSO [Radiation Safety Officer] via telephone. The RSO arrived on site at approximately 0810 and determined that both sources were intact within the gauge housing. Readings attained around the damaged gauge with a radiation monitor and indicated normal levels. The gauge was placed back in the case and additional readings were [obtained] from the soil at the accident location with negative results. The gauge was then transported to a licensed service provider for inspection and storage. The service provider inspected the gauge and performed a leak test which indicated that the sources were not leaking.

"Investigation is ongoing."

Sealed Source Gauge. Manufacturer: QSA GLOBAL, Model Number: X.2084, Serial Number: A-7879, 0.050 Ci Am/Be-241 source and Model Number: X.8, Serial Number: C-7879, 0.010 Ci Cs-137 source.

Ohio: Item Number: OH160001

BRACHYTHERAPY DOSE LESS THAN PRESCRIBED DUE TO EQUIPMENT MALFUNCTION

The following was received from the licensee via email:

"Medical Event on a Prostate HDR [high dose rate brachytherapy] Fraction #2. The patient was previously treated to Fraction #1 2 weeks earlier without any issue.

"A patient was under spinal anesthesia for a treatment to the prostate to a prescribed dose of 13.5 Gy. The plan called for 19 interstitial catheters to the 30 cc prostate gland. The V100 of the prostate was expected to be 99.75% (100% dose of 13.5 Gy covered 99.75% of the prostate volume). All coverage and critical organ sparing criteria were met and physician approved the plan.

"However during treatment and after completion of 9 catheters the treatment console reported an error (and subsequently retracted the source after 2 dwell positions were treated of the 10th catheter). The error code 9 message was source has moved from dwell position and a reset of the treatment console was required.

"[The medical physicist] went inside the treatment room with the survey meter to ensure the source indeed retracted and transfer tube and applicator appropriately connected. Which they were. Attempts were made to continue with the treatment as the error code direction was cancel the error and try again.

"However, the afterloader would not resume treatment and the treatment console reported an another error code 117 error during check out-drive in channel (driving out the check cable).

"Several attempts were made with help of Elekta field service and phone support to troubleshoot the issue as the message on the treatment console with these errors is that if the problem persists, contact your local Elekta service representative. Troubleshooting continued afterwards with the field service engineer coming on site. We were later informed by the engineer that parts had to be ordered to resolve the issue and that they would arrive early the next morning.

"The procedure was eventually halted due to the service issue and patient was sent to recovery and family informed.

"[The licensee is] now assessing what dose was delivered.

"The total treatment time called for 386.6 s. However, only 158.5 s was treated. On the treatment planning system using the catheters and dwell positions and time of 158.5 s the v100 to the prostate is showing as 12.52% (100% of the dose of 13.5 Gy covered 12.52% of the prostate volume) of the partially treated procedure. There was no excessive dose anywhere i.e. to critical structures, just lack thereof to the intended treatment volume of the prostate. The dosimetrist is working with the plan to put on dose points near treated catheters to provide us further details.

"[The licensee] wanted to take the appropriate direction going forward in regards to documentation, reporting and planning for treatment for the patient on a subsequent date. The machine issue initially occurred at approximately [1430 EDT on 3/16/16]. Service on the unit is ongoing so exact details of the repair are not yet available. Remaining prostate patients scheduled for this week been rescheduled for a later date."

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 - MOISTURE DENSITY GAUGE DAMAGED

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

"March 16, 2016 about 1600 [EDT]: [The GeoConcepts field representative] notified [the licensee's Radiation Safety Officer] (RSO) of the incident and that the gauge had been damaged. [The field representative] informed [the RSO] that a John Deere Dozer 700 had back up over the gauge. [The field representative], had just completed taking a compaction and moisture test. When the site foreman called to [the field representative] to ask about failing test results, [the field representative] placed the trigger lock back onto the gauge and walked over to the site foreman who was approximately 8-10 feet from where the gauge was located. The John Deere Dozer 700 operator was grading soil and placing it onto an onsite stockpile. The John Deere Dozer 700 operator proceeded to back up, in the vicinity of the gauge. When [the field representative] noticed the operator in close proximity to the gauge, he began to try and get the operators' attention. The operator was not able to see [the field representative's] attempts to gain his attention nor was he able to hear [the field representative] or the site foreman. At that time, the gauge was struck by John Deere 700, which resulted in cracking of the gauge case and breaking of the source rod.

"March 16, 2016 about 1620: The RSO called the assistant CS [Construction Site] manager and RSO, INC., to inform them of the incident and to immediately get RSO, Inc. to the site and address the issue. [The assistant CS manager] also placed a call to NRC and was informed to call Maryland NRC to notify them of the incident.

"March 16, 2016 about at 1630: The RSO, left our Ashburn [VA] office for the project in Maryland. [The RSO] arrived onsite at 1730 [EDT] to meet [the representative] of RSO Inc. RSO Inc. proceeded to perform a leak test and take readings of surrounding areas and construction equipment. [The source did not leak and there were no reports of radiation exposures.]

"March 16, 2016 about 1700: The RSO Inc. representatives were able to retract the source rod into the gauge case shielding. They packaged the gauge back into the carrying case; [The licensee's RSO] took the gauge back to the Ashburn office to secure it.

"March 17, 2016: The RSO, picked up the gauge and transported it to NETS (North East Technical Services), for the gauge to be disposed."

The gauge is a Humboldt model number 5001 EZ, serial number 4704.

The licensee is licensed in the Commonwealth of Virginia, VA License #45-25467-01 and MD Material License # MD-13-020-01.

Maryland Case Number: 1654