Event Notification Report for December 23, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/22/2016 - 12/23/2016
Agreement State
Event Number: 52459
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: WESTROCK TEXAS LP
Region: 4
City: SILSBEE State: TX
County:
License #: 01095
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: WESTROCK TEXAS LP
Region: 4
City: SILSBEE State: TX
County:
License #: 01095
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2016
Notification Time: 15:00 [ET]
Event Date: 12/23/2016
Event Time: 00:00 [CST]
Last Update Date: 12/23/2016
Notification Time: 15:00 [ET]
Event Date: 12/23/2016
Event Time: 00:00 [CST]
Last Update Date: 12/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - LEAKING KRYPTON-85 SOURCE
The following report was received via e-mail:
"On November 17, 2016 the Agency [Texas Department of State Health Services] received notice from a service company that it had a gauge which appeared to have leaked the radioactive material. The gauge potentially leaked Krypton-85 gas because the device failed to operate normally. The device activity did not produce acceptable measurements and was removed from service/operation. The device was removed from service by the service company and set into a storage area and labeled to prevent movement. The licensee made arrangements for the manufacturer to service the gauge stating to the Agency [Texas Department of State Health Services] that it would take the manufacturer three weeks before it could schedule a visit to the plant site. The manufacturer must confirm that Kr-85 indeed did leak from the gauge.
"Device information provided included by the licensee:
Manufacturer - Valmet/Metso,
Gauge model - BMW2,
Gauge S/N - 50048138,
Isotope - Kr-85,
Activity - 400mCi,
Source S/N - QA00168.
"On December 23, 2016, the licensee verbally confirmed the device had leaked the Kr-85 gas. The manufacturer will be providing a service description and details of how the device was checked and or repaired. Awaiting the service report from the manufacture."
The seam on the source capsule had ruptured.
Texas incident: I-9442
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following report was received via e-mail:
"On November 17, 2016 the Agency [Texas Department of State Health Services] received notice from a service company that it had a gauge which appeared to have leaked the radioactive material. The gauge potentially leaked Krypton-85 gas because the device failed to operate normally. The device activity did not produce acceptable measurements and was removed from service/operation. The device was removed from service by the service company and set into a storage area and labeled to prevent movement. The licensee made arrangements for the manufacturer to service the gauge stating to the Agency [Texas Department of State Health Services] that it would take the manufacturer three weeks before it could schedule a visit to the plant site. The manufacturer must confirm that Kr-85 indeed did leak from the gauge.
"Device information provided included by the licensee:
Manufacturer - Valmet/Metso,
Gauge model - BMW2,
Gauge S/N - 50048138,
Isotope - Kr-85,
Activity - 400mCi,
Source S/N - QA00168.
"On December 23, 2016, the licensee verbally confirmed the device had leaked the Kr-85 gas. The manufacturer will be providing a service description and details of how the device was checked and or repaired. Awaiting the service report from the manufacture."
The seam on the source capsule had ruptured.
Texas incident: I-9442
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 52470
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: SEATTLE CANCER CARE ALLIANCE
Region: 4
City: SEATTLE State: WA
County:
License #: M0225
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: DONALD NORWOOD
Licensee: SEATTLE CANCER CARE ALLIANCE
Region: 4
City: SEATTLE State: WA
County:
License #: M0225
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/30/2016
Notification Time: 18:48 [ET]
Event Date: 12/23/2016
Event Time: 00:00 [PST]
Last Update Date: 01/17/2017
Notification Time: 18:48 [ET]
Event Date: 12/23/2016
Event Time: 00:00 [PST]
Last Update Date: 01/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MISADMINISTRATION DURING HIGH DOSE RATE PROCEDURE
The following information was received via facsimile:
"At approximately 1355 PST on Friday, 12/30/2016, Seattle Cancer Care Alliance called the Washington State Radioactive Materials Section to report a medical event. The event had occurred on Friday, 12/23/2016 but the date that the event was discovered was not provided. The summary of the event is as follows: An Ir-192 source was incorrectly positioned during an HDR procedure, resulting in a reduced dose to the treatment volume and an unintended dose to the surrounding healthy tissue. Limited information was provided by the licensee because they are still investigating the misadministration, but additional information will be provided in a follow-up conversation on Tuesday, 1/3/2017."
Washington Incident Number: WA-16-049
* * * UPDATE ON 01/17/2017 AT 1714 EST FROM ANDREW HALLORAN TO STEVEN VITTO * * *
The following was received via email from the State of Washington:
"Patient was referred to SCCA [Seattle Cancer Care Alliance] for high dose rate (HDR) brachytherapy for treatment to a cervical lesion extending primarily on the left lateral side with upper to mid-vaginal involvement. Procedures were initially being developed to treat the patient with an interstitial Syed applicator. However, due to a medical condition that arose, the patient was no longer a candidate for this procedure. Therefore, the plan was to treat the patient with intracavitary brachytherapy, consisting of two fractions (1 & 2) with a tandem and ovoid (T&O) applicator set (because of a more favorable paracervical dose distribution provided by the T&O applicator configuration), and an additional two fractions (3 & 4) using the Miami cylinder applicator with tandem (to enable dose delivery to the vaginal target using the cylinder configuration).
"The first two tandem and ovoid (T&O) HDR treatments (fx 1 & 2) were delivered as intended on 12/19/16 and 12/21/16. During the first fraction of the Tandem/Miami cylinder applicator (fx 3) delivered on 12/23/16, an incorrect tandem applicator length (119.8 cm) was entered into the treatment planning system instead of the 131.9 cm distance for the Miami tandem. This error was not caught prior to treatment delivery and the treatment dose in the tandem was offset by 12 cm inferiorly. The error was discovered prior to the 4th fraction being delivered on 12/29/16. The patient was notified of the error and the treatment was corrected and postponed to 12/30/16.
"The intended dose to the cervical tumor volume for the 3rd fraction was 660 cGy, and the actual dose delivered for the fraction was 65 cGy to 90 percent of the target volume."
Notified R4DO (Werner) and NMSS Events Notification via email.
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 received via facsimile:
"At approximately 1355 PST on Friday, 12/30/2016, Seattle Cancer Care Alliance called the Washington State Radioactive Materials Section to report a medical event. The event had occurred on Friday, 12/23/2016 but the date that the event was discovered was not provided. The summary of the event is as follows: An Ir-192 source was incorrectly positioned during an HDR procedure, resulting in a reduced dose to the treatment volume and an unintended dose to the surrounding healthy tissue. Limited information was provided by the licensee because they are still investigating the misadministration, but additional information will be provided in a follow-up conversation on Tuesday, 1/3/2017."
Washington Incident Number: WA-16-049
* * * UPDATE ON 01/17/2017 AT 1714 EST FROM ANDREW HALLORAN TO STEVEN VITTO * * *
The following was received via email from the State of Washington:
"Patient was referred to SCCA [Seattle Cancer Care Alliance] for high dose rate (HDR) brachytherapy for treatment to a cervical lesion extending primarily on the left lateral side with upper to mid-vaginal involvement. Procedures were initially being developed to treat the patient with an interstitial Syed applicator. However, due to a medical condition that arose, the patient was no longer a candidate for this procedure. Therefore, the plan was to treat the patient with intracavitary brachytherapy, consisting of two fractions (1 & 2) with a tandem and ovoid (T&O) applicator set (because of a more favorable paracervical dose distribution provided by the T&O applicator configuration), and an additional two fractions (3 & 4) using the Miami cylinder applicator with tandem (to enable dose delivery to the vaginal target using the cylinder configuration).
"The first two tandem and ovoid (T&O) HDR treatments (fx 1 & 2) were delivered as intended on 12/19/16 and 12/21/16. During the first fraction of the Tandem/Miami cylinder applicator (fx 3) delivered on 12/23/16, an incorrect tandem applicator length (119.8 cm) was entered into the treatment planning system instead of the 131.9 cm distance for the Miami tandem. This error was not caught prior to treatment delivery and the treatment dose in the tandem was offset by 12 cm inferiorly. The error was discovered prior to the 4th fraction being delivered on 12/29/16. The patient was notified of the error and the treatment was corrected and postponed to 12/30/16.
"The intended dose to the cervical tumor volume for the 3rd fraction was 660 cGy, and the actual dose delivered for the fraction was 65 cGy to 90 percent of the target volume."
Notified R4DO (Werner) and NMSS Events Notification via email.
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.