Event Notification Report for August 24, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/23/2017 - 08/24/2017
EVENT NUMBERS
52979529285292952925
Agreement State
Event Number: 52979
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: STEVE SANDIN
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/19/2017
Notification Time: 10:38 [ET]
Event Date: 08/24/2017
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2017
Notification Time: 10:38 [ET]
Event Date: 08/24/2017
Event Time: 00:00 [EDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SILAS KENNEDY (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DOSE DELIVERED 20% GREATER THAN PRESCRIBED AND GREATER THAN 50 REM TO THE TARGETED AREA
The following information was received from the State of Georgia via email:
"Emory University had new software installed for their HDR on 2/2/2016. During the time span of 3/2016 through 6/2017 [five] 5 patients received doses that were greater than 20% [percent] and greater than 50 rem to the targeted area. The misadministration was due to a software defect with Elekta's Oncentra Brachy Software version 4.5.2. using the ring applicator. The licensee was only aware of the defect on Aug 22, 2017 when Elekta notified all of their customers of the defect. Emory unofficially notified the State of Georgia on Aug 24, 2017 of a possibility that several of their patients may have been involved in a medical event. The medical event was confirmed on Sept 19, 2017 that [five] 5 patients were involved in a medical event.
"Cause and Corrective Actions: The events were due to a software issue utilizing the Oncentra Brachy Software version 4.5.2. A misadministration occurred due to an inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size.
"Device/Associated Equipment: Oncentra Brachy Software version 4.5.2. in a Elekta Nucleotron MicroSelection v3 HDR using a ring applicator."
The targeted area that received the greater than 50 rem was the tissue of the upper vaginal wall.
The defect in the equipment is identified and described in EN #52922.
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 from the State of Georgia via email:
"Emory University had new software installed for their HDR on 2/2/2016. During the time span of 3/2016 through 6/2017 [five] 5 patients received doses that were greater than 20% [percent] and greater than 50 rem to the targeted area. The misadministration was due to a software defect with Elekta's Oncentra Brachy Software version 4.5.2. using the ring applicator. The licensee was only aware of the defect on Aug 22, 2017 when Elekta notified all of their customers of the defect. Emory unofficially notified the State of Georgia on Aug 24, 2017 of a possibility that several of their patients may have been involved in a medical event. The medical event was confirmed on Sept 19, 2017 that [five] 5 patients were involved in a medical event.
"Cause and Corrective Actions: The events were due to a software issue utilizing the Oncentra Brachy Software version 4.5.2. A misadministration occurred due to an inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size.
"Device/Associated Equipment: Oncentra Brachy Software version 4.5.2. in a Elekta Nucleotron MicroSelection v3 HDR using a ring applicator."
The targeted area that received the greater than 50 rem was the tissue of the upper vaginal wall.
The defect in the equipment is identified and described in EN #52922.
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: 52928
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: UNIVERSITY OF KANSAS HOSPITAL
Region: 4
City: KANSAS CITY State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: DONG HWA PARK
Licensee: UNIVERSITY OF KANSAS HOSPITAL
Region: 4
City: KANSAS CITY State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2017
Notification Time: 15:20 [ET]
Event Date: 08/24/2017
Event Time: 15:15 [CDT]
Last Update Date: 08/25/2017
Notification Time: 15:20 [ET]
Event Date: 08/24/2017
Event Time: 15:15 [CDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN COLLINS (NMSS)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN COLLINS (NMSS)
AGREEMENT STATE REPORT - CONTAMINATION RESULTING FROM Y-90 SETUP
The following was received from the State of Kansas via email:
"During Therasphere setup, a technician forgot to prime the syringe and inserted it into the vial of Y-90. She realized the syringe was not primed, but because the syringe cannot be removed, her attempt at priming it opened the vial inadvertently. It got tracked all over the room and to some extent all around the Interventional Radiology (IR) department. IR is now completely closed. She was put in a bunny suit immediately and sent to emergency to get deconned at the shower. There was no risk of internal contamination due to the rapidity of the decon after the incident. Highest contamination is at 90k on her scrubs. Most of the contamination was on her lead apron. The clothes are currently sequestered and lacking skin contamination, she was sent home. They are currently in the process of cleaning up and recovering to get IR back in business.
"An investigator will be sent on Monday to gain first-hand knowledge of the incident. The RSO and ARSO were at a conference, arriving home last night, and were not present during the incident.
"Reporting under 10 CFR 30.50(b) (corresponding to K.A.R. 28-35-184b in Kansas Annotated Regulations), area closed to workers and public for more than 24 hours due to an unplanned contamination."
The following was received from the State of Kansas via email:
"During Therasphere setup, a technician forgot to prime the syringe and inserted it into the vial of Y-90. She realized the syringe was not primed, but because the syringe cannot be removed, her attempt at priming it opened the vial inadvertently. It got tracked all over the room and to some extent all around the Interventional Radiology (IR) department. IR is now completely closed. She was put in a bunny suit immediately and sent to emergency to get deconned at the shower. There was no risk of internal contamination due to the rapidity of the decon after the incident. Highest contamination is at 90k on her scrubs. Most of the contamination was on her lead apron. The clothes are currently sequestered and lacking skin contamination, she was sent home. They are currently in the process of cleaning up and recovering to get IR back in business.
"An investigator will be sent on Monday to gain first-hand knowledge of the incident. The RSO and ARSO were at a conference, arriving home last night, and were not present during the incident.
"Reporting under 10 CFR 30.50(b) (corresponding to K.A.R. 28-35-184b in Kansas Annotated Regulations), area closed to workers and public for more than 24 hours due to an unplanned contamination."
Agreement State
Event Number: 52929
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNKNOWN
Region: 1
City: MEMPHIS State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Licensee: UNKNOWN
Region: 1
City: MEMPHIS State: TN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2017
Notification Time: 16:02 [ET]
Event Date: 08/24/2017
Event Time: 00:00 [EDT]
Last Update Date: 09/05/2017
Notification Time: 16:02 [ET]
Event Date: 08/24/2017
Event Time: 00:00 [EDT]
Last Update Date: 09/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
AGREEMENT STATE REPORT - DAMAGED PACKAGING - SOURCE INTACT
The following was received from the State of Illinois via email:
"The corporate RSO [Radiation Safety Officer] for [common carrier] contacted the agency [Illinois Emergency Management Agency] at approximately 1300 [CDT] on August 25, 2017 to notify that last night (August 24, 2017) a Type A package containing 140 GBq of high dose rate brachytherapy lr-192 seeds had suffered physical damage at a [common carrier] facility in South Holland, IL. The package was en route from Community Hospital in Munster, IN to an out of state site for Alpha Omega and shifted during transit. The impact resulted in a cracked rim of the Type A package; however, there was no loss of contents, contamination, or exposure to personnel. Exposure rate surveys verified package contents but no contamination surveys were completed. The incident is being reported to the National Response Center concurrently."
Item number: IL177027
National Response Center Incident Report # 1188386
* * * UPDATE ON 9/5/17 AT 1142 EDT FROM ROY PARKER TO BETHANY CECERE * * *
This update is to correct the title of the original event report from "Damaged Source" to "Damaged Packaging - Source Intact" to better reflect the source integrity status.
Notified R1DO (Dentel), R3DO (Stone), and NMSS Event Notification (by email).
The following was received from the State of Illinois via email:
"The corporate RSO [Radiation Safety Officer] for [common carrier] contacted the agency [Illinois Emergency Management Agency] at approximately 1300 [CDT] on August 25, 2017 to notify that last night (August 24, 2017) a Type A package containing 140 GBq of high dose rate brachytherapy lr-192 seeds had suffered physical damage at a [common carrier] facility in South Holland, IL. The package was en route from Community Hospital in Munster, IN to an out of state site for Alpha Omega and shifted during transit. The impact resulted in a cracked rim of the Type A package; however, there was no loss of contents, contamination, or exposure to personnel. Exposure rate surveys verified package contents but no contamination surveys were completed. The incident is being reported to the National Response Center concurrently."
Item number: IL177027
National Response Center Incident Report # 1188386
* * * UPDATE ON 9/5/17 AT 1142 EDT FROM ROY PARKER TO BETHANY CECERE * * *
This update is to correct the title of the original event report from "Damaged Source" to "Damaged Packaging - Source Intact" to better reflect the source integrity status.
Notified R1DO (Dentel), R3DO (Stone), and NMSS Event Notification (by email).
Agreement State
Event Number: 52925
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0253-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: HOWIE CROUCH
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0253-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2017
Notification Time: 22:09 [ET]
Event Date: 08/24/2017
Event Time: 18:00 [EDT]
Last Update Date: 08/25/2017
Notification Time: 22:09 [ET]
Event Date: 08/24/2017
Event Time: 18:00 [EDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
NORTH CAROLINA AGREEMENT STATE REPORT - MISSING PORTABLE NUCLEAR GAUGE
The following information was obtained from the state of North Carolina via email:
"North Carolina Radioactive Materials Branch (RMB) was notified on 8/24/17 at 7:58 PM [EDT] that a portable nuclear gauge went missing at around 6:00 PM at a job site at Ten-Ten Road in Garner, NC 27603.
"Licensee: ECS Southeast, LLP
License Number: 092-0253-1
Gauge Manufacturer: Instrotek Xplorer
Model #: 3500
Serial #: 3194
"The gauge contains 11 milliCuries of cesium-137 and 44 milliCuries of americium-241: beryllium. The gauge was not trigger locked and not locked in its original carrying case at the time it went missing. RMB is investigating the incident and working with local authorities to develop a press release. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC as this investigation is ongoing."
* * * UPDATE AT 1058EDT ON 08/25/17 FROM TRAVIS CARTOSKI TO S. SANDIN VIA EMAIL * * *
"NC Radioactive Materials Branch (RMB) would like to report that the missing gauge has been found this morning 8/25. Three members of the RMB were dispatched last night to initiate an investigation and reconvened this morning to continue. The gauge appeared to have no damage and is being returned to the manufacturer for verification. Surveys were taken on and around the gauge once it was found and all surveys appeared normal indicating the sources were still intact within the gauge.
"Through interviews of personnel on-site, it was determined that source rod was never extended from when the gauge went missing to when it was found. An on-site construction worker found the gauge unattended yesterday afternoon and secured it until this morning.
"RMB is continuing its investigation from a compliance stand point. Further details will be provided to satisfy the details of this incident following conclusion of this investigation."
Notified R1DO (Kennedy) and NMSS Events Notification and ILTAB via email.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
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 information was obtained from the state of North Carolina via email:
"North Carolina Radioactive Materials Branch (RMB) was notified on 8/24/17 at 7:58 PM [EDT] that a portable nuclear gauge went missing at around 6:00 PM at a job site at Ten-Ten Road in Garner, NC 27603.
"Licensee: ECS Southeast, LLP
License Number: 092-0253-1
Gauge Manufacturer: Instrotek Xplorer
Model #: 3500
Serial #: 3194
"The gauge contains 11 milliCuries of cesium-137 and 44 milliCuries of americium-241: beryllium. The gauge was not trigger locked and not locked in its original carrying case at the time it went missing. RMB is investigating the incident and working with local authorities to develop a press release. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC as this investigation is ongoing."
* * * UPDATE AT 1058EDT ON 08/25/17 FROM TRAVIS CARTOSKI TO S. SANDIN VIA EMAIL * * *
"NC Radioactive Materials Branch (RMB) would like to report that the missing gauge has been found this morning 8/25. Three members of the RMB were dispatched last night to initiate an investigation and reconvened this morning to continue. The gauge appeared to have no damage and is being returned to the manufacturer for verification. Surveys were taken on and around the gauge once it was found and all surveys appeared normal indicating the sources were still intact within the gauge.
"Through interviews of personnel on-site, it was determined that source rod was never extended from when the gauge went missing to when it was found. An on-site construction worker found the gauge unattended yesterday afternoon and secured it until this morning.
"RMB is continuing its investigation from a compliance stand point. Further details will be provided to satisfy the details of this incident following conclusion of this investigation."
Notified R1DO (Kennedy) and NMSS Events Notification and ILTAB via email.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
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