Event Notification Report for July 29, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/28/2002 - 07/29/2002
Other Nuclear Material
Event Number: 39106
Rep Org: US ARMY
Licensee: US ARMY
Region: 1
City: ABERDEEN State: MD
County:
License #: 19-30563-01
Agreement: Y
Docket:
NRC Notified By: KUYKENDALL
HQ OPS Officer: CHAUNCEY GOULD
Licensee: US ARMY
Region: 1
City: ABERDEEN State: MD
County:
License #: 19-30563-01
Agreement: Y
Docket:
NRC Notified By: KUYKENDALL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 08/02/2002
Notification Time: 15:12 [ET]
Event Date: 07/29/2002
Event Time: 00:00 [EDT]
Last Update Date: 08/02/2002
Notification Time: 15:12 [ET]
Event Date: 07/29/2002
Event Time: 00:00 [EDT]
Last Update Date: 08/02/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
J. BRADLEY FEWELL (R1)
E. WILLIAM BRACH (NMSS)
J. BRADLEY FEWELL (R1)
E. WILLIAM BRACH (NMSS)
THE 503 CHEMICAL DETACHMENT IN HEIDELBERG, GERMANY LOST A CHEMICAL AGENT DETECTOR
During an inventory check on 6/13/02, by the 503rd Chemical Detachment in Heidelberg, Germany, it was discovered that a M43A1 Chemical Agent Detector containing 300 microcuries of Americium - 241 was unaccounted for. An investigation was made but the device was not located.
During an inventory check on 6/13/02, by the 503rd Chemical Detachment in Heidelberg, Germany, it was discovered that a M43A1 Chemical Agent Detector containing 300 microcuries of Americium - 241 was unaccounted for. An investigation was made but the device was not located.
Hospital
Event Number: 39101
Rep Org: WILLIAM BEAUMONT HOSPITAL
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: ROYAL OAK State: MI
County:
License #: 2101333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: MIKE NORRIS
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: ROYAL OAK State: MI
County:
License #: 2101333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: MIKE NORRIS
Notification Date: 07/30/2002
Notification Time: 09:49 [ET]
Event Date: 07/29/2002
Event Time: 12:30 [EDT]
Last Update Date: 07/30/2002
Notification Time: 09:49 [ET]
Event Date: 07/29/2002
Event Time: 12:30 [EDT]
Last Update Date: 07/30/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
BRUCE BURGESS (R3)
JOHN HICKEY (NMSS)
BRUCE BURGESS (R3)
JOHN HICKEY (NMSS)
MEDICAL MISADMINISTRATION
A coronary brachytherapy of the intermediate artery was performed with a Sr-90, 40 mm source train. The written directions called for a treatment time of 2 minutes and 52 seconds which would result in a total dose of 18.4 Grays. The catheter had a kink near the proximal marked location which caused the source train to get stuck before the distal portion of the catheter. This caused an unintended treatment of an area proximal to the treatment site. The source was observed out of position by panning the table and using the fluoroscopy tube, at this time the source was retracted. The source was in the patient for 2 minutes and 32 seconds, resulting in a total dose of 16.4 Grays.
The hospital has implemented process improvements to prevent another occurrence.
A coronary brachytherapy of the intermediate artery was performed with a Sr-90, 40 mm source train. The written directions called for a treatment time of 2 minutes and 52 seconds which would result in a total dose of 18.4 Grays. The catheter had a kink near the proximal marked location which caused the source train to get stuck before the distal portion of the catheter. This caused an unintended treatment of an area proximal to the treatment site. The source was observed out of position by panning the table and using the fluoroscopy tube, at this time the source was retracted. The source was in the patient for 2 minutes and 32 seconds, resulting in a total dose of 16.4 Grays.
The hospital has implemented process improvements to prevent another occurrence.