Event Notification Report for January 25, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/24/2005 - 01/25/2005
Hospital
Event Number: 41361
Rep Org: UNIVERSITY OF MINNESOTA
Licensee: UNIVERSITY OF MINNESOTA
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 22-00187-46
Agreement: N
Docket:
NRC Notified By: JERRY STAIGER
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF MINNESOTA
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 22-00187-46
Agreement: N
Docket:
NRC Notified By: JERRY STAIGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/27/2005
Notification Time: 13:00 [ET]
Event Date: 01/25/2005
Event Time: 21:30 [CST]
Last Update Date: 01/27/2005
Notification Time: 13:00 [ET]
Event Date: 01/25/2005
Event Time: 21:30 [CST]
Last Update Date: 01/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVID HILLS (R3)
SANDRA WASTLER (NMSS)
DAVID HILLS (R3)
SANDRA WASTLER (NMSS)
MEDICAL EVENT DURING TREATMENT FOR CANCER OF THE CERVIX
A patient undergoing a 31 hour treatment plan for cervical cancer received less than the prescribed dose delivered to the treatment site and a higher than intended dose to other tissue(s)/organ(s), specifically:
Treatment site A: planned 1643 centiGray, delivered 821 centiGray
Treatment site B: planned 465 centiGray, delivered 372 centiGray
Bladder: planned 1147 centiGray, delivered 1448 centiGray
Rectum: planned 1147 centiGray, delivered 2012 centiGray
Treatment was delivered from 1430 hours on 1/24 and 2130 hours on 1/25 using a low dose rate tandem brachytherapy device containing three Cs-137 sources; 14 milligram Ra-equiv, 9.8 milligram Ra-equiv and 9.8 milligram-equiv. There were two additional Cs-137 ovoid sources, each 14.1 milligram Ra-equiv. The tandem device has a rod that was cut 6 cm. short such that when the tandem was positioned in the patient, the three tandem sources were not extended the proper distance inside the tandem device. The ovoid sources were properly positioned.
The referring physician and patient have been informed. The radiation staff oncologist does not believe that this medical event will have any adverse effect on the patient and a new treatment plan is being prepared for the patient.
A patient undergoing a 31 hour treatment plan for cervical cancer received less than the prescribed dose delivered to the treatment site and a higher than intended dose to other tissue(s)/organ(s), specifically:
Treatment site A: planned 1643 centiGray, delivered 821 centiGray
Treatment site B: planned 465 centiGray, delivered 372 centiGray
Bladder: planned 1147 centiGray, delivered 1448 centiGray
Rectum: planned 1147 centiGray, delivered 2012 centiGray
Treatment was delivered from 1430 hours on 1/24 and 2130 hours on 1/25 using a low dose rate tandem brachytherapy device containing three Cs-137 sources; 14 milligram Ra-equiv, 9.8 milligram Ra-equiv and 9.8 milligram-equiv. There were two additional Cs-137 ovoid sources, each 14.1 milligram Ra-equiv. The tandem device has a rod that was cut 6 cm. short such that when the tandem was positioned in the patient, the three tandem sources were not extended the proper distance inside the tandem device. The ovoid sources were properly positioned.
The referring physician and patient have been informed. The radiation staff oncologist does not believe that this medical event will have any adverse effect on the patient and a new treatment plan is being prepared for the patient.
Power Reactor
Event Number: 41356
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: MIKE RIPLEY
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 01/25/2005
Notification Time: 23:36 [ET]
Event Date: 01/25/2005
Event Time: 20:58 [CST]
Last Update Date: 01/25/2005
Notification Time: 23:36 [ET]
Event Date: 01/25/2005
Event Time: 20:58 [CST]
Last Update Date: 01/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
MIKE RUNYAN (R4)
MIKE RUNYAN (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
POTENTIALLY CONTAMINATED WORKER TRANSPORTED TO OFFSITE MEDICAL FACILITY
"This report is being made pursuant to 10 CFR 50.72(b)(3)(xii), 'Any event requiring the transport of a radioactively contaminated person to an offsite medical facility for treatment.'
"At 20:58, Central Standard Time, Cooper Control Room was notified of an individual that was overheated and not feeling well. Cooper is currently in a refueling outage and this individual was working inside the drywell. Initial radiological surveys were started at the scene but were not completed until transportation to medical facilities was commenced. Individual was transported in Cooper Station ambulance. At the time of transport the individual was listed as potentially contaminated. Radiological surveys were completed prior to arrival at the medical facility. These radiological surveys determined that the individual was not contaminated.
"NRC Resident has been notified."
"This report is being made pursuant to 10 CFR 50.72(b)(3)(xii), 'Any event requiring the transport of a radioactively contaminated person to an offsite medical facility for treatment.'
"At 20:58, Central Standard Time, Cooper Control Room was notified of an individual that was overheated and not feeling well. Cooper is currently in a refueling outage and this individual was working inside the drywell. Initial radiological surveys were started at the scene but were not completed until transportation to medical facilities was commenced. Individual was transported in Cooper Station ambulance. At the time of transport the individual was listed as potentially contaminated. Radiological surveys were completed prior to arrival at the medical facility. These radiological surveys determined that the individual was not contaminated.
"NRC Resident has been notified."
Other Nuclear Material
Event Number: 41467
Rep Org: UNITED STATES NAVY
Licensee: UNITED STATES NAVY
Region: 1
City: State: VA
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: CMDR. FRAGOSO
HQ OPS Officer: HOWIE CROUCH
Licensee: UNITED STATES NAVY
Region: 1
City: State: VA
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: CMDR. FRAGOSO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/07/2005
Notification Time: 13:34 [ET]
Event Date: 01/25/2005
Event Time: 00:00 [EST]
Last Update Date: 03/07/2005
Notification Time: 13:34 [ET]
Event Date: 01/25/2005
Event Time: 00:00 [EST]
Last Update Date: 03/07/2005
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):
MOHAMED SHANBAKY (R1)
MICHELE BURGESS (NMSS)
MOHAMED SHANBAKY (R1)
MICHELE BURGESS (NMSS)
UNRECOVERED RADIOACTIVE MATERIAL
On January 25, 2005, a U.S. Navy CH-53E Super Stallion helicopter executed a forced water landing and subsequently sank off of the Virginia Cape Operations area. An in-flight safety feature onboard the aircraft, containing approximately 3500 microCuries of Strontium-90, sank with the helicopter. The U.S. Navy is planning on recovering the aircraft (and sources) when the weather becomes more amenable to recovery operations.
The licensee has notified the Region 1 Division of Nuclear Materials Safety.
On January 25, 2005, a U.S. Navy CH-53E Super Stallion helicopter executed a forced water landing and subsequently sank off of the Virginia Cape Operations area. An in-flight safety feature onboard the aircraft, containing approximately 3500 microCuries of Strontium-90, sank with the helicopter. The U.S. Navy is planning on recovering the aircraft (and sources) when the weather becomes more amenable to recovery operations.
The licensee has notified the Region 1 Division of Nuclear Materials Safety.