Event Notification Report for August 15, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/14/2005 - 08/15/2005
EVENT NUMBERS
41930419324199442091
General Information or Other
Event Number: 41930
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNKNOWN
Region: 3
City: Dayton State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: BILL HUFFMAN
Licensee: UNKNOWN
Region: 3
City: Dayton State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/18/2005
Notification Time: 12:19 [ET]
Event Date: 08/15/2005
Event Time: 00:00 [EDT]
Last Update Date: 08/18/2005
Notification Time: 12:19 [ET]
Event Date: 08/15/2005
Event Time: 00:00 [EDT]
Last Update Date: 08/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KENNETH RIEMER (R3)
JOSEPH HOLONICH (NMSS)
KENNETH RIEMER (R3)
JOSEPH HOLONICH (NMSS)
AGREEMENT STATE REPORT - SOURCE OF UNKNOWN ORIGIN FOUND IN RAILCAR
The State provided the following information via email:
"On 8/15/05 a sealed source was discovered on a rail car in Norfolk and Southern rail yard in Dayton, Ohio. Rail car was parked on spur line adjacent to a scrap yard. Source was discovered when rail car was being moved. Dayton HAZMAT unit was called who, in turn, notified the ODH Bureau of Radiation Protection. Bureau staff member responded to site and found source to be made of stainless steel and aluminum, 4" diameter and 18" long. Labeled as a GL device with the following information: Thermo System, Inc. St. Paul, Minn, Kr-85, 10 mCi, June 1974, Model # 8054, SN 31112. Dose rate at contact with the source was 0.8 milliR/hr and 12 microR/hr at 3 feet, as measured with Ludlum model 19 microR survey instrument. Source was stored overnight in locked trailer at rail yard. Source was taken for disposal by a disposal contractor on 8/16/05. Bureau has been unable to date to trace source back to original owner or determine how the source came to be on the rail car."
This event involves material that is less than IAEA Category 3 sources. 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.
For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
Ohio Report Number OH2005-092
The State provided the following information via email:
"On 8/15/05 a sealed source was discovered on a rail car in Norfolk and Southern rail yard in Dayton, Ohio. Rail car was parked on spur line adjacent to a scrap yard. Source was discovered when rail car was being moved. Dayton HAZMAT unit was called who, in turn, notified the ODH Bureau of Radiation Protection. Bureau staff member responded to site and found source to be made of stainless steel and aluminum, 4" diameter and 18" long. Labeled as a GL device with the following information: Thermo System, Inc. St. Paul, Minn, Kr-85, 10 mCi, June 1974, Model # 8054, SN 31112. Dose rate at contact with the source was 0.8 milliR/hr and 12 microR/hr at 3 feet, as measured with Ludlum model 19 microR survey instrument. Source was stored overnight in locked trailer at rail yard. Source was taken for disposal by a disposal contractor on 8/16/05. Bureau has been unable to date to trace source back to original owner or determine how the source came to be on the rail car."
This event involves material that is less than IAEA Category 3 sources. 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.
For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
Ohio Report Number OH2005-092
General Information or Other
Event Number: 41932
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIV OF TX SW MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL HUFFMAN
Licensee: UNIV OF TX SW MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/19/2005
Notification Time: 16:20 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 08/19/2005
Notification Time: 16:20 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 08/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
GARY SANBORN (R4)
JOSEPH HOLONICH (NMSS)
AGREEMENT STATE - MEDICAL EVENT
The State provided the following information via facsimile:
The State received a telephone call from an RSO with The University of Texas Southwestern Medical Center (UTSWMC) at Dallas on August 16, 2005 at 4:00 p.m. to report a patient misadministration of a therapy dose at UTSWMC Moncrief Medical Center. The event occurred on August 15, 2005 around 4:00 pm. The patient was scheduled to receive 1100 centiGray in two fractions for cancer treatment. Each fraction was supposed to be 550 centiGray to the vaginal vault. The first dose was oriented interior 4 1/2 cm, i.e. too close. The true target point of the vaginal vault received a dose of 1451 centiGray. The second dose was not administered and the patient is not returning for further treatment. Source was an Ir-192 HDR (high dose rate) afterloader.
The State provided the following information via facsimile:
The State received a telephone call from an RSO with The University of Texas Southwestern Medical Center (UTSWMC) at Dallas on August 16, 2005 at 4:00 p.m. to report a patient misadministration of a therapy dose at UTSWMC Moncrief Medical Center. The event occurred on August 15, 2005 around 4:00 pm. The patient was scheduled to receive 1100 centiGray in two fractions for cancer treatment. Each fraction was supposed to be 550 centiGray to the vaginal vault. The first dose was oriented interior 4 1/2 cm, i.e. too close. The true target point of the vaginal vault received a dose of 1451 centiGray. The second dose was not administered and the patient is not returning for further treatment. Source was an Ir-192 HDR (high dose rate) afterloader.
General Information or Other
Event Number: 41994
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH 414, INC.
Region: 4
City: FIFE State: WA
County:
License #: WN-NP005-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: ARLON COSTA
Licensee: CARDINAL HEALTH 414, INC.
Region: 4
City: FIFE State: WA
County:
License #: WN-NP005-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: ARLON COSTA
Notification Date: 09/14/2005
Notification Time: 13:18 [ET]
Event Date: 08/15/2005
Event Time: 00:00 [PDT]
Last Update Date: 09/14/2005
Notification Time: 13:18 [ET]
Event Date: 08/15/2005
Event Time: 00:00 [PDT]
Last Update Date: 09/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MIKE RUNYAN (R4)
M. WAYNE HODGES (NMSS)
CANADA CNSC (FAX)
MIKE RUNYAN (R4)
M. WAYNE HODGES (NMSS)
CANADA CNSC (FAX)
AGREEMENT STATE REPORT - LOSS OF CASE CONTAINING TECHNETIUM-99m
The licensee provided the following information via email:
"A customer of Cardinal Health called Cardinal on Tuesday, 16 August 2005, to inform Cardinal that they had not received part of their nuclear medicine order for Monday, 15 August. Only one of the two cases ordered had been delivered. The missing case contained 6 doses of diagnostic technetium-99m (a maximum total activity of 9.36 Megabecquerels [253 millicuries] as of ~ 06:30 am on 15 August). Cardinal Health indicates the doses were prepared early the morning of 15 August. The driver who delivered to the customer location on 15 August stated that only one case had been picked up from the pharmacy for that customer. Survey of delivery vehicle confirmed absence of missing radioactive material. The customer is sure that they did not receive the shipment. ORP performed a Cardinal facility site investigation on 19 August. Cardinal Health has not yet been able to explain what actually happened. Cardinal Health and ORP continue to investigate the event (Event Report # WA-05-047)."
Less than the quantity of an IAEA Category 3 source. 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.
For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
The licensee provided the following information via email:
"A customer of Cardinal Health called Cardinal on Tuesday, 16 August 2005, to inform Cardinal that they had not received part of their nuclear medicine order for Monday, 15 August. Only one of the two cases ordered had been delivered. The missing case contained 6 doses of diagnostic technetium-99m (a maximum total activity of 9.36 Megabecquerels [253 millicuries] as of ~ 06:30 am on 15 August). Cardinal Health indicates the doses were prepared early the morning of 15 August. The driver who delivered to the customer location on 15 August stated that only one case had been picked up from the pharmacy for that customer. Survey of delivery vehicle confirmed absence of missing radioactive material. The customer is sure that they did not receive the shipment. ORP performed a Cardinal facility site investigation on 19 August. Cardinal Health has not yet been able to explain what actually happened. Cardinal Health and ORP continue to investigate the event (Event Report # WA-05-047)."
Less than the quantity of an IAEA Category 3 source. 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.
For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.
General Information or Other
Event Number: 42091
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UT SOUTHWESTERN MEDICAL CENTER
Region: 4
City: FORT WORTH State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL GOTT
Licensee: UT SOUTHWESTERN MEDICAL CENTER
Region: 4
City: FORT WORTH State: TX
County:
License #: L00384-004
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2005
Notification Time: 17:50 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 10/28/2005
Notification Time: 17:50 [ET]
Event Date: 08/15/2005
Event Time: 16:00 [CDT]
Last Update Date: 10/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHUCK CAIN (R4)
DANIEL GILLEN (NMSS)
CHUCK CAIN (R4)
DANIEL GILLEN (NMSS)
AGREEMENT STATE REPORT
The licensee provided the following information via email:
"The written prescribed dose for this treatment was 550 cGy with the plan of repeating another procedure one week afterwards for a total prescribed dose of 1100 cGy. This dose, to be given in 2 fractions, was to be delivered to the vaginal cavity using High Dose Rate (HDR) afterloader device. The first fractionation of 550 cGy was delivered incorrectly, approximately 4.5 cm anterior to the correct position. This resulted in the intended target area receiving 1451 cGy in one treatment.
"The medical physicist discovered the error in the brachytherapy vision software (planning system). When digitizing the calculation point of the coronal plane, the sagittal plane viewing plane was in an incorrect position that resulted in the calculation point being entered incorrectly. There was no other medical physicist to second check the plan at that time due to personnel shortage issues.
"The prescribing physician determined that the clinical effect of the dose is negligible and there is no impact to the patient's well being."
Texas Incident number: I-8253
Event Report ID No: TX-05-41932
The licensee provided the following information via email:
"The written prescribed dose for this treatment was 550 cGy with the plan of repeating another procedure one week afterwards for a total prescribed dose of 1100 cGy. This dose, to be given in 2 fractions, was to be delivered to the vaginal cavity using High Dose Rate (HDR) afterloader device. The first fractionation of 550 cGy was delivered incorrectly, approximately 4.5 cm anterior to the correct position. This resulted in the intended target area receiving 1451 cGy in one treatment.
"The medical physicist discovered the error in the brachytherapy vision software (planning system). When digitizing the calculation point of the coronal plane, the sagittal plane viewing plane was in an incorrect position that resulted in the calculation point being entered incorrectly. There was no other medical physicist to second check the plan at that time due to personnel shortage issues.
"The prescribing physician determined that the clinical effect of the dose is negligible and there is no impact to the patient's well being."
Texas Incident number: I-8253
Event Report ID No: TX-05-41932