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Event Notification Report for December 20, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/19/2005 - 12/20/2005

** EVENT NUMBERS **


41835 42088 42205 42207

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General Information or Other Event Number: 41835
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: QUEST TRU-TEC, L.P
Region: 4
City: LAPORTE State: TX
County:
License #: L03913
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/12/2005
Notification Time: 14:49 [ET]
Event Date: 06/29/2005
Event Time: [CDT]
Last Update Date: 12/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
SCOTT MOORE (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE

The State provided the following information via email:

"Texas Radiation Control received a telephone call from [the licensee's RSO] . The RSO was contacted by Landauer regarding an exposure to a 'film badge' in excess of 1,000 (one thousand) rads.

"The badge was being worn by [name deleted]. His exposure for the previous quarter was 350 millirem and for 2004 he received a total exposure of 290 Mr. The badge had been returned for evaluation with 4 other badges, which had no problems with excessive exposure.

"[The individual] only performed four tracer study jobs during the monitoring period and worked with a 34 mCi Ir-192 source. [The RSO] believes the badge was not worn. The licensee will be requesting the exposure be deleted.

"Texas Incident Investigation Program has contacted the licensee and requested additional information. A written report will be submitted within 30 days. The Event has received no media attention."

Texas Incident No.: I - 8242

***** UPDATE ON 12/19/05 AT 1830 EST from Latischa M. Hanson (via e-mail) entered by MacKinnon ******

"The licensee believes that the badge worn by (name deleted) during the first quarter of 2005 was intentionally exposed. The licensee states that the reported dose was in excess of the reporting capabilities of 1000 rad & concluded that the reported dose was not accurate. The licensee reported that (name deleted) terminated employee at the end of the first month of the quarterly monitoring period & that the employee worked with sealed sources during the first week & radiation work was performed afterward until time of termination. All jobs were short duration & neither the individual nor his single co-worker (supervisor) reported any unusual occurrences that would have resulted in a higher than normal dose. Based on the amount of the extremely high dose, the licensee concluded that the employee was not the recipient of 1000 rem (rad) dose & that the dose should be considered erroneous. Permanent dose record for (name deleted) reported by the licensee is as follows: 1st quarter 2005 - 0.349 rem; 2nd quarter 2005 - 0.100 rem.

Licensee corrective action: "No corrective actions taken or planned since reported dose appears to be incorrect. The licensee has calculated a dose of 0.100 rem for the 2nd quarter & consequently assigned this to (name deleted) permanent personnel monitoring record. This is based on the individual's previous cumulative six-month period dose of 0.593 rem, which averages to (approx) 0.100 rem/month."

R4DO (Shaffer) & NMSS EO (Essig) notified.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42088
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: EDWARD HARRISON
HQ OPS Officer: BILL GOTT
Notification Date: 10/27/2005
Notification Time: 17:38 [ET]
Event Date: 10/27/2005
Event Time: 13:28 [CDT]
Last Update Date: 12/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTINE LIPA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

UNANALYZED CONDITION

"As part of an ongoing Appendix R assessment, it has been determined that Operator actions credited in the Fire Hazards Analysis (FHA) potentially would not be met in fire zones credited for post fire safe shutdown per 10 CFR 50 Appendix R. Specifically, the FHA credited the availability of two in plant operators to conduct two separate series of operator actions that are required to be performed simultaneously within the first 20 minutes. However, the site Fire Plan requires one of these in plant operators to respond to a plant fire as a Fire Brigade member. Since no barrier was put in place to compensate for the lack of the credited operator; this event is reportable as an unanalyzed condition that significantly degraded plant safety."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM BOB MURELL TO W. GOTT AT 1314 ON 12/19/05 * * *

"Further review has determined that adequate operator resources are and have been available to perform the required post fire safe shutdown actions. Therefore, this event is not an unanalyzed condition that significantly degrades plant safety and is being retracted."

The licensee notified the NRC Resident Inspector.

Notified R3DO (H. Peterson)

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General Information or Other Event Number: 42205
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: EAST COAST ISOTOPES, INC.
Region: 1
City: BEAUFORT State: SC
County: BEAUFORT
License #: 705
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: RONALD HARRINGTON
Notification Date: 12/14/2005
Notification Time: 16:30 [ET]
Event Date: 12/14/2005
Event Time: 06:30 [EST]
Last Update Date: 12/14/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
THOMAS ESSIG (NMSS)
DONNA-MARIE PEREZ (TAS)
GEORGE PANGBURN (R1)

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOACTIVE MATERIAL

The State provided the following information via facsimile:

"Event type: Theft of Nuclear Pharmacy delivery vehicle en route to hospital

"Notifications: Local Police Department.

"Event description: The SC Department of Health and Environmental Control was notified on Wednesday (a.m.), December 14, 2005, by the pharmacist/RSO for the facility that one of their delivery vehicles had been stolen at gunpoint. The vehicle was en route to a hospital to deliver radiopharmaceuticals. The vehicle was carrying approximately 795 millicuries of Technetium 99m, 42 millicuries of Thallium 201 and one Iodine 123 capsule at 0.36 millicuries. The Port Royal Police Department was contacted and responded to the incident. The search is still ongoing at this point. The event is still under investigation and updates will be made through the national NMED system as they become available."

Contact the NRC Headquarters Operations Officer for additional details

South Carolina Event Report ID No.: SC050007

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.

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General Information or Other Event Number: 42207
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/15/2005
Notification Time: 12:26 [ET]
Event Date: 09/12/2005
Event Time: [CST]
Last Update Date: 12/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
SANDRA WASTLER (NMSS)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via email:

"On December 14, 2005 the licensee's Radiation Safety Officer, [name deleted], called the Division and forwarded information describing a medical misadministration that involved a brachytherapy dose that was greater than 10 percent from the intended treatment. The misadministration had occurred some months ago. The event was discovered as a result of a review of past treatments during an attempt to understand, what appeared to be, anomalies for certain cases.

"In a particular case on September 12, 2005, a patient began treatment for cervical cancer with a 'Fletcher Suit' manual brachytherapy afterloader using Cs-137 sealed sources. A transposition error was made in the digitization of the patient's lateral film used to construct the applicator's position and thus the positions of the radiation sources relative to the locations of the dose calculation points. Therefore, the digital locations used for mapping and treatment planning of points 'right A' and 'left A' relative to the sources were incorrectly determined.

"These calculated points used in the treatment planning were located in a region of lower dose rate within the tumor than the true anatomical 'A points', at which the prescription should have been defined. As a result, the prescription/final treatment plan used incorrect lower dose rate points and called for the use of an erroneously high source loading. Based on a retrospective analysis, instead of the calculated average dose rate of 0.545 Gy/hr for the erroneous 'A points', the actual delivered averaged dose rate to the true 'A points' was 0.74 Gy/hr. This resulted in an average dose of 54.3 Gy delivered to the true points A instead of the planned 40.0 Gy. The dose to the other points, namely rectum and bladder, were calculated correctly because their location did not involve the digitization step in which the transposition error occurred. These doses, which were calculated correctly, were all within acceptable limits. Only the tumor dose was in excess of the intended dose.

"This event occurred because of a misunderstanding concerning use of the new treatment planning system (TPS) that was being introduced into the clinic. The TPS allows digitizing either a right or left lateral film for locating the sources, bladder and rectal points for calculating doses. However the location of target point 'A', which is used for dose prescription, must be determined manually. Therefore a separate program is used which requires digitizing the source applicator on AP and lateral films to localize these points. In this additional step, the orientation of the lateral film on the digitizer was reversed left to right from what the program required, resulting in sign reversal of the anterior-posterior coordinate of the left and right 'A points'. This error was discovered in December, when looking into why positions of calculated points sometimes appeared unusual. This error was not caught at the time of the original implants.

"Once this potential source of dose discrepancy was discovered, the licensee reviewed all the patients whose dosimetry plans were determined with the new TPS since treatments were first initiated some three months ago. Three total patients were identified. The magnitude of the effect was found to also depend upon the orientation of the applicator in the patient. Only the case described above had those adverse complications which resulted in a medical event. A review of the two additional dosimetry plans showed that due to the orientation of the apparatus in the patient, the dose to the true prescription point was less than 5% greater than the planned dose. The clinical consequences for the patient concerned in this report are being evaluated by physicians.

"Four Cs-137 sealed sources with a total activity of 178 mCi were inserted into the patient. The planned averaged point A dose was 40.0 Gy and the actual administered dose was 54.3 Gy. Other than the 'point A' dose, no other dose calculation points were outside of the treatment specifications. The physicians are reviewing the revised dosimetry plans to determine if there will be any increased risk of complications for this patient. The clinical consequences for the patient concerned in this report are being evaluated by physicians. The dose at the various calculation points were:

"Dose points/Planned Dose (Gy/hr)/Actual Dose (Gy/hr)
Right A/0.56/0.74, Left A/0.530.74, Right B/0.18/0.18, Left B/0.17/0.17, r-rectum/0.33/0.37, s-rectum/0.35/0.39, t-rectum/0.31/0.32, u-rectum/0.21/0.21, B-bladder/0.47/0.43.

"This matter will be included during an pending routine inspection which will be conducted in the next 30 days.

"Corrective Actions:
Action Number / Corrective Action: 1 PROCEDURE MODIFIED 2 PERSONNEL RECEIVED ADDITIONAL TRAINING

"Patient Information: Patient Number: 1 Patient Informed: N Date Informed:
Therapeutic BRACHY, MANUAL AFTERLOADER
Organ: CERVIX
Dose: 5430 rad 54.3 Gy % Dose Exceeds Prescribed: 36
% Dose is Less Than Prescribed:
Effect on Patient: UNKNOWN Administered By: PHYSICIAN
Dose to Family: 0 rem 0 Sv Dose to Newborn: 0 rem 0 Sv Dose to Fetus: 0 rem 0 Sv
Source of Radiation: Due to the nature of the event, this matter was reported to the U.S. NRC Operations Center on December 15, 2005. It was assigned event number 42207
Source Number: 1
Form of Radioactive: SEALED SOURCE Radionuclide or Voltage (kVp/MeV): CS-137
Source Use: BRACHYTHERAPY Activity: .178 Ci 6.586 GBq
Manufacturer: Model Number: Serial Number: Device/Associated Equipment: Device Number: 1
Device Name: MANUAL AFTERLOADER Model Number: Manufacturer: UNKNOWN Serial Number:
Reporting Requirement: 32 IAC 335.1080 - Any administration of radioactive materials that results in a 'reportable event' (misadministration), licensee shall notify the agency by telephone NLT next day after licensee ascertains and confirms that a 'reportable event' has occurred.
Mode Reported: Written"

Illinois Item No. IL-050073

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012