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Event Notification Report for January 18, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/17/2006 - 01/18/2006

** EVENT NUMBERS **


42255 42256 42264

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General Information or Other Event Number: 42255
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHICAGO PROSTATE CANCER CENTER
Region: 3
City: WESTMONT State: IL
County:
License #: IL-02015-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: ARLON COSTA
Notification Date: 01/12/2006
Notification Time: 17:32 [ET]
Event Date: 01/05/2006
Event Time: [CST]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
C.W. (BILL) REAMER (NMSS)

Event Text

LEAKING SEALED SOURCE DUE TO IMPROPERLY PACKAGED MATERIAL

The State provided the following information via email:

"On January 11, 2005 the Division learned of an event involving a leaking sealed source that was intended for the therapeutic treatment of prostate cancer. On January 5, 2006, the Chicago Prostate Cancer Center (CPCC) in Westmont, IL (IL-02015-01) received four packages [which] contained sources that had been loaded into [an] applicator as well as 'loose seeds' for reference and potential application. One of the four packages contained 10 sealed sources of Cs-131 and 42 additional sources (actual activity of 3.8 milliCi, each) [were] pre-loaded into treatment applicators by Anazao Health of Tampa Florida via IsoRay, Inc of Richland Washington who manufactured the sources.

"Although the outer packaging was shown to be free from contamination, once the cardboard outer container was opened, and the secondary lead container was opened, a seed was visually detected on the outer lead container. The seed was also notably damaged. Associated contamination was subsequently found on the secondary container, and the primary lead container as well as a second 'seed' of Cs-131 that had been trapped and bent within the primary lead container. Although all the sources were accounted for, none of the 10 seeds were contained within the innermost glass vial as its lid was not engaged with the vial. Cs-131 is a very low energy gamma emitter (33 KeV) with a half life of 9.7 days. The form of Cs involved is bound to a non-volatile, insoluble material.

"The Division discovered that the CPCC had experienced widespread contamination within the source preparation area as a result of the damaged sources and the failure to don proper protective gloves. The affected surfaces and items had been subsequently decontaminated and set aside as waste by the staff that was present on January 5, 2005. Contamination levels ranged from 1,000 cpm to 5,000 cpm as measured by their Geiger counter and rate meter. Items which had been touched by the medical physicist who had not been wearing disposable gloves were found to be contaminated. One of the assisting staff members experienced contamination on their hand that was later completely decontaminated.

"A Division representative was dispatched from the West Chicago offices to the facility shortly after we were notified, to determine the effectiveness of the decontamination effort, the extent of contamination that may have remained and to interview the Radiation Safety Officer [redacted]. The inspector's initial investigation today showed that contamination was limited to the source handling room which is a restricted area and that indeed all the sources were accounted for and secured. She also obtained the verbal report from [the RSO]. The only remaining contamination she was able to find were two spots on a counter of approximately 1,000 cpm - 2,000 cpm and the containers which were involved. The inspector returned to the facility on the following day to interview the responsible physicist, and the assisting technician. Gamma spectroscopy performed on samples of the contaminated items indicate the presence of Cs-131 rather than any of the other nuclides used by the facility.

"The Division is continuing its investigation and is acquiring additional information from the licensee. The Division has been in contact with the State of Washington regarding this matter. A formal report is due from the licensee within the next 30 days. This event was reported to the U.S. NRC Operations Center on January 12 and assigned event number 42255."

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General Information or Other Event Number: 42256
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: CAREALLIANCE HEALTH SERVICES ROPER HOSPITAL
Region: 1
City: CHARLESTON State: SC
County:
License #: 646
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/13/2006
Notification Time: 16:24 [ET]
Event Date: 01/12/2006
Event Time: [EST]
Last Update Date: 01/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1)
C.W. (BILL) REAMER (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"The South Carolina Department of Health and Environmental Control was notified (telephone) on January 13, 2006, by the licensee, that a medical misadministration had occurred. A patient being treated with a Iridium 192 HDR after loading brachytherapy system received a fractionated dose that differed from the prescribed dose, for a single fraction, by 50 percent or more. The patient was undergoing the first of three treatments to the pelvic region. The prescribed dose for this first treatment was 700 centigray but the patient only received 233 centigray, approximately one third of the intended dose. Further details of the misadministration will be supplied by the licensee in the forthcoming written report. Updates to this event will be made through the NMED system."

SC Report ID No. - SC060001

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Fuel Cycle Facility Event Number: 42264
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PIKETON State: OH
County: PIKE
License #: GDP-2
Agreement: Y
Docket: 0707002
NRC Notified By: RICK LARSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/17/2006
Notification Time: 18:03 [ET]
Event Date: 01/17/2006
Event Time: 08:56 [EST]
Last Update Date: 01/17/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
CHARLES R. OGLE (R2)
LAWRENCE KOKAJKO (NMSS)

Event Text

AUTOCLAVE STEAM LEAKAGE DURING HEATING OPERATION


"On 01/17/06 at approximately 0856 hours, X-344 Operations Personnel identified visible steam out leakage on Autoclave #2. The autoclave was operating in Operational Mode II 'Heating' at time of discovery. The out leakage was determined to be a failure of the autoclave shell 'O' Ring ( 'Q' Safety System Component) which seals the autoclave enclosure. The steam was immediately valved off, autoclave placed in Non-TSR applicable Mode VII 'Shutdown', and declared inoperable by the Plant Shift Superintendent. No release of Radiological Material occurred. This incident is being reported as a Safety Equipment Failure while operating in a TSR Applicable Mode."

The licensee also notified NRC Region 2 (Hartland) and the DOE Site Representative.

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