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Event Notification Report for June 9, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/08/2006 - 06/09/2006

** EVENT NUMBERS **


42618 42619 42620

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General Information or Other Event Number: 42618
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-30957-01
Agreement: N
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/05/2006
Notification Time: 12:32 [ET]
Event Date: 04/04/2006
Event Time: 08:00 [EDT]
Last Update Date: 06/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1)
GREG MORELL (NMSS)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE - UNPLANNED EXPOSURE DURING TRAINING

The State provided the following information via email:

"The Kentucky Radiation Health Branch was notified on April 4, 2006, by [the licensee], Radiation Safety Officer for Varian Medical Systems, 700 Harris Street, Suite 109, Charlottesville, VA, NRC license no. 45-30957-01, of an incident involving an HDR unit at the University of Kentucky Medical Center. A 10.5 Ci [Curie] Ir-192 brachytherapy HDR source assembly (SS&D registry no. CA-1080-S-102-S) on a VariSource Brachytherapy HDR Remote Afterloader (SS&D Registry no. CA-0661-D-103-S) had been extended beyond the shielded source housing by manually turning the over ride handle on the emergency retraction system. The incident occurred during a training exercise simulating an emergency HDR source retraction involving a medical physicist and four (4) medical students. The unit was in the 'Idle' mode which disabled the internal GM and emergency retract system on the HDR unit. The source was recovered by the RSO and two Varian service representatives on April 7, 2006."

The state is awaiting official notification of the actual doses received but reported that the highest dose was around 20-30 milliRem.

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General Information or Other Event Number: 42619
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: LAKE CHARLES State: LA
County:
License #: LA-9098-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/06/2006
Notification Time: 15:40 [ET]
Event Date: 06/02/2006
Event Time: 09:30 [CDT]
Last Update Date: 06/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SCOTT MOORE (NMSS)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - PERSONNEL OVEREXPOSURE

The State provided the following information via facsimile:

On June 1, 2006, a radiographer technician and an assistant from Team Industrial Services, Inc. performed multiple radiography exposures. After the 19th exposure, the radiographers reported "slightly more friction and resistance" when performing exposures at an elevated location. Approximately at 09:30, the final exposure was performed at an elevated location, the source was retracted with the fore noted additional resistance, and the "crank handle was rotated to the shielded position. No abnormal operation was noted and the lock plunger came up to the locked position. However, a survey of the exposure device is required by Team Industrial Services' Operating and Emergency procedures, the NRC and the LA DEQ [Louisiana Department of Environmental Quality]. No survey was performed." The radiographers then had difficulty disconnecting the source tube and control assembly. The camera was placed in the truck.

The truck was then driven to the control room, to the OSI trailer, and to the shop. The radiographers then went to lunch. After lunch, the radiographers went to their shop, unloaded the camera and realized the source pigtail was not in the camera. The calculated worst case dose to Control Room personnel was 0.38 milliRem, to OSI trailer personnel was 20.7 milliRem, an inhabited office near the OSI trailer was 10.83 milliRem, and a second inhabited location near the OSI trailer was 29 milliRem. "At no time during the sequence of events did any unmonitored personnel approach the truck."

Team Industrial Services, Inc. calculated the worse case dose for the technician as 13 Rem and the actual TLD dose was 1.1 Rem. The calculated worse case dose for the assistant was 14.5 Rem and the actual TLD dose was 2.2 Rem. These TLD doses included previous doses received in May. The licensee is performing radiation blood analysis on the two radiographers.

Source: Ir-192, 40.5 Curies.
Louisiana Report: LA060010

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General Information or Other Event Number: 42620
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MERCY HEALTH CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-07018-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/06/2006
Notification Time: 18:06 [ET]
Event Date: 06/05/2006
Event Time: 09:00 [CDT]
Last Update Date: 06/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL TREATMENT UNDERDOSE

The licensee administered a 66% under dose during one of a series of brachytherapy doses to a patient. On June 6, 2006, during the second fractional dose in the series, the licensee noted that the administration of the dose took a longer time period than the dose administered to the patient on June 5, 2006. This was unexpected so the licensee performed a preliminary investigation. The licensee discovered that the computer used to time the dose incorrectly recorded the time taken for a quality control (QC) check and the dose time to the patient as one period of time. This was a first time use of this equipment by the licensee. The licensee determined that the patient received a dose of 116 centigray instead of 360 centigray during the administration of the first dose on June 5, 2006. A sealed 6 curie Ir-192 brachytherapy source manufactured by Varian was used. The licensee has informed the patient of the dose discrepancy. Additional controls have been implemented by the licensee to ensure that the computer will not record the time taken for the QC check as dose time to the patient in the future.

The State of Oklahoma is following up on the report by sending an inspector to the site.

*** UPDATE FROM STATE TO KNOKE AT 10:34 EDT ON 06/07/06 ***

The State provided the following information via facsimile:

"This was the first use of a new HDR modality mammosite treatment. The QC on this instrument was done prior to patient treatment. The treatment plan was sent from dosimetry computer to HDR control computer. Computer (or possibly human, not clear at this writing) chose the plan used from QC. Computer interpreted this to mean that a particular amount of dose had already been given. The computer delivered the remainder of dose, 116 centigrays, out of the prescribed 360 centigrays. Time was noted to be shorter than expected, but no alarm raised at the time. A second fraction was given later that day, and it was noticed that the time to deliver the dose was longer than in first dose. Inspection of computer records showed the dose had been stopped during treatment on the first fraction. It was then realized for sure that there was a problem.

"Corrective Action: QC ACTIVITY WILL BE DONE IN A WAY THAT IT CANT BE CONFUSED WITH THERAPY."

Notified NMSS (Wastler ) and R4DO (Runyan).

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Friday, March 30, 2012