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Event Notification Report for September 5, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/01/2006 - 09/05/2006

** EVENT NUMBERS **


42811 42812 42823 42824

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General Information or Other Event Number: 42811
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH COPELY MEDICAL CENTER
Region: 3
City: AURORA State: IL
County:
License #: IL-01207-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/29/2006
Notification Time: 10:35 [ET]
Event Date: 08/22/2006
Event Time: [CDT]
Last Update Date: 08/29/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HIRONORI PETERSON (R3)
MICHELE BURGESS (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via email:

"Yesterday [name deleted] the medical physicist for this Aurora, IL based licensee (IL-01207-01) called to report a medical event which had come to her attention. While preparing a 'Mammosite' treatment plan for an upcoming patient, she had found that two previously administered therapy treatments were not as intended (on 7/28/06 and 8/22/06). Both treatment plans called for a dose of 3400 cGy to be administered to each of the patients over 10 fractions at 340 cGy per fraction with two fractions delivered each of 5 days. However, due to confusion and misunderstanding of the data entry into the treatment planning software, an error occurred and the dose per fraction delivered was only 34 cGy for a total treatment dose of only 340 cGy. Thus, both patients received only 10% of the dose they should have received for their cancer treatments.

"The treatment planning software, named Eclipse, developed by Varian Medical Systems had a known issue with regards to 'fractionated doses'. A company technical bulletin, (CTB-BV-318) had been generated by the company in March of 2003 and provided to its customers alerting them to the appropriate method for data entry for fractionated doses. The technical bulletin for the treatment planning software contains a warning that 'incorrect use could possibly cause a misadministration.' However, Rush Copley did not acquire its high dose rate afterloading system and treatment planning software until August of 2005 and although the treatment planning software had been updated to a newer version, the same issue remained in the new version. According to the authorized user and the medical physicist, there was no training provided on this aspect of use of the treatment planning software when they had attended the manufacturer's training last year.

"The hospital has administered only these two fractionated doses since they acquired the unit. Both patients have been contacted by the authorized user and the patients are considering the available options for additional treatment if necessary. Considering the treatment regimen is designed for post surgical lumpectomies of the breast, the physician believes the effect of the under dose on the patients will be minimal. The licensee has been advised of the need to file the appropriate report in the next 15 days including its corrective action.

"Because the dose to the patient differs by more than 20% from that originally prescribed, the Agency must notify the U.S. NRC Operations Center with this event.

"Patient Information:
"Patient Number: 1; Patient Informed: Y; Date Informed: 08/28/2006
"Therapeutic: BRACHY, REMOTE AFTERLOADER, HDR
"Organ: BREAST, RIGHT
"Dose: 340 rad 3.4 Gy; % Dose is Less Than Prescribed: 90
"Effect on Patient: OTHER
Administered By: PHYSICIAN

"Patient Number: 2; Patient Informed: Y; Date Informed: 08/28/2006
"Therapeutic: BRACHY, REMOTE AFTERLOADER, HDR
"Organ: BREAST, RIGHT
"Dose: 340 rad 3.4 Gy; % Dose is Less Than Prescribed: 90
"Effect on Patient: OTHER
"Administered By: PHYSICIAN

"Source of Radiation:
"Form of Radioactive: SEALED SOURCE; Radionuclide or Voltage (kVp/MeV): IR-192
"Source Use: BRACHYTHERAPY; Activity: 10.2 Ci 377.4 GBq; Manufacturer: ALPH-OMEGA SERVICES
"Model Number: VS2000; Serial Number: 02-01-0699-001-062106-10250-03

"Device/Associated Equipment:
"Device Name: REMOTE AFTERLOADER HDR Model Number: VARISOURCE
"Manufacturer: VARIAN Serial Number: VS60037

"Reporting Requirements:
"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: Telephone"

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General Information or Other Event Number: 42812
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: BLACKBURN CONSULTING, INC.
Region: 4
City: AUBURN State: CA
County:
License #: 6589-31
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/30/2006
Notification Time: 00:00 [ET]
Event Date: 08/29/2006
Event Time: 12:30 [PDT]
Last Update Date: 08/30/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
C.W. (BILL) REAMER (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A POTENTIALLY DAMAGED TROXLER

The State provided the following information via facsimile:

"[The] Alternate Radiation Safety Officer called RHB to report their Troxler 3430, serial # 31984 (containing 8 mCi of Cesium-137 and 40 mCi of Americium-241) had just been run over by a water truck on a construction site in Lincoln, CA. [The Alternate RSO] stated the source rod was still intact. The gauge was taken to the Troxler facility in Rancho Cordova, CA. Troxler performed a leak test with negative results. The gauge is to be sent to Troxler headquarters in Research Triangle Park, NC for repair or eventual disposal."

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General Information or Other Event Number: 42823
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ADAMS STEEL
Region: 4
City: ANAHEIM State: CA
County: LOS ANGELES
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGOR
HQ OPS Officer: JASON KOZAL
Notification Date: 08/31/2006
Notification Time: 20:29 [ET]
Event Date: 08/29/2006
Event Time: 13:00 [PDT]
Last Update Date: 08/31/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
JOSEPH GIITTER (NMSS)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - INAPPROPRIATE DISPOSAL OF SOURCE

The State provided the following information via email:

"A truck carrying waste materials from Adams Steel in Anaheim set off the radiation alarm at the Simi Valley Landfill on 8/29/06. The landfill monitor reading was approximately 600K (bkg 4K). LA County (Joji Ortego) responded to the landfill on 8/30/06 and identified the nuclide as Cs-137, with radiation levels of 13 mR/hr on the side of the truck, 1.2 mR/hr at 3 feet from the side of the truck, and background in the cab of truck. Based on these radiation readings, it appears the source is located approximately 1 foot inside of the truck and is approximately 10 milliCi in activity. A DOT exemption form was completed by LA County and the truck returned to the Adams Steel yard late on 8/30/06, and parked in a remote location. LAC completed their own 5010 (082906) on the response to Simi Valley.

"RHB responded to Adams Steel on 8/31/06, and located an approximate 7 milliCi Cs-137 bare source, located approximately 3 feet from the top of the trailer load and approximately 1 foot in from the side of the trailer. The source was taken by RHB to hold until Adams Steel can arrange for disposal of the source."

California incident #083006

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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Power Reactor Event Number: 42824
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: JASON KOZAL
Notification Date: 09/01/2006
Notification Time: 12:01 [ET]
Event Date: 09/01/2006
Event Time: 11:15 [EDT]
Last Update Date: 09/01/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
JAMES DWYER (R1)
CINDY FLANNERY (NMSS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

SHIPMENT EXERNAL RADIATION LEVELS IN EXCESS OF LIMITS

"At 1115 EDT on 9/01/2006, Susquehanna LLC personnel became aware that a shipment received from another site exceeded the 10CFR71.47(b)(2) limit of 200 mr/hr contact dose rate. Contact dose rates on the bottom of the shipment are 820 mr/hr, and therefore reportable per the requirements of 10CFR20.1906(d)(2).

"There is no identified surface contamination on the shipment, and the shipment only exceeded the dose rate limit on the bottom once it was lifted off the transport trailer. Doses under the trailer prior to lifting the shipment did not exceed the limit"

"The transport company and the originating site have been notified. The transport vehicle left the Vermont Yankee facility on 8/31/06 and was received by SSES on 9/1/06 at 0805." . . . The driver has been contacted by the transport company.

"The vehicle made two stops during transport. The first was at the first rest stop traveling west on the Massachusetts Turnpike. The second was at the first rest stop on I-87 south after exiting I-90. No one to the knowledge of the driver came in contact with the shipment. The driver arrived at Susquehanna on 8/31/06 at 2045, and slept in the truck. The driver was wearing dosimetry [TLD]."

The licensee will notify State of Pennsylvania Emergency Management and has notified the NRC Resident Inspector.

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Friday, March 30, 2012