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Event Notification Report for January 17, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/16/2007 - 01/17/2007

** EVENT NUMBERS **


43087 43091 43104

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General Information or Other Event Number: 43087
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: CARE ALLIANCE HEALTH SERVICES ROPER HOSPITAL
Region: 1
City: CHARLESTON State: SC
County:
License #: 646
Agreement: Y
Docket:
NRC Notified By: JAMES PETERSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/10/2007
Notification Time: 17:30 [ET]
Event Date: 01/09/2007
Event Time: [EST]
Last Update Date: 01/10/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)
JOSEPH GIITTER (NMSS)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT - BRACHYTHERAPY

The State provided the following information via facsimile:

"Licensee has notified State Agency within 24 hours.

"A Mick applicator malfunctioned during the planned treatment of a prostate patient. The patient was scheduled to receive I-125 seed implants totaling 11 millicuries at 0.25 millicuries per seed. A total of 8.25 millicuries were implanted when the malfunction occurred. This will most likely result in the total dose delivered differing from prescribed dose by 20 percent or more. The dose information was not currently available but will follow in NMED reporting. The seeds not implanted have all been accounted for and have been placed in storage. The licensee will provide a written report within 15 days. No further information is available at this time."

SC Event Report: SC070001

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 43091
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLINTON MEMORIAL HOSPITAL
Region: 3
City: CLINTON State: OH
County:
License #: OH02300140000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/11/2007
Notification Time: 13:09 [ET]
Event Date: 12/01/2006
Event Time: [EST]
Last Update Date: 01/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS KOZAK (R3)
JANET SCHLUETER (NMSS)

Event Text

AGREEMENT STATE - OHIO - EQUIPMENT MALFUNCTION OF A COBALT TELETHERAPY DEVICE

On January 2, 2007, Ohio Bureau of Radiation Protection received a written report that an equipment failure of a Cobalt Teletherapy Device had occurred on December 1st while treating a patient. The sealed source did not return to the closed positron after completing treatment. The therapists immediately entered the room and returned the source to a safe configuration. The department requested additional information from the licensee on January 2 and received the additional information on January 9, 2007. It has been determined that the licensee did not perform a 24 hour notification as required in rule 3701-40-20 of the Administrative Code. The patient was exposed to less that thirty seconds exposure time and a determination was made from the additional information provided that a medical event did not occur. The unit was repaired by Neutron Products on December 8, 2006. The problem identified was an old air cylinder and detent pin which was replaced returning the unit to normal operation. The Department notified the NRC Operations Center on January 11, 2007 after determination of reporting requirements.

Teletherapy unit is a Theratron-80, s/n 2640986, which is manufactured by Neutron Products. The Co-60 sealed source is 1690 Ci or 62530 GBq, model number NPTY, s/n T-1444.

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Other Nuclear Material Event Number: 43104
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: PRUDHOE BAY State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: LARRY RUSSELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/16/2007
Notification Time: 17:54 [ET]
Event Date: 01/10/2007
Event Time: 09:00 [YST]
Last Update Date: 01/16/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
VIVIAN CAMPBELL (R4)
SCOTT FLANDERS (NMSS)

Event Text

RADIOGRAPHY CAMERA MALFUNCTION

During an equipment checkout prior to use, the ball of the drive cable broke during hookup of the pigtail to the drive cable. The source was locked in the safe position and no exposure was realized due to this incident. The radiography camera is an INC IR100 Model 32 (Serial # 4813) with a 65.8 curie Ir-192 source (serial # J590). The camera will be sent to the manufacturer for inspection and evaluation of the failure.

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