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Event Notification Report for March 2, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/01/2007 - 03/02/2007

** EVENT NUMBERS **


43183 43188 43192

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General Information or Other Event Number: 43183
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: IPS
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: 310-0901
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: BILL GOTT
Notification Date: 02/23/2007
Notification Time: 20:43 [ET]
Event Date: 02/22/2005
Event Time: 06:00 [CST]
Last Update Date: 03/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
JOSEPH HOLONICH (FSME)
THOMAS BLOUNT (IRD)
CHUCK CAIN (R4)
BRUCE MALLET (R4)
LEN WERT (R4)
CHARLES MILLER (FSME)
MARTIN VIRGILIO (DEDO)
MELVYN LEACH (NSIR)
ROY ZIMMERMAN (NSIR)

Event Text

AGREEMENT STATE REPORT - MISPLACED SOURCE CAUSES POSSIBLE OVEREXPOSURE

At approximately 0600 on 2/22/07 while loading a well logging source (Gulf Nuclear CSV H90 1 Curie Cs-137 source) into the pig on the truck, the crew unknowingly dropped the source in the motor pool parking lot. The source was picked up by a mechanic at approximately 0900 and he put it in the pocket of his jacket. He did not realize that it was radioactive, but thought it might be a part to something. The mechanic wore the jacket for about 4 hours. He visited several businesses including a sandwich shop. He hung the jacket in the break room where it remained for the remainder of the day and over night. On 02/23/07, the mechanic put the jacket back on. The well logging crew returned to the facility at approximately 0600 and discovered that the source was missing when they unpacked their equipment. The crew did not discover the missing source earlier because they did not need to use the source on a job site. The crew immediately started a search for the source. The mechanic produced the source when he heard that it was missing. In total the mechanic wore the jacket about 5.5 hours over the 24 hour period. This is an estimate based on an interview with the mechanic who was uncertain about the exactness of his recollection for the time he wore the jacket.

The mechanic and a couple of coworkers were taken to a local hospital emergency room and examined. No abnormalities were noted. They are scheduled to return to the emergency room on 2/24/07. Oklahoma continues to investigate. There has been no media interest.

The R4 PAO (V. Dricks) was also notified.

* * * UPDATE ON 02/24/07 AT 1025 EST BY MIKE BRODERICK TO MACKINNON * * *

Patient received two white blood cell counts, one on 02/23 and the other on 02/24, at Integris Baptist Hospital, Oklahoma City, Oklahoma, and both white blood cell counts were normal. The Doctor does not think the patient received a large dose. Patient is to report back in 1 week for follow-up testing.

A blood sample of the patient will be sent to RPA located in London, England for chromosome analysis.

R4DO ( Bill Jones) and NMSS EO (Joe Holonich) notified.

* * * UPDATE ON 02/24/07 AT 1228 EST BY MIKE BRODERICK TO W. GOTT * * *

The patient visited the hospital emergency room again on 2/24/07. The ER Physician stated there was no sign of radiation effects. Oklahoma is arranging for the exposed individual to see a radiologist and/or oncologist at the OU Health Sciences Center. Blood samples will be drawn and provided to RPA in the UK for chromosome analysis. The state investigation is continuing.

R4DO ( Bill Jones) and NMSS EO (Joe Holonich) notified.

* * * UPDATE ON 02/26/07 AT 1117 EST BY MIKE BRODERICK TO P. SNYDER * * *

The state provided a matrix of dose rate readings taken around the source by the licensee. The state is evaluating the information. The NRC continues to interface with the state on this event.

Notified R4 (C. Cain), R4DO (D. Powers) and NMSS EO (S. Wastler).

* * * UPDATE ON 02/26/07 AT 1255 EST BY MIKE BRODERICK TO J. KNOKE * * *

"When the mechanic removed the jacket containing the source, he initially hung it on a bollard (cement & metal post to keep vehicles away from a building) outside the logging company office. It was there all afternoon, the assistant mechanic stated that he was working in that area, so he has the possibility for exposure. The mechanic who was the main exposed person moved the jacket to the company break room at quitting time. There were staff working around the clock Thursday night, so there is a definite possibility staff were near the jacket while it was hanging there. Fortunately, the break room is small (more like a large closet) so most likely they would have gotten coffee and left. We will be interviewing staff this afternoon to try to nail this down."

"The exposed individual will see a very well-qualified physician, this afternoon. DEQ staff asked him to sign medical releases authorizing release to DEQ and to NRC. A blood sample will be taken and shipped to England for chromosome analysis.

"DEQ staff will be doing interviews this afternoon with facility staff who were potentially exposed to the source. DEQ staff will use this information to determine who else may warrant medical follow-up. We will also get confirmatory readings on the radiation level of the source with an ion chamber (as opposed to the GM tubes used by the company measures sent earlier).

Notified R4 (C. Cain) Email only, R4DO (D. Powers) and NMSS EO (S. Wastler).

* * * UPDATE ON 02/26/07 AT 1908 EST BY MIKE BRODERICK TO W GOTT * * *

"The primary exposed individual ('A') has been seen by a physician from the OU Health Sciences Center who has strong radiation protection credentials. The physician's belief is that the patient will probably suffer radiation burns on his abdomen, and possibly on his fingertips. He doesn't expect any other short-term effects. No burns or other effects are visible now. There is no sign of GI tract syndrome. 'A' is going to have follow-up visits with the physician at one week and two weeks, and possibly additional visits.

"A blood sample has been taken from 'A' and tomorrow it will be shipped to England for chromosome analysis. There was some delay due to international shipping requirements for biohazardous material.

"DEQ and OU HSC staff worked together this afternoon to take measurements using ion chambers. The measurements showed lower readings than those calculated through inverse square law. We will prepare a detailed report tomorrow and send it. In short, the dose level with the ion chamber case in contact with the source was 3.3 rem/hour, falling off to 139 mrem/hour at one meter. A badge was exposed to the source at one inch for 3 minutes 35 seconds, and is being sent to Landauer for emergency processing, which will give us more information.

"DEQ staff interviewed additional personnel at the licensee this afternoon, focusing on determining who might have been exposed to excess dose other than 'A.' Tentatively, the most at-risk individual appears to be a coworker who rode with 'A' to lunch. While they were in the cab of a pickup truck, the coworker was sitting in the passenger seat on the opposite side of 'A's' body from the source, and across a sandwich shop booth from 'A' during lunch. After lunch, 'A' and the coworker worked together on a logging truck with the coat (and source) hanging a couple of yards away. They spent most of their time under the truck, which would have provided considerable shielding. Tentatively we think it is conceivable the coworker broke the limit for dose to the public, but doubt there was medically significant exposure. We will do a detailed analysis tomorrow to test this."

Notified R4DO (D. Powers) and FSME EO (J. Holonich)

* * * UPDATE PROVIDED BY MIKE BRODERICK TO JEFF ROTTON VIA EMAIL AT 1723 EST ON 02/27/07 * * *

"The results for the dosimeter that was exposed to the Cesium source at one inch for 3 minutes 35 seconds were reported from Landauer this afternoon. Deep dose was 16,106 mrem and shallow dose was 15,374 mrem. This works out to about 4.4 R/minute or 264 R/hour skin dose.

"The package containing the blood sample from 'A' was shipped to England via overnight delivery this afternoon. Results are expected in the first half of next week."

The results of the examination of 'A' by an OUHSC radiologist have been received and will be combined with the ER records from the weekend and faxed to the NRC on 02/28/07. The results were not substantially different from the verbal report on 02/26/07 and described in the update on the afternoon of 02/26/07.

Notified R4DO (Powers) and FSME EO (Mohseni).

* * * UPDATE PROVIDED BY MIKE BRODERICK TO BILL HUFFMAN AT 0030 EST ON 03/01/07 * * *

OK DEQ provided corrections to the previous report information. Specifically, the well logging source was originally reported to be a directional source. DEQ states that the source was not a directional source. In addition, the update on 2/27/07 reported a dose rate of 4.4 mrem/minute. This should have been 4.4 Rem/minute. The text of the previous report information has been corrected accordingly.

Notified R4DO (Powers) and FSME EO (Davis).

* * * UPDATE PROVIDED BY MIKE BRODERICK TO HUFFMAN AT 1000 EST ON 03/01/07 VIA E-MAIL * * *

The blood sample for chromosomal analysis has arrived in England and been received in good condition. They advise us they expect results on Tuesday.

Notified R4DO (Powers) and FSME EO (Morell).

* * * UPDATE PROVIDED BY MIKE BRODERICK TO JASON KOZAL AT 1524 EST ON 03/01/07 VIA E-MAIL * * *

"This morning the DEQ investigators visited the facility. We met with corporate management. They briefed us on their investigation and steps so far. They are doing root cause analysis of the incident. They will be doing several equipment upgrades to reduce exposure and increase certainty in handling sources. As a temporary measure they have removed the sources of the type in the incident (which did not have positive engagement of the source with the handling stick) from service until the handling sticks can be upgraded. They are doing additional staff training and will be seeking to change the safety culture at the company. As a temporary measure, they have a policy that a member of management must be present during all source handling at the shop. We explained our enforcement process to them. We informed management that based on calculations by NRC and DEQ, it appeared that a coworker of 'A' may have exceeded the dose limit for non-radiation workers, with a calculated dose of 140 mrem. We met with the coworker and explained his potential exposure, setting it in context by comparing it to the dose rate from natural background and the dose limits for radiation workers. As a precautionary measure, the company expects to do medical follow-up for this worker's exposure. We met with 'A' to follow up on his visit with a radiologist on Monday. He complained of nervous stress, but stated he had experienced no sensitivity or evidence of burns in the affected areas. We urged him to contact the radiologist immediately if he experienced any of the expected radiation symptoms. We asked 'A' some questions to clarify his interactions when he unknowingly had the source with him off-site. It does not appear that there was anyone off-site who had enough potential exposure to warrant follow-up."

Notified R4DO (Powers) and FSME EO (Morell).

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General Information or Other Event Number: 43188
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SOUTHWEST RESEARCH INSTITUTE
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L00775
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/26/2007
Notification Time: 15:31 [ET]
Event Date: 02/26/2007
Event Time: [CST]
Last Update Date: 02/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SANDRA WASTLER (NMSS)
DALE POWERS (EMAIL) (R4)

Event Text

AGREEMENT STATE REPORT

"On 2/26/07 at about 13:30 the licensee notified the Agency that they had received 8 sources from White Sands Missile Base containing cobalt sixty (Co-60) sources. Four were estimated to have activities of 3,000 curies and four had estimated activities of 1,000 curies. Southwest opened one of the containers used to ship the sources to leak test the source. Upon opening the container, it appeared that the source was no longer contained in a source capsule. The leak test results indicated 5 million DPM. The container was resealed and no other containers were opened."

Containers were opened with automation equipment, therefore no exposure to personnel occurred.

TX Report TX-07-43188


* * * UDPATE ON 02/27/07 AT 0950 EST FROM ARTHUR TUCKER VIA E-MAIL TO MACKINNON * * *

"On 2/26/07 at about 11:00 the licensee notified the Agency that they had received eight (8) cobalt sixty sources from White Sands Missile Range. Each of the eight sources was contained in a separate container. Four sources had estimated activities of 3,000 curies and four had estimated activities of 1,000 curies. The outside of each container was surveyed after receipt and contamination levels were found to be below their limits. SWR opened one of the containers used to ship the sources to leak test the source. The source was a Neutron Products Inc. model no. NPU-25-13000 capsule serial # T-96-5. The container was opened in SWR hot cell using manipulator arms. Upon opening the source container, it appeared that the source capsule had been breached. The leak test results indicated 5 E6 dpm of contamination. The container was sealed and no other sources were opened. The sources were removed from the hot cell. The hot cell was surveyed and found to be contaminated. The hot cell was decontaminated and returned to service.

R4DO (Dale Powers) & NMSS EO (Greg Morell) notified.

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General Information or Other Event Number: 43192
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120-78-0000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2007
Notification Time: 14:04 [ET]
Event Date: 09/27/2006
Event Time: [EST]
Last Update Date: 03/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

At 1405 EST on 02/26/07, the state received a report via the US Mail from Akron General Medical Center. On 09/27/06 a patient was receiving a 10 fraction dose for Mammo-site Breast Brachytherapy using a HDR afterloader with a total prescribed dose of 3400 RAD. A problem with the PLATO planning computer digitized the breast image using an incorrect treatment factor which doubled the fractional dose. The same total prescribed dose was delivered but in 5 vice 10 fractional doses. The patient was made aware of the error on 09/27/06. Tissue necrosis was observed due to the procedure, but it is being evaluated if any additional necrosis occurred due to the delivery of the total dose in 5 fractions vice the 10 planned fractional doses. The licensee is taking corrective action to prevent a reoccurrence of this type of error.

* * * UPDATE FROM FSME (FLANNERY) TO KNOKE ON 02/28/07 * * *

This event has been reviewed and determined to be a reportable medical event.

* * * UPDATE FROM OHIO DEPARTMENT OF HEALTH (MARK LIGHT) TO HUFFMAN ON 03/01/07 AT 1000 EST * * *

The State provided the following update to this report via facsimile:

"On September 28, 2006, the licensee notified the ODH Bureau of Radiation protection that they had an event which did not meet the reporting requirement of a medical event but they were revising their HDR program to prevent a recurrence. The Bureau requested a report that was received on February 26, 2006. The patient was to receive a total dose of 3400 rad total dose through 10 fractions of 340 rad each. The patient received 5 fractions of 680 rad for a total dose of 3400 rad. Upon review of the report it was determined by consultation with NRC Region 3 that a medical event did occur because 'Prescribed Dose' for remote afterloaders includes Total Dose and Fractionated dose. The reason for the event was the Physicist entered the wrong planning film magnification into the treatment system. The patient has experienced some tissue necrosis at the treatment site, although some necrosis is expected with this therapy (MammoSite). The necrosis may have been exacerbated by the dosage scheme. The patient is being followed by her attending physician. The patient and attending physician were notified on 09/27/2006. The Bureau conducted an inspection on November 2, 2006 and identified problems with the licensee's HDR program an additional inspection will be conducted during the week of March 5, 2007."

The R3DO (Lanksbury) and FSME EO (Morell) were notified.

Ohio Report OH2007-11

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.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012