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Event Notification Report for April 18, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/17/2007 - 04/18/2007

** EVENT NUMBERS **


43301 43302 43305

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General Information or Other Event Number: 43301
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City:  State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/13/2007
Notification Time: 15:56 [ET]
Event Date: 03/07/2007
Event Time: [EDT]
Last Update Date: 04/16/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1)
ABY MOHSENI (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"A brachytherapy misadministration involving a 31year old female patient with a history of vaginal cancer was reported to NYS DOH BERP on 3/9/07.

"The patient was successfully treated to 5590 cGy to the target volume using external beam (IMRT) therapy and she was to receive 2500-3000 cGy via interstitial brachytherapy with both Cesium-137 and lridium-192 (seeds in ribbons) sources.

"The medical physicist developed a treatment plan as directed by the authorized user/ radiation oncologist using a commercial treatment planning software application. Eleven ribbons with 8 seeds each and an activity of 1.855 mgRaEq per Ir-192 [3.19 mCi] seed were ordered from Best Industries. Hospital owned Cs-137 sources were selected for use. The medical physicist verified source strength of all sources. The oncologist reviewed and approved the plan. He prescribed a total dose of 2500 cGy to be delivered to the 50 cGy-isodose line for a total treatment time of 50 hours.

"At 2:30 PM on 3/6/07 the sources were placed into the patient. A Syed template was used to place the ribbons and the Cs-137 sources were loaded into a tandem applicator.

"On 3/7/07, late in the morning, the medical physicist performed a manual check of the treatment plan calculations and identified a significant discrepancy - the hand calculations indicated a significantly higher dose rate than what was generated from the treatment planning software. An investigation ensued, which included consultation with the TPS vendor's application specialist. After several hours of investigation it was determined that the original treatment plan was in error, and at 5:30 PM on 3/7/07, after 27 of the intended 50 hour treatment time, the radiation oncologist decided to remove the sources [from the patient].

"Instead of the intended 2500cGy, the patient received an estimated dose of 4590 cGy and the anterior rectal dose was approximately 7300 cGy.

"The licensee provided a written report as required, and DOH staff performed an on-site investigation on 3/21/2007.

"Cause and contributing factors:

"1. The primary error was the use of an inappropriate Dose Rate Factor in the TPS. The value used corresponded to the DRF for Air Kerma however the source strength entered was in MgRaEq. The physicist should have changed the units of source strength or entered the correct DRF.

"2. Changing the units of activity in the TPS does not generate a prompt for a new Dose Rate Constant.

"3. During the physics review it was determined that acceptance testing of this treatment planning software did not include Iridium-192. The acceptance testing covered Cesium -137 and Iodine -125 seeds which where the only materials being used at the time. If this testing had been performed the physicist would have been more likely to recognize that the treatment planning system does not automatically select the correct dose rate factor when the source strength units are changed.

"4. There was no check of the preplan before the seeds arrived although there was sufficient time (sources ordered 2/27/07). The plan was approved on 3/6/07.

"5. Neither the physicist nor the radiation oncologist had prepared a treatment with Ir-192 in six years and the physicist had not used this particular TPS for Ir-192 implants. It would have been prudent to have an additional review or outside review in order to verify there were no oversights or errors.

"6. The double check was not done until after the day after sources had been implanted. Again while the physicist was observing the minimum requirements of Part 16 it would have been prudent to perform a check of the calculations either prior to the implant or immediately thereafter.

"Corrective action: The policy and procedures have been changed to require a check of calculations for any single fraction brachytherapy treatment to be performed and approved prior to initiation of treatment.

"Patient condition and follow-up: The radiation oncologist disclosed that the patient is at risk for radiation cystitis, rectal proctitis and more importantly, fistula formation between the rectum and the vagina. The patient will be monitored closely over the next year by both her gynecologic oncologist and the radiation oncologist. The patient is currently being treated with broad spectrum antibiotics along with daily treatments in a hyperbaric oxygen chamber."

NY Event No: NYS-DOH 07-001

* * * UPDATE ON 4/16/2007 AT 1112 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN * * *

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

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: 43302
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS INSTRUMENTS
Region: 4
City: DALLAS State: TX
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOE O'HARA
Notification Date: 04/13/2007
Notification Time: 18:15 [ET]
Event Date: 03/15/2007
Event Time: [CDT]
Last Update Date: 04/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
ABY MOHSENI (FSME)

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

Event Text

AGREEMENT STATE REPORT - THREE LOST TRITIUM EXIT SIGNS

"The RSO called [1625 CDT on 4/13/07] to report that during their quarterly inventory check, the facility discovered that (3) tritium exit signs were lost: Mfg: BetaLux Model 171-20-R-U-WH-D-RD, Serial Numbers: 255-381; 255-319; 255-399, Activity Source: 20 Ci each.

"Root Cause: The RSO [and] Incident Review board believe the exits signs were inadvertently knocked down [and] thrown away, so that the person responsible would not be found out [and] held accountable. TI runs a 24 hour-7day operation, so the RSO explains it is very difficult to find the culprit(s).

"Committee corrective action: Current [and] replacement signs will be attached with a secondary tether so that if the signs are knocked down, they will not fall down, but dangle until refastening is performed.

"Texas Incident Number: I-8403."

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

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Fuel Cycle Facility Event Number: 43305
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: BILLY WALLACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/17/2007
Notification Time: 11:36 [ET]
Event Date: 04/16/2007
Event Time: 19:15 [CDT]
Last Update Date: 04/17/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOEL MUNDAY (R2)
GREG MORELL (NMSS)

Event Text

LARGE WATER LEAK ON HIGH PRESSURE FIRE WATER SYSTEM

"At 1915, on 04/16/07, the Plant Shift Superintendent was notified of a large water leak on High Pressure Fire Water system. This system provides water for fire suppression to the plants process buildings. An alarm was received indicating a drop in the level of High Pressure Fire Water (HPFW) elevated tank. The buildings were contacted to look for a large water leak and the leak was quickly located inside the C-337 process building. The exact system leaking was not apparent as the leak was under the building concrete floor. To stop the leak the
HPFW pumps supporting the system were shutdown and the sectional valves outside the building were closed. This action made the HPFW system for all process buildings inoperable. LCO actions 2.4.4.8 and 2.4.4.6 were entered. The leak was determined to be on C-337 system C-12 and this system and the two adjacent systems were isolated and all other previously isolated valves were reopened. The HPFW pumps were restarted and the HPFW elevated tank was refilled to the TSR required level. These actions restored HPFW operability to the other areas in the plant at 2101 hours. TSR required hourly fire patrols were initiated for the affected area in C-337. The leak is located on an underground eight inch header under the alarm and actuation controls for system C-12 inside the building.

"This is being reported as an event in which equipment is disabled or fail to function as designed when the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and no redundant equipment is available."

The licensee stated that this leak caused substantial damage to the concrete pad on the floor of the building. No structural damage is believe to have occurred but the concrete pad with have to be completely removed, the piping repaired, and eroded earth backfilled. A new concrete pad will then likely need to be poured. Nearly half a million gallons of water may have been lost through the break before it was isolated. The licensee has checked the site outfalls and no contamination was detected.

The licensee notified the NRC Resident Inspector.

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