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Event Notification Report for July 3, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/02/2007 - 07/03/2007

** EVENT NUMBERS **


43445 43447 43448 43468

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General Information or Other Event Number: 43445
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PROVIDENCE MEDFORD MEDICAL CENTER
Region: 4
City: MEDFORD State: OR
County:
License #: ORE-91035
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/26/2007
Notification Time: 19:12 [ET]
Event Date: 06/25/2007
Event Time: [PDT]
Last Update Date: 06/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
EDWIN HACKETT (FSME)

Event Text

OREGON AGREEMENT STATE REPORT - UNDERDOSE DUE TO EQUIPMENT MALFUNCTION

"On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated.

"Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment.

"Dosimetry reconstruction of the delivered dose indicates that 17.8% of the prescribed dose was delivered. Physician will reconstruct new treatment plan. Treatment Details: The patient was receiving HDR treatment #2 to a Miami vaginal cylinder with tandem. This apparatus is connected to the HDR After loader (with radioactive wire) with 7 separate connecting tubes, one for each treatment channel. During connection, bloody fluid was noted on one of the connectors, cleaned, and the tube connected. The treatment was initiated, but after that tube was treated, the device's computer indicated the wire positioning was not reproducible (error code 18 - Wire drift detected) and the treatment was paused. The QA positioning test was run and within acceptable limits. The treatment was continued, but the device again indicated positioning errors. The treatment was discontinued without being fully completed.

"Protective caps covering the tubes were removed in surgery instead of waiting until the patient arrived in the department, a typical procedure that had not caused an incident in the past. In the future, it is prudent to leave them connected until the patient is ready to be connected to the treatment device. Two lessons learned from this experience: For HDR cases using a tandem, the tandem channel should be treated first, since the prescribed dose is more influenced by tandem dose than by ovoids or vaginal cylinder. The protective caps on the applicator should be left on as long as possible to reduce or preclude any fluid in the closed system.

"Device: Varian VariSource High Dose Rate After loader, S/N#: 600379, SS&D #: CA-0661-D-103-S,
Source: Alpha - Omega Model #: VS 2000, SS&D #: CA-1080-S-102-S, S/N #: 02-01-0588-001-041907-10089-97, Activity: 10.089 Ci on 4/19/07"


* * * UPDATE AT 0844 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *

"This event (EN43443) 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: 43447
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: STARMET NMI
Region: 1
City: CONCORD State: MA
County:
License #: SM-0179, SU-1
Agreement: Y
Docket:
NRC Notified By: BOB GALLAGHAR
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/27/2007
Notification Time: 09:05 [ET]
Event Date: 06/26/2007
Event Time: 20:00 [EDT]
Last Update Date: 06/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - SMALL FIRE AT LICENSEE'S FACILITY

"On Wednesday, June 26, 2007, at approximately 8:00 PM EST a fire was reported at the Starmet NMI facility in Concord, Massachusetts [2229 Main Street]. Starmet NMI possesses two materials licenses with Massachusetts, License No. SM-0179 and License No. SU-1453. The fire occurred in the foundry area within the facility, formerly used for the manufacture of depleted uranium munitions. The fire appeared to be contained to a small area within the building, in the vicinity of a 55-gal drum, a 5-gal bucket and a small pile of metal shavings.

"Radiological surveys performed once the fire was extinguished resulted in no elevated readings from any of these containers or the material. The investigation is ongoing and more information will be provided as it is obtained."

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General Information or Other Event Number: 43448
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: ECS - CAROLINAS, LLP
Region: 1
City: WILMINGTON State: NC
County:
License #: 584
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/27/2007
Notification Time: 09:29 [ET]
Event Date: 06/26/2007
Event Time: 13:05 [EDT]
Last Update Date: 06/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE RREPORT - DAMAGED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"The SC Department of Health and Environmental Control (DHEC) was notified on Tuesday, June 26, 2007, at 1315 hrs, that a Humboldt Model EZ 5001, s/n 4965, containing 10 mCi of Cs-137 and 40 mCi of Am-241:Be, had been damaged at 1305 hrs on June 26 2007. The RSO stated that the gauge had been damaged by a bulldozer. [The SC DEHC] Duty Officer responded to the scene and arrived at 1510 hrs. The area around the gauge had been properly roped off and the source rod was locked in its shielded position. The gauge handle and rod had been snapped off at the top of the gauge and the top of the gauge was cracked open at the rod end. The gauge was secured in the transport container and the inspector advised the RSO to return the gauge to the permanent storage location, secure it from further use, and to contact the gauge manufacturer for further instruction regarding disposal.

"The RSO was advised by [the SC DEHC] to submit a written report detailing this event to the Department within 30 days. The event is open and pending the licensee's investigation and report to the Department, updates will be made through the national NMED system.

"Location: Calvary Baptist Church, 3810 Grandview Drive, Spartanburg, SC"

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Other Nuclear Material Event Number: 43468
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-01222-05
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/02/2007
Notification Time: 17:03 [ET]
Event Date: 06/26/2007
Event Time: [EDT]
Last Update Date: 07/02/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROGER LANKSBURY (R3)
EDWIN HACKETT (FSME)

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

Event Text

DAMAGED CAMPBELL PACIFIC MOISTURE DENSITY GAUGE

On June 26, 2007, the 62nd Engineering Unit, located in Ft. Hood, Texas and recently returned from deployment, sent an email to the US Army TACOM LCMC, located in Warren , MI regarding a damaged Campbell Pacific (CPN) MC-1 moisture density gauge, serial number: M7112095. The device contains a 10 millicurie Cs-137 source and a 50 millicurie Am-241:Be source (1977 activity strength). The email requested guidance on the failure of the device handled assembly to lock in 'safe' or any other position. The lead trap door is disconnected from pushrod and fails to allow source rod to extend. The unit is on recuperative leave and the US Army will follow up with the unit personnel later this week. The US Army will continue to investigate to determine the status of the device, where and when it was damaged, and the status of the sources and the device's storage location.

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.

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