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Event Notification Report for October 10, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/09/2007 - 10/10/2007

** EVENT NUMBERS **


43685 43691 43703 43704

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Hospital Event Number: 43685
Rep Org: CARILION CLINIC
Licensee: CARILION CLINIC
Region: 1
City: ROANOKE State: VA
County:
License #: 45-25395-01
Agreement: N
Docket:
NRC Notified By: JOE SURACE
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/03/2007
Notification Time: 14:21 [ET]
Event Date: 08/31/2006
Event Time: [EDT]
Last Update Date: 10/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
RAY POWELL (R1)
MICHELE BURGESS (FSME)

Event Text

MEDICAL EVENT INVOLVING HIGHER THAN PRESCRIBED DOSE

On August 31, 2006 a female patient received mammosite treatment for a breast lesion using a HDR with an Ir-192 source. The treatment consisted of placing a catheter into the treatment site, inflating a balloon with between 35-75 ml saline and positioning the Ir-192 source inside the catheter into the center volume of the saline balloon. This allows for a homogenous dose to the treatment site. While in the OR (Operating Room), the catheter was inserted and saline introduced through one of the two catheter connections to inflate the balloon. The patient was taken to the HDR location where the technologist inadvertently connected the HDR to the saline vice the HDR connector. This resulted in draining the saline balloon into the HDR unit. The technologist recognized that the HDR was improperly connected, broke the connection and reconnected to the proper port. When the prescribed 416 second treatment was commenced, the HDR automatically shutdown after 223 seconds retracting the Ir-192 source to the safe position. An evaluation by the licensee concluded that the incident was not reportable since it did not meet the criteria for an underdose.

During an inspection conducted 7/26/07 (Inspection Report No. 2007-001), the NRC Inspector noted that since the saline balloon had been inadvertently drained tissue in a .5 cubic centimeter volume adjacent to the source received a significantly higher dose (approximately 20 Gray) than prescribed. In a follow-up call from NRC Region I on 10/03/07, the licensee was requested to notify the NRC Operations Center of this finding.

The licensee informed the prescribing physician and the patient was also notified. No adverse effects to the patient have been noted.

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: 43691
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KEYMASTER
Region: 4
City: KENNEWICK State: WA
County:
License #: WN-I0282-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: PETE SNYDER
Notification Date: 10/04/2007
Notification Time: 18:29 [ET]
Event Date: 09/24/2004
Event Time: [PDT]
Last Update Date: 10/04/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
NADER MAMISH (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

"Keymaster's Radiation Safety Officer reported they had recently (in September 2004) received a batch of eleven Cobalt 57, foil sources, Model PHI-0106, from Isotope Products Laboratory. One of the eleven sources failed its receipt leak test. The others were tested and were not leaking.

The State of Washington provided the following information via e-mail:

"The contaminated foil source had Serial Number B9-774 and had an activity of 437 megabecquerels (11.8 millicuries). When wiped, the level of contamination was about 500 counts per minute above background. The source may have been leaking or could have had residual contamination; this was never determined. The source was returned to the supplier.

"The work areas and personnel were surveyed and found uncontaminated.

"No media attention at present.

"Subsequent inspections by DOH performed 10/31/2005 and 9/21/2006 found no contamination and no additional reoccurrences of receiving contaminated sources.

"Notification Reporting Criteria: WAC 246-221-250

"Isotope and Activity involved: Cobalt 57, 437 mBq (11.8 mCi).

There were no overexposures. The leaking source was an Isotope Products Laboratories XRF source Model PHI-0106, S/N B7-461. The leaking source was wiped down to 416 counts, placed back into its shield. It was returned to supplier.

There was minor contamination in the source storage area. The licensee has since cleaned the area. Wipe surveys performed by the licensee and DOH showed no contamination.

State of Washington Event Report # WA-04-042.

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Power Reactor Event Number: 43703
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOM POETZSCH
HQ OPS Officer: JASON KOZAL
Notification Date: 10/09/2007
Notification Time: 09:41 [ET]
Event Date: 10/09/2007
Event Time: 09:15 [EDT]
Last Update Date: 10/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CAROLYN EVANS (R2)

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 N 0 Refueling 0 Refueling

Event Text

ELEVATED ONSITE TRITIUM LEVELS

"Thirty new ground water monitoring wells were recently installed at Catawba Nuclear Station in support of the Nuclear Energy Institute (NEI) ground water initiative. The initial sampling of one of these wells displayed a level of tritium that triggered the communication protocol of the NEI initiative on ground water protection. The tritium concentration for this well was 42,335 picocuries per liter (pCi/l). The threshold for initiating the communication protocol is 20,000 pCi/l. This well is inside the owner controlled area. Adjacent wells surrounding this well do not have similar tritium levels. The station is continuing to investigate the source of tritium identified in this well. Samples from the remaining wells are far below the communication protocol threshold. There is no public risk associated with this well sample. There is no indication that tritium has migrated off the Catawba site in the ground water at the communication threshold. Also this well is not a drinking water source and therefore, there is no potential dose to plant workers or the public."

The licensee notified the NRC Resident Inspector.

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Research Reactor Event Number: 43704
Facility: PENNSYLVANIA STATE UNIVERSITY
RX Type: 1000 KW TRIGA MARK III
Comments:
Region: 1
City: UNIVERSITY PARK State: PA
County: CENTRE
License #: R-2
Agreement: N
Docket: 05000005
NRC Notified By: MARK TRUMP
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/09/2007
Notification Time: 16:45 [ET]
Event Date: 10/09/2007
Event Time: 16:00 [EDT]
Last Update Date: 10/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
WILLIAM COOK (R1)
MARVIN MENDONCA (NRR)
ALEXANDER ADAMS (NRR)
SCOTT FLANDERS (FSME)
MARK CUNNINGHAM (NRR)

Event Text

POSSIBLE LEAK AT PENN STATE RESEARCH REACTOR

Pennsylvania State University Operations personnel noticed increased makeup at the Breazeale (Triga) reactor, an open pool reactor. At 1600, the leak rate was measured at approximately ten gallons per hour. The Pennsylvania Department of Environmental Health was notified of the probable leak to the environment (possibly to the ground around the containment pool). The licensee has not reached any required reporting criteria.

Water activity:
Gross Alpha: less than minimum detectable
Gross Beta: approx. 3.8 picoCuries/liter
Chromium Gamma: approx. 103 picoCuries/liter

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