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Event Notification Report for April 17, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/16/2008 - 04/17/2008

** EVENT NUMBERS **


44133 44136 44137 44144

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General Information or Other Event Number: 44133
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: NETWORK CANCER CARE
Region: 4
City: PLANO State: TX
County:
License #: L05348
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOE O'HARA
Notification Date: 04/11/2008
Notification Time: 13:00 [ET]
Event Date: 04/11/2008
Event Time: [CDT]
Last Update Date: 04/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD DEESE (R4)
RON ZELAC (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING STRONTIUM-90 BETA APPLICATOR

The State of Texas reported that a 55 milliCuries strontium-90 beta applicator, Amersham Model SIA.20, is currently missing. The device was formally used at a cancer treatment facility in Plano, Texas, which has since filed for bankruptcy protection. The device was not returned to the authorized user upon sale of the property. The state believes the device is locked and stored in the building and is attempting to gain access through the bankruptcy trustee. The state is investigating and will provide further details at a later date.

* * * UPDATE FROM RAY JISHA TO JOE O'HARA AT 1730 0N 4/11/08 * * *

The State of Texas has inspected the business and accounted for the missing beta applicator. Additionally, they have discovered some other nuclear source material. The state has served an impoundment order on the business and has secured all of the sources in the building pending additional investigation and follow-up.

Texas Incident No. I-8500

Notified R4DO(Deese) and FSME(Kock).

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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General Information or Other Event Number: 44136
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City:  State: MS
County: HOLMES
License #: MS-493-01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2008
Notification Time: 10:02 [ET]
Event Date: 04/09/2008
Event Time: 07:00 [CDT]
Last Update Date: 04/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - MISSISSIPPI - TRAFFIC ACCIDENT INVOLVING TRUCK CARRYING TC-99M

The State provided the following information via email:

"DRH [Mississippi Division of Radiological Health] received a phone call from Cardinal Health RSO on 4-9-08 about a transportation accident involving one of their transport vehicles and an 18 wheeler on Hwy 49 South near Tchula, MS. The accident happened around 7:00 AM. The Cardinal driver had already made his deliveries to the facilities and only had the return packages (used doses) from the day before. According to RSO, driver hit the rear of the 18 wheeler after he made a sudden stop on the highway. According to RSO, all packages stayed secured and braced and their was no contamination or contents spilled out of the packages. Another driver was in route to location to pick up the other driver and the radioactive packages to return them to the Flowood facility."

The material being transported was used doses of Tc-99m and there was no spillage or cleanup required.

MS Report No. MS-493-01

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General Information or Other Event Number: 44137
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/14/2008
Notification Time: 11:22 [ET]
Event Date: 12/11/2007
Event Time: [CDT]
Last Update Date: 04/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MISSISSIPPI - MISADMINISTRATION INVOLVING AN HDR TREATMENT

The State provided the following information via email:

"On 3-26-08, licensee's RSO notified DRH [Mississippi Division of Radiation Health] of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. "

MS Report No. MS-08004

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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Power Reactor Event Number: 44144
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: TIM BUNKELMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 04/16/2008
Notification Time: 18:08 [ET]
Event Date: 04/16/2008
Event Time: 14:26 [CDT]
Last Update Date: 04/16/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAURA KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

TWO GALLONS OF RADIOACTIVE WATER SPILLED IN PROTECTED AREA

"A small quantity of radioactive water spilled on the concrete in the Protected Area and is in the process of being cleaned up. Approximately two gallons of water leaked from a shipping container being moved from Containment. The water was contained to the local concrete and tractor trailer receiving the load. The tractor trailer remains in the Protected Area and will be processed for free release. Initial analysis shows the presence of Co-58, Mn-54, Co-60, and Cs-137. Specific activity levels are not available at this time. No individual contaminations occurred during this event.

"The licensee has reported this event to the Wisconsin Department of Natural Resources (WDNR) pursuant to WDNR Regulation NR706.03 at 1426 CDT. Subsequent review has determined that this event was not reportable to the WDNR and an update was provided to the WDNR at 1800 CDT.

"This event is reportable under 10 CFR 50.72 (b)(2)(xi), 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.'"

The Licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012