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Event Notification Report for July 16, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/15/2008 - 07/16/2008

** EVENT NUMBERS **


44219 44341 44343 44344

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Hospital Event Number: 44219
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 07/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)

Event Text

POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED

"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.

"Permittee: VA Medical Center, Philadelphia, PA

"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.

"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.

"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.

"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.

"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."

* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *

"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.

"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).

R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.

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.


* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *

"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.

"VHA provided an initial update on June 6, 2008. This update reflects the most current information.

"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.

"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.

"Patient notification:

"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).

* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *

"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.

"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.

"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.

"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.

"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.

"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.

"The permanent implant brachytherapy program is suspended and an external review is in progress.

"Effect on patients:

"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.

"Patient notification:

"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.

"Other notification:

"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."

Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."

Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).

* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).

* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *

"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."

Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).


* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *

A 15-day written report of one of the medical events was submitted to NRC Region III.


Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).

* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.

"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)

* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).

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General Information or Other Event Number: 44341
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEO ENVIRON
Region: 4
City: ANAHEIM State: CA
County:
License #: 6636-30
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/10/2008
Notification Time: 15:44 [ET]
Event Date: 11/07/2007
Event Time: [PDT]
Last Update Date: 07/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
ROBERT LEWIS (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

Received report via email:

"On November 8, 2007, the licensee left a voice-mail message stating a moisture density gauge (Troxler Model 3430, S/N 29865), with a nominal 8 mCi of Cs-137 and 40 mCi of Am-241, had been run over the night before at a construction site. The cesium source was originally reported to be locked in its shielded position, although it was later discovered that the source was shielded, but not lockable. The electronics were severely damaged. While the gauge was being used at the construction site, the user stepped away, and the gauge was run over by a piece of heavy machinery."

California Event # 110807

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General Information or Other Event Number: 44343
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: KELLOGG USA, INC
Region: 4
City: OMAHA State: NE
County:
License #: GL0552
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/11/2008
Notification Time: 12:08 [ET]
Event Date: 05/01/2008
Event Time: [CDT]
Last Update Date: 07/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
CINDY FLANNERY (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM SIGNS

This report was submitted by Nebraska via e-mail:

"The general licensee, which is a large food processing facility, did its annual inventory in May of 2008. Four Tritium exit signs were discovered missing during the inventory. Sign 1 was in a high traffic forklift area. The sign was protruding from the wall at a right angle. The licensee thinks that it was likely knocked off and disposed of improperly in regular trash. Signs 2 and 3 were colocated in the same holder. They were in an area of construction and maintenance. The licensee can not find them. They may have been disposed of improperly in regular trash but the licensee was unable to determine how they were disposed of. Sign 4 was located in a warehouse overhead area and was likely knocked down via forklift traffic. It was improperly disposed of in regular trash. This general licensee will communicate to all hourly, salaried and outside contractors the importance of maintaining control of the exit signs and notifying appropriate people in the event they become dislodged, or need to be removed or relocated. The licensee will increase inspections on the signs in their current locations in order to verify that signs are still there. The general licensee will begin systematically changing out a set number of the signs each year with nonradioactive materials until all are removed from their facility."

Nebraska Event Date: 1/2/2008
Nebraska Discovery Date: 5/1/2008
Nebraska Report Date: 6/13/2008
Nebraska Report Number: NE080005
Activity per sign: 17.51 Ci
Manufacturer: SRB Technologies Inc.
Device Name: Radioluminescent Sign
Model BXU20SW S/N: 217815
Model BXU20SW S/N: 217885
Model BXU20SW S/N: 217886
Model B100U20S S/N: 220072

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: 44344
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: MIKE TESTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/11/2008
Notification Time: 15:54 [ET]
Event Date: 07/11/2008
Event Time: 11:30 [EDT]
Last Update Date: 07/11/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
EUGENE GUTHRIE (R2)
DENNIS DAMON (NMSS)
FUELS OUO VIA EMAIL ()

Event Text

ITEM RELIED ON FOR SAFETY DISCOVERED INOPERABLE

"NOX (nitrogen dioxide, nitric oxide, etc) detection is IROFS [Item Relied On For Safety] BPF-43 for the BPF facility. This IROFS is one of the two controls used to prevent chemical occupational exposure to NOX emissions due to the U-Aluminum Bowl Cleaning operations. The NOX detector alarms prior to exceeding 5 ppm NOX to allow Operations to perform monitoring and/or evacuation actions. On July 11, 2008 it was identified that the calibration gas used to functionally test the NOX detector has expired. The calibration expiration date was September 2007. The prior functional test of the NOX detector was performed on January 24, 2008. Due to use of expired calibration gas, it was determined that the NOX detector (IROFS BPF-43) has been in a degraded condition since the last functional test (January 2008).

"The other IROFS credited in the ISA Summary for this accident is BUA-43, (power is automatically removed from caustic pumps securing sodium hydroxide flow to U-Aluminum dissolvers upon low sodium nitrate flow as detected by flow switches). From late May until early July of 2008, these flow switches were not functioning correctly, so written and approved compensatory measures were implemented. However, per NFS procedure, these temporary compensatory measures were not incorporated into the ISA Summary so were not available to help meet the performance criteria of 10 CFR 70.61. Since IROFS BPF-43 was in a degraded condition during this time period, performance criteria were not met."

The licensee has ceased operations in the affected building. The functional test performed in January 2008 utilized the out-of-date calibration gas. The functional test previous to the functional test performed in January 2008 was performed in July 2007. The licensee has had no indication or evidence that NOX emissions occurred during the degraded condition period. The licensee is investigating this incident to determine further controls required to prevent reoccurrence.

The licensee has notified the NRC Resident Inspector.

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