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Event Notification Report for July 24, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/23/2008 - 07/24/2008

** EVENT NUMBERS **


44353 44360 44362

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General Information or Other Event Number: 44353
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: CHERYL ROGERS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/17/2008
Notification Time: 12:05 [ET]
Event Date: 07/14/2008
Event Time: [CDT]
Last Update Date: 07/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DOSE LESS THAN PRESCRIBED DOSE

The following report was received from the State of Wisconsin via facsimile:

"On 7/14/2008, a patient was simulated and treatment planning performed for High Dose Rate (Ir-192) partial breast irradiation to the right breast using a Contura (SenoRx) balloon. The authorized user prescribed a dose of 3.65 Gy per fraction x 9 fractions for a total dose of 32.85 Gy to the Planning Target Volume. After the planning was done, the length of each of the five catheters was measured by the Nucletron Source Position Simulator. The readings were found to be 1154 each. The treatment file in the High Dose Rate treatment console was modified from its default value of 1500 to 1154 and patient was treated. The patient was treated in the High Dose Rate machine located in Room 'A'.

"On 7/15/08, the patient was scheduled to be treated in the High Dose Rate machine located in Room 'B'. Since the sources are different in activity, total time check was performed, at which time, the medical physicists also compared the measured lengths with a second patient under treatment with the Contura balloon in Room 'B'. At this point they noted the difference in the measured lengths between the two cases. The medical physicist checked the Source Position Simulator and noticed that there was an obstruction at the 1154 reading. The review of the actual delivered dose during the first fraction revealed that the source did not enter the patient's body and thus the negative impact was mitigated. A small region of the skin surface received some radiation dose, but the clinical impact is insignificant. The incident was immediately reported to the primary Radiation Oncologist and the Authorized User. The licensee states that no long-term, permanent side effects are anticipated as a result of the medical event.

"Due to the licensee's investigation of the Source Position Simulator revealing that a welded junction in the cable of this measuring device was kinked, it was immediately replaced with a new one. The licensee has also developed a new Quality Assurance form which will be exclusively used for Contura balloons and which incorporates the expected length for the five catheters. Department of Health Services (DHS) staff have been dispatched to investigate this incident."

Wisconsin Report Number: WI080017

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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Other Nuclear Material Event Number: 44360
Rep Org: CALUMET TECHNICAL SERVICES
Licensee: CALUMET TECHNICAL SERVICES
Region: 3
City: Griffith State: IN
County:
License #: 13-16347-01
Agreement: N
Docket:
NRC Notified By: THOMAS KEILMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/23/2008
Notification Time: 09:38 [ET]
Event Date: 07/22/2008
Event Time: 09:30 [EDT]
Last Update Date: 07/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MONTE PHILLIPS (R3)
MICHELLE BURGESS (FSME)

Event Text

SAFETY EQUIPMENT FAILURE

While conducting radiography at the Stiglitz Park Tank Farm in Lake County, Indiana, the radiographer noticed that the source failed to retract with the drive cable in his radiography camera. Upon noticing the detached source, the radiographer immediately covered the source with lead blankets and established an area boundary around the source. He then contacted the Radiation Safety Officer (RSO) who dispatched personnel to the site. There were no reported overexposures to radiography personnel as a result of this incident.

Licensee radiographers were able to retrieve the source, place it back into the camera, and transport the source and camera back to the licensee's main facility. They inspected the camera, source, drive cable and connector and did not find any damage. They were not able to determine why the source became disconnected. They reconnected the source to the camera, functionally tested it satisfactorily, and placed the camera back into service. The licensee did not have the camera vendor inspect or test the device.

The camera is an Amersham model 880, serial number D4044 with a 65 Curie Ir-192 source, serial number 45541B.

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Power Reactor Event Number: 44362
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVE FUNK
HQ OPS Officer: JOE O'HARA
Notification Date: 07/23/2008
Notification Time: 20:20 [ET]
Event Date: 07/23/2008
Event Time: 17:08 [EDT]
Last Update Date: 07/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK LESSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION OF OIL SPILL TO FLORIDA DEPT. OF ENVIRONMENTAL PROTECTION

"At 1708 EDT on 7/23/08, the Control Room was notified that a 900ml initial baseline sample from a potential ground water monitoring well contained 120ml of oil. During the sample, it was also noted that the well was partially filled with debris. This well is not part of the site ground water monitoring program. There was no indication that any oil has entered the storm drain system.

"Although the quantity of oil recovered does not exceed any EPA regulations, a courtesy notification was made to the Florida Department of Environmental Protection at 1723 EDT on 7/23/08.

"This 4-hour NRC notification is being made based on a notification to an off-site government agency."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012