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Event Notification Report for October 3, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/02/2008 - 10/03/2008

** EVENT NUMBERS **


44219 44340 44469 44524 44529 44533

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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: 10/02/2008
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).

* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "

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

* * * UPDATE ON 7/22/2008 AT 1500 EDT FROM WILLIAMS TO HUFFMAN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional five patients on July 22, 2008. This brings the total number of medical events to 37 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III."

The licensee will notify NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events.

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

* * * UPDATE FROM GARY WILLIAMS TO JOE O'HARA 1145 EDT ON 7/25/08 * * *

"As the result of an ongoing review, medical events were discovered for an additional two patients on July 25, 2008. This brings the total number of medical events to 39 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 additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (W.Cook), R3DO (M.Phillips), and FSME (C.Flannery)

* * * UPDATE AT 0805 ON 08/06/08 FROM THOMAS HUSTON TO JEFF ROTTON * * *

"As the result of an ongoing review, medical events were discovered for an additional four patients on August 05, 2008. This brings the total number of medical events to 43 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."

Notified R1DO (Gray), R3DO (D Hills), and FSME (C. Einberg)

* * * UPDATE AT 1002 EDT ON 8/13/08 FROM HUSTON TO SANDIN * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional four patients on August 12, 2008. This brings the total number of medical events to 47 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these four 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 (Holody), R3DO (Kozak) and FSME (Burgess).


* * * UPDATE AT 1422 EDT ON 8/22/08 FROM HUSTON TO KNOKE * * *

"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional eight patients on August 21, 2008. This brings the total number of medical events to 55 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these four additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."

Notified by email: R1DO (Perry), R3DO (Lipa) and FSME (Burgess).

* * * UPDATE AT 1704 ON 10/2/2008 FROM THOMAS HUSTON TO MARK ABRAMOVITZ * * *

"As the result of an ongoing reviews, medical events were discovered for an additional 37 patients on October 1, 2008. This brings the total number of medical events to 92 under Event Report #44219.

"The circumstances are related to those previously reported for this event number with the following clarifications:
- 35 of the additional medical events involve doses to organs or tissues other than the treatment site and are considered to meet medical event criteria described in 10 CFR 35.3045(a)(3).
- 2 of the additional medical events involve doses to the treatment site (prostate) that had a D90 dose below 80% of the prescribed dose.
- These 37 additional medical events involve different patient cases that have not been previously reported as medical events under this event report.

"A 15-day written report of these 37 additional medical events will be submitted to NRC Region III.

"We informed our NRC Project Manager, Cassandra Frazier (NRC Region III), of the additional events."

Notified R1DO (White), R3DO (Lara), and FSME (Bradford).

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General Information or Other Event Number: 44340
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: MIDWEST INDUSTRIAL X-RAY, INC.
Region: 4
City: CASSELTON State: ND
County: CASS
License #: 33-14907-01
Agreement: Y
Docket:
NRC Notified By: DAN HARMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/09/2008
Notification Time: 17:03 [ET]
Event Date: 07/09/2008
Event Time: [MDT]
Last Update Date: 10/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
ROBERT LEWIS (FSME)

Event Text

NORTH DAKOTA AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE FROM RADIOGRAPHY CAMERA

Midwest Industrial X-ray, Inc. was performing radiography at an ethanol plant in Casselton County, ND. After taking a shot, the radiographer was retracting the source when it became detached. The radiographer covered the source with a lead blanket and contacted the company Radiation Safety Officer. The camera contained a 24.5 Ci Ir-192 source.

The licensee transported the source back to their facility. The licensee performed calculations that indicated the radiographer received approximately 4 Rem exposure while securing the source. No calculations were reported concerning the assistant radiographer. The calculations performed by the State of North Dakota indicate that the radiographer received greater than 5 Rem. Both individual's film badges were sent to Landauer laboratories for processing.

The State of North Dakota will be investigating this incident.


* * * UPDATE FROM DAN HARMAN VIA EMAIL TO J. KNOKE AT 1725 EDT ON 07/10/08 * * *

"The doses for the lead radiographer are as follows:
The badge reading for this monitoring period (June 20 - Jul 8) 575 mR. The yearly total deep dose is 827 mR."

Notified FSME (Lewis) and R4DO (Hay)

* * * UPDATE ON 7/14/2008 AT 1900 FROM DANIEL HARMAN TO MARK ABRAMOVITZ * * *

This agreement state report update was received via e-mail:

"Initial Assumption: the source was full exposed in the source tube between the camera and the collimator; the exposure time estimate was 2 minutes; estimated average distance to source was 0.3 meters; gamma constant = 0.59; source strength = 24.5 Ci; and estimated exposure was 5.3 mR.

"Investigation Results - Hardware: The camera was a QSA 660B. Maintenance had been performed on this camera two days prior to this event. The source became detached from the wire and lodged inside the camera at or near the connection between the camera and the guide tube. The survey meters used were NDS-2000. Both had recently been calibrated. The one that failed had been sent in for repair in November 2007. The RA-500 worn by [the assistant radiographer] had been sent in twice for repair. We will follow up with asking the company to review the maintenance records for these two devices to determine if they should be replaced ahead of schedule.

"Investigation Results - Personnel and Dose update: the primary person exposed was [the assistant radiographer]. By Thursday afternoon his annual badge exposure data had been compiled, including the expose for this event. This data is as follows: deep total - 825 mR, lens - 839 mR and Shallow - 835 mR. The badge for the period June 20 - July 19 was read by Landauer on July 11, 2008, and indicated 575 mR. Dosimeter data for the badge period showed a dose of 88 mR. The badge reading - the badge period dosimeter data shows an exposure of 487 mR for this event.

"There were four other personnel involved in the actual event and source retrieval. They are (job lead radiographer, dose: 40 mR); (radiographer, dose: 40 mR), (intern, dose: 32 mR) and (RSO, dose: 55 mR). These data were taken from the pocket dosimeters.

"Investigation Results - Source Recovery: There are some inconsistencies between what was stated to have happened and what the investigators believe could have happened. Most relate to positions with respect to the camera/source. We expect to have these resolved by Friday, July 18, 2008."

Notified FSME (Lewis) and R4DO (Johnson).

* * * UPDATE @ 1750 EDT ON 10/2/08 FROM DAN HARMAN TO HOWIE CROUCH VIA EMAIL * * *

"Investigation Results - Hardware: The QSA Model 660B camera and control cable was returned to QSA for evaluation. QSA's evaluation determined the problem was a 'misconnect' not a 'disconnect' of the source assembly from the drive cable. The 'misconnect' was due to wear on the plug assembly, the male connector and the apparent age of the drive cable.

"The NDS 2000 survey meter used by [the assistant radiographer] failed to respond due to a loose battery connection.

"The Alarm Rate Meter worn by [the assistant radiographer] failed to alarm. This meter had been sent to NDS to have the audio transducer replaced in December and was calibrated at that time. After the incident, the meter was tested in Midwest's lab and the meter did not chirp until 750 mR/hr and was continuous at 1000 mR/hr. According to NDS, this is a 'Low Battery' indication. The rate meter [the assistant radiographer] used did not have a low battery indicator light.

"Investigation Results - Conclusions: 1) The alarm rate meter failed due to a low battery condition. 2) The survey meter failed due to a battery disconnect. 3) [The assistant radiographer] read his survey meter while on the platform, next to the camera, saw it read '0', but did not realize the significance of the reading and get off the platform and back on the ground.

"The survey meter was repaired and the battery was replaced in the alarm rate meter. Both devices were returned to service.

"Investigation Results - Department Actions: The North Dakota Department of Health considers this investigation closed. No penalties will be assessed against Midwest Industrial X-Ray, Inc."

Notified R4DO (Bywater) and FSME EO (Bradford).

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General Information or Other Event Number: 44469
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: NONDESTRUCTIVE AND VISUAL INPECTION
Region: 4
City: HOUMA State: LA
County:
License #: LA-5601 L01
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/05/2008
Notification Time: 20:45 [ET]
Event Date: 09/02/2008
Event Time: [CDT]
Last Update Date: 10/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE - OVEREXPOSURE FROM STUCK RADIOGRAPHY SOURCE

The following information was provided by the State of Oklahoma via e-mail:

"On Tuesday, September 2, radiographers were doing pipeline weld testing near Ardmore, Oklahoma. They were operating in a three man team, the radiographer (who held a current Texas card) would move ahead of the group dropping off film at each weld. Assistant #1 moved behind him putting the film in place on each weld. Assistant #2 followed with the radiography camera balanced behind him on the seat of a 4-wheeled All Terrain Vehicle (ATV) and would position the camera and take the shots at each weld. The camera and guide tube where not disassembled between shots.

"At approximately 10 AM Tuesday, the camera fell off the ATV while being transported, and the guide tube bent where it attaches to the camera. One of the assistants was able to straighten the guide tube, and they were able to crank the source in and out, though with increased resistance. They continued working with this guide tube, though they report they had another guide tube available at the site.

"At approximately Noon Tuesday, assistant #2 decided the terrain near the next weld was too rugged to drive the ATV over, so he dismounted and disassembled the radiography setup to carry it to the weld. When he unscrewed the guide tube, he saw the cable inside, and realized the source was not secured inside the camera. The crew was able to retract the source into the camera. Assistant #2's pocket dosimeter was reading off scale. When his alarming rate meter was tested, it did not work.

The utilization log for the morning states that the alarming rate meter did work when checked out in the morning. State investigators could not get the alarming rate meter to work, and they believe the batteries are dead, though they did not test to confirm that. Assistant #2 had a survey meter, but was not checking it at the time of the incident. Note that state investigators found that the crew had two calibrated survey meters, but one of them was damaged and not operational. The crew states that the meter was working at the time of the incident, but had been damaged on Friday morning as the other two crew members continued to work.

"Assistant #2 ceased work, and his badge was sent for emergency processing. The badge provider reports a whole body dose of 16 rem. A representative of the company contacted the state of Oklahoma shortly after receiving the report. The company did not contact Oklahoma before receiving the report. The company states that Louisiana has been informed of the incident.

"Assistant #2 states that he rode the ATV with the camera on the seat of the ATV behind him. Distance from the camera to his body was about one foot, and it is believed that this is similar to the distance from the source to his body. He estimates that he spent 2-3 minutes riding this way between the prior shot and the time he noticed that the source was not properly retracted. The crew states that film from prior shots has been developed and shows no anomalies or signs of overexposure. The crew states that Assistant #2 was the only person who worked with the camera from the time the tube was damaged till the incident was discovered. Assistant #2 states he does not remember whether his badge was on his front pocket or back pocket. If it was worn on his front pocket, the dose reported for him is probably lower than his actual dose.

"A representative of the company is coming from Louisiana to Oklahoma to return Assistant #2 to Louisiana. Oklahoma will encourage the company to have him examined by a physician with a strong radiation background, seeking the advice of the state of Louisiana on a suitable physician.

"The above is a preliminary report based on telephonic communication with DEQ inspectors in the field, and is basically all that is known at this time. It has not been reviewed by the inspectors. DEQ will investigate, do enforcement, and keep NRC and Louisiana informed of the progress of our investigation."

The State noted that Nondestructive and Visual Inspection dba NVI has a Louisiana License (LA-5601 L01) out of Houma, Louisiana and had been operating in Oklahoma under reciprocity. The company home office has been heavily affected by Hurricane Gustav and company staff stated that they had just returned to their office for the first time on 9/5/08.

* * * UPDATE FROM LOUISIANA DEPT. OF ENVIRONMENTAL QUALITY (RICHARD PENROD) TO PETE SNYDER ON 9/8/08 AT 1050 EDT * * *

The State of Louisiana provided the following information via facsimile:

This event has been identified State of Louisiana Event Report ID No. LA0800018.

* * * UPDATE FROM MIKE BRODERICK TO PETE SNYDER ON 9/8/08 AT 1040 AND 1144 EDT * * *

The following is a summary of information provided by the State of Oklahoma via e-mail:

The source strength and isotope of the source referred to in the original report was 111 curies of Ir-192. The State of Louisiana requested blood work be done on the exposed individual. The company RSO had been unable to find a physician to do the work in Louisiana because of the recent tropical storm but did solicit help from REAC T/S where blood samples were sent for evaluation on 9/8/08.

Notified R4DO (Walker) and FSME (Flannery).

* * * UPDATE FROM MIKE BRODERICK TO PETE SNYDER ON 9/10/08 AT 1036 AND 1226 EDT * * *

"The last sentence of the [9/8/08 update] (about blood samples being sent to REACT/S on 9/8) is incorrect. No blood samples have been sent to REACT/S.

"There are actually two different sets of blood samples, one (several samples) to be processed locally, and one (a single sample) to be processed by REACT/S. REACT/S has sent the special container needed to the licensee in Louisiana, and the blood sample will be drawn on Monday and shipped overnight to Oak Ridge for processing."

"[On 9/9/08] the affected individual saw an occupational physician and the blood samples were drawn. The licensee [will] provide these results to DEQ and REACT/S as soon as they are available. The physician inspected the individual for signs of acute radiation exposure and found none.

"The licensee RSO reports that he spoke to the exposed individual by phone." The individual did not report any symptoms.

Notified R4DO (Walker) and FSME (Flannery).

* * * UPDATE AT 1714 ON 10/2/2008 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *

Received from the state via e-mail:

"REACT/S reports their Cytogenic dosimetry estimate for the exposed individual is 0 to 30 rem, with a most likely result of 11 rem. This is consistent with the 16 rem reported already."

Notified the R4DO (Bywater) and FSME (Bradford).

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Hospital Event Number: 44524
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER WASHINGTON DC
Region: 1
City: WASHINGTON State: DC
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/26/2008
Notification Time: 18:15 [ET]
Event Date: 09/26/2008
Event Time: [EDT]
Last Update Date: 09/26/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3)
REBECCA TADESSE (FSME)

Event Text

MEDICAL DOSE LESS THAN 80% OF PRESCRIBED DOSE

"In response to medical events discovered at the VA Medical Center Philadelphia, which have been reported under Event Number 44219, reviews are ongoing of samples of patient charts from other VA facilities with permanent prostate seed implant brachytherapy programs.

"As the result of these ongoing reviews, possible medical events were discovered on September 26, 2008, for 3 patients treated at the VA Medical Center in Washington DC.

"These 3 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances may meet the definition of a medical event under 10 CFR 35.3045. (The D90 is the dose that covers 90% of the volume of the prostate.)

"The VHA National Health Physics Program will ensure that the medical center follows NRC requirements for notification of the patients. These treatments and their possible effects on the patients will be reviewed by medical experts.

"A 15-day written report on these 3 possible medical events will be submitted to NRC Region III pursuant to 10 CFR 35.3045. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"The US Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.

"Address of permittee involved in this event: VA Medical Center, 50 Irving Street NW, Washington DC 20422.

"The VHA permit number of the permittee involved in event: Permit No. 08-00942-05."

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: 44529
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: HWA GEOSCIENCES
Region: 4
City: LYNNWOOD State: WA
County:
License #: I0176
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2008
Notification Time: 16:50 [ET]
Event Date: 09/29/2008
Event Time: [PDT]
Last Update Date: 09/30/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSS BYWATER (R4)
ANNA BRADFORD (FSME)

Event Text

WASHINGTON AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The State of Washington provided the following information via e-mail:
"The licensee reported to the Washington State Department of Health (DOH) that a Troxler 3440 nuclear density gauge, serial number 28433, with 8 mCi of Cs-137 and 40 mCi of Am-241/Be, was struck by a truck at a landfill site at about 12:45 p.m. on 9/29/08. The gauge was struck while the operator was taking measurements with the source rod extended into the soil. It was reported that a truck tried to skim by the operator and gauge, narrowly missing the operator and hitting the gauge. The truck caught the gauge handle breaking it and the guide rod from the gauge. The source rod and the rest of the gauge remained intact and in place. The licensee field engineer and lead gauge operator went to the scene to assist with the incident. Since the handle was broken from the gauge, the source rod was placed back into the gauge by turning the gauge on its side and striking the bottom of source rod with a mallet. This action caused the source rod to move completely out of the top of the gauge. The lead individual put the source rod into a bucket and found a max reading of 20 mR/hr. The lead [operator] returned the source rod back into the shielded position in the gauge and secured [it] in place with duct tape. Additional wraps of duct tape were made around the top and bottom of the gauge to keep the source rod from coming out again. A reading of 2.4 mR/hr was found on contact with the gauge with the licensees' TroxAlert. Additional readings were taken on the bucket and the testing site indicating background readings. The gauge was placed back into the transport case and taken to the licensed storage location prior to determining its final disposition. DOH staff will visit the licensee to make confirmatory measurements and start an investigation."

Washington Report Number: WA080072

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Power Reactor Event Number: 44533
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: VINCE KLCO
Notification Date: 10/02/2008
Notification Time: 12:03 [ET]
Event Date: 10/02/2008
Event Time: 09:15 [EDT]
Last Update Date: 10/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
STEVE ORTH (R3)

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

Event Text

POSITIVE FITNESS FOR DUTY TEST

A non-licensed contract employee supervisor had a confirmed positive for alcohol during a follow up fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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