Event Notification Report for November 14, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/13/2008 - 11/14/2008
Hospital
Event Number: 44667
Rep Org: WALTER REED ARMY MEDICAL CENTER
Licensee: WATER REED ARMY MEDICAL CENTER
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01738-02
Agreement: N
Docket:
NRC Notified By: COL. MARK MELANSON
HQ OPS Officer: HOWIE CROUCH
Licensee: WATER REED ARMY MEDICAL CENTER
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-01738-02
Agreement: N
Docket:
NRC Notified By: COL. MARK MELANSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/19/2008
Notification Time: 13:08 [ET]
Event Date: 11/14/2008
Event Time: 09:00 [EST]
Last Update Date: 11/19/2008
Notification Time: 13:08 [ET]
Event Date: 11/14/2008
Event Time: 09:00 [EST]
Last Update Date: 11/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MARIE MILLER (R1)
MICHELE BURGESS (FSME)
MARIE MILLER (R1)
MICHELE BURGESS (FSME)
BRACHYTHERAPY SEEDS TEMPORARILY LOST AND UNACCOUNTED FOR
"On 10 NOV 08, a patient was admitted for a brachytherapy treatment. The patient received 77.8 mCi of Ir-192 in the form of eight nylon ribbons, each ribbon containing 7 seeds, for a total of 56 seeds (each seed containing 1.39 mCi of Iridium-192).
"The initial dose rate was 50 cGy/hour with a prescribed dose of 4500 cGy to be delivered over a 90 hour treatment time.
"On 14 NOV 08 at 0900, when the sources were scheduled to be removed, it was discovered that three ribbons (containing 29.2 mCi of Ir-192) were missing. It was later learned that the ribbons were improperly removed from the room when a physician improperly changed the bandage on the patient (the ribbons were stuck to the bandage with tape).
"A search was made of the trash compactor located on the back loading dock. The compactor had just been unloaded at 0600 hours on 14 NOV 08. A survey of the trash compactor discovered the sources (all three ribbons with all 21 seeds) at 1210 [hrs.] on 14 NOV 08. Hence, the sources were placed in the compactor between 0600 and 0900 on 14 NOV 08.
"Verification of the sources was visually made by the therapy physicist (the sources did not have serial numbers or other indentifying markings). As a precaution, leak tests were performed on the previously missing sources and the results did not indicate any detectable activity.
"Based upon interviews of the medical and the housekeeping staff, the following events occurred:
"a. The physician improperly removed the bandage (and the sources stuck to the bandage with tape) and threw it in the trash can located within the room..
"b. The housekeeping staff improperly entered the patient's room and removed the trash from the trash can, placing it in a larger barrel. The barrel was then taken to the loading dock and emptied into the trash compactor. All of this occurred between 0600 and 0900. The compactor is situated in an unoccupied area of the back loading dock (no break areas or smoking areas).
"c. The maximally exposed individual in this scenario was the housekeeping worker who removed the trash and took it to the compactor on the loading dock:
i. The dose rate at one meter from the sources was measured as 13 mR/h.
Ii. The sources were assumed to be 0.5 meters from the custodial worker.
Iii. The transit time from the room to the compactor was 20 minutes (based upon interview with the custodial worker).
Iv. The estimated dose to the worker is 17.3 mRem [based on a provided calculation].
"A complete investigation is being made of the incident and will be reported at the next scheduled meeting of the Walter Reed Army Medical Center Radiation Safety Committee currently scheduled for 4 DEC 08."
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.
"On 10 NOV 08, a patient was admitted for a brachytherapy treatment. The patient received 77.8 mCi of Ir-192 in the form of eight nylon ribbons, each ribbon containing 7 seeds, for a total of 56 seeds (each seed containing 1.39 mCi of Iridium-192).
"The initial dose rate was 50 cGy/hour with a prescribed dose of 4500 cGy to be delivered over a 90 hour treatment time.
"On 14 NOV 08 at 0900, when the sources were scheduled to be removed, it was discovered that three ribbons (containing 29.2 mCi of Ir-192) were missing. It was later learned that the ribbons were improperly removed from the room when a physician improperly changed the bandage on the patient (the ribbons were stuck to the bandage with tape).
"A search was made of the trash compactor located on the back loading dock. The compactor had just been unloaded at 0600 hours on 14 NOV 08. A survey of the trash compactor discovered the sources (all three ribbons with all 21 seeds) at 1210 [hrs.] on 14 NOV 08. Hence, the sources were placed in the compactor between 0600 and 0900 on 14 NOV 08.
"Verification of the sources was visually made by the therapy physicist (the sources did not have serial numbers or other indentifying markings). As a precaution, leak tests were performed on the previously missing sources and the results did not indicate any detectable activity.
"Based upon interviews of the medical and the housekeeping staff, the following events occurred:
"a. The physician improperly removed the bandage (and the sources stuck to the bandage with tape) and threw it in the trash can located within the room..
"b. The housekeeping staff improperly entered the patient's room and removed the trash from the trash can, placing it in a larger barrel. The barrel was then taken to the loading dock and emptied into the trash compactor. All of this occurred between 0600 and 0900. The compactor is situated in an unoccupied area of the back loading dock (no break areas or smoking areas).
"c. The maximally exposed individual in this scenario was the housekeeping worker who removed the trash and took it to the compactor on the loading dock:
i. The dose rate at one meter from the sources was measured as 13 mR/h.
Ii. The sources were assumed to be 0.5 meters from the custodial worker.
Iii. The transit time from the room to the compactor was 20 minutes (based upon interview with the custodial worker).
Iv. The estimated dose to the worker is 17.3 mRem [based on a provided calculation].
"A complete investigation is being made of the incident and will be reported at the next scheduled meeting of the Walter Reed Army Medical Center Radiation Safety Committee currently scheduled for 4 DEC 08."
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.
Power Reactor
Event Number: 44659
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID LANYI
HQ OPS Officer: JASON KOZAL
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID LANYI
HQ OPS Officer: JASON KOZAL
Notification Date: 11/14/2008
Notification Time: 09:41 [ET]
Event Date: 11/14/2008
Event Time: 07:00 [EST]
Last Update Date: 11/14/2008
Notification Time: 09:41 [ET]
Event Date: 11/14/2008
Event Time: 07:00 [EST]
Last Update Date: 11/14/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2)
BRIAN BONSER (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF ERDADS
"This notification is being made due to an unplanned loss of ERDADS communication to the NRC for greater than one hour.
"At 0700 on November 14, 2008, the Unit 2 Control Room noted that the information from ERDADS did not appear to be updating. Notifications were made and Engineering and Operations responded to investigate. The B train of ERDADS failed at 0357 and the backup A train did not auto transfer as expected. The B train was manually failed over and the A train assumed control at 0730. The B train was rebooted and has assumed the standby position.
"The system is currently functioning as expected and all communications have been restored."
The licensee notified the NRC Resident Inspector.
"This notification is being made due to an unplanned loss of ERDADS communication to the NRC for greater than one hour.
"At 0700 on November 14, 2008, the Unit 2 Control Room noted that the information from ERDADS did not appear to be updating. Notifications were made and Engineering and Operations responded to investigate. The B train of ERDADS failed at 0357 and the backup A train did not auto transfer as expected. The B train was manually failed over and the A train assumed control at 0730. The B train was rebooted and has assumed the standby position.
"The system is currently functioning as expected and all communications have been restored."
The licensee notified the NRC Resident Inspector.