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Event Notification Report for December 18, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/17/2008 - 12/18/2008

** EVENT NUMBERS **


44522 44720 44722 44726

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Hospital Event Number: 44522
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: ED LEIDHOLDT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/25/2008
Notification Time: 20:12 [ET]
Event Date: 09/24/2008
Event Time: [CDT]
Last Update Date: 12/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
REBECCA TADESSE (FSME)
JAMNES CAMERON (R3)

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 24, 2008, for 7 patients treated at the VA Medical Center in Jackson, Mississippi.

"These 7 possible medical events involved seed distributions in the patients that may result in D90 doses less than 80% of the prescribed doses. These circumstances are interpreted as meeting 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 are under review by medical experts.

"A 15-day written report of these 7 possible medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these possible medical events.

"Additional Information

"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, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.

"VHA permit number of permittee involved in event: Permit No. 23-08786-01."

* * * UPDATE AT 1945 ON 10/8/2008 FROM EDWIN LEIDHOLDT TO MARK ABRAMOVITZ * * *

"This report is an update to Event Report Number 44522. As the result of an ongoing review, an additional possible medical event was discovered on October 7, 2008. This brings the total number of possible medical events to eight (8) under Event Report Number 44522. The circumstances are similar to those previously reported for this event number.

"A 15-day written report of this additional medical event will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III) of this additional possible medical event."

Notified the R3DO (Lara) and FSME (Einberg).

* * * UPDATE AT 1058 EDT ON 10/30/08 FROM HUSTON TO CROUCH * * *

"This report is an update to Event No. 44522. An additional medical event was discovered on October 29, 2008, for a patient treated at the VA Medical Center in Jackson, Mississippi.

"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).

"A total of eight (8) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to nine (9) for this facility.

"A 15-day written report on this additional medical event will be submitted to NRC Region III. I have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."

Notified R3DO (Kozak) and FSME (Burgess).

* * * UPDATE AT 1235 EST ON 12/17/08 FROM HUSTON TO CROUCH * * *

"This report is an update to Event No. 44522. One additional medical event was discovered on December 16, 2008, for a patient treated at the VA Medical Center, Jackson, Mississippi.

"This medical event involved a patient who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distribution in the patient was associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. The circumstances were interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1).

"A total of nine (9) events have been previously reported to the NRC under this event number. This additional event brings the total number of events to ten (10) for this facility.

"A 15-day written report on this additional medical event will be submitted to NRC Region III. We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of this additional medical event."

Notified R3DO (Skokowski) and FSME (Flannery).

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: 44720
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: WAL-MART
Region: 4
City: OMAHA State: NE
County:
License #: GL0633
Agreement: Y
Docket:
NRC Notified By: TRUDY K. HILL
HQ OPS Officer: PETE SNYDER
Notification Date: 12/15/2008
Notification Time: 11:09 [ET]
Event Date: 12/06/2008
Event Time: [CST]
Last Update Date: 12/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

"Wal-Mart employed the Shaw Group Inc. as a contractor to replace the H3 exit signs in their stores nation-wide. Shaw Group conducted an inventory of the store on March 11, 2008. They returned to the store on May 26, 2008 to replace the H3 sign with a non-tritium exit sign but found it missing. They had no information on the sign being transferred. The Shaw Group conducted interviews with store personnel and reviewed shipment and inventory records, but were not able to locate any additional information about the location or condition of the lost sign.

1. Site: Wal-Mart #5361; Source Material: Sealed source luminous; Manufacturer: SRB Technologies Inc.; Model Number: BX-20-GY; Serial Number: 310248; Activity 17.51 Ci.

NE report number - NE080010.

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: 44722
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: BRUKER AXS HANDHELD, INC.
Region: 4
City: KENNEWICK State: WA
County:
License #: WN-I0282-1
Agreement: Y
Docket:
NRC Notified By: PHILLIP CLARK
HQ OPS Officer: JASON KOZAL
Notification Date: 12/15/2008
Notification Time: 17:44 [ET]
Event Date: 12/01/2008
Event Time: [PST]
Last Update Date: 12/15/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE - SAFETY EQUIPMENT MALFUNCTION

"A General Licensee, a customer of Bruker AXS Handheld (Bruker) that is a device manufacturer located in Richland, Washington, returned one of Bruker's Map 4 XRF analyzers. The device had not been operating properly. When Bruker received the shipment they noticed that the package exhibited radiation levels on contact with the package of 4.9 mR/hr as measured with a GM survey instrument. This reading was unusual because it was significantly above the 0.5 mR/hr limit allowed for excepted radioactive instruments and articles transportation packaging. These packages are identified as NOS UN 2910 on the bill of lading. Bruker's receiving staff took the device to a shielded work area and when disassembled they discovered that the device's trigger mechanism was not operating properly. The mechanism did not allow the source to be fully shielded after it was released. A Bruker instrument technician discovered that one of the screws was partially backed out preventing the source block from fully closing. This screw had initially been installed per manufacturing procedure using lock-tite. This part has had no history of coming loose. The screw was replaced per the manufacturing procedure again using lock-tite on the threads as required. Bruker reported that this was the only problem like this they had experienced. The generally licensed device contained a Co-57 source, model F3-038, with a current activity of 318 megabecquerel (8.6 mCi).

"The source was removed and checked for contamination. None was found. The device was repaired, calibrated and sent back to the customer. Bruker has established new guidelines for their technicians when they receive a call about a device problem / malfunction. The Bruker RSO will be notified and will work directly with the customer to assess the problem prior to the device being shipped to Bruker for repair."

Washington Report # - WA-08-093

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Power Reactor Event Number: 44726
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: ED BERTRAM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/17/2008
Notification Time: 13:59 [ET]
Event Date: 12/17/2008
Event Time: 09:42 [EST]
Last Update Date: 12/17/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JAY HENSON (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

FITNESS FOR DUTY

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

The licensee has notified the NRC Resident Inspector.

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