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Event Notification Report for September 28, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/25/2009 - 09/28/2009

** EVENT NUMBERS **


45378 45379 45384

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General Information or Other Event Number: 45378
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER
Region: 4
City: DALLAS State: TX
County:
License #: L00384
Agreement: Y
Docket:
NRC Notified By: ANNIE BACKHAUS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/22/2009
Notification Time: 18:32 [ET]
Event Date: 09/21/2009
Event Time: [CDT]
Last Update Date: 09/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT- PATIENT RECEIVED IMPROPER DOSAGE

On September 21, 2009, a patient undergoing mammosite brachytherapy did not receive the proper dose administration due to the Ir-192 (9.6 Ci) source failing to retract. The administering physician retrieved the source from the patient and placed it back in the device. A dose estimate is in progress, however, the licensee does not expect the dosage to exceed 50 percent of the prescribed dose. The afterloader was cleaned recently and the licensee does not expect any debris from the device. The State will report any results of the dose assessment.

Texas License Number: L00384

Texas Incident Number: #8673

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: 45379
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: J.L. SHEPHARD & ASSOCIATES
Region: 4
City: SAN FERNANDO State: CA
County:
License #: 1777
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/23/2009
Notification Time: 19:05 [ET]
Event Date: 09/23/2009
Event Time: [PDT]
Last Update Date: 09/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
KEVIN HSUEH (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided from the State of California via email:

"J.L. Shepherd & Associates (JLS&A) performed a source exchange on a Model 44, serial number 7079, category 1 panoramic irradiator of their own manufacture.

"The source is identified as JLS&A Type 7810 capsule, manufactured by General Electric Company, Nuclear Center. The serial number is GEC-05-04. CA Sealed Source & Device registry: CA0598S122S

"At the time of source exchange, the Co-60 source was estimated to have [approximately] 250 Ci of activity. Wipe tests were taken at the location of the resourcing and showed no indication of leaks. The source holder rod was discolored and had evidence of corrosion. Source assembly was shipped to JL Shepherd's facility in San Fernando, CA.

"On September 22, 2009, the source was removed from the transport container in their hot cell with remote manipulators. The source was wiped and determined to have 0.0688 microCi of removable contamination. The source was decontaminated to between 0.001 - 0.0025 microCi level on smears, and placed into a stainless steel pipe and sealed with caps. This will remain in storage at their facility until disposed of in a proper manner."

California reference number: 092209

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Other Nuclear Material Event Number: 45384
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/27/2009
Notification Time: 12:30 [ET]
Event Date: 09/27/2009
Event Time: 02:00 [YDT]
Last Update Date: 09/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL SHANNON (R4DO)
KEVIN HSUEH (FSME)

Event Text

RADIOGRAPHY CAMERA SOURCE FAILS TO FULLY RETRACT INTO CAMERA

Technicians were performing radiography at the Kuparuk Oil Field in Prudhoe Bay, Alaska. The IR-100 camera experienced a lockout with the source within the camera but not fully retracted. The technicians were trained on this problem and were able to reset the lockout and fully retract the source. No exposure resulted from resetting the lockout.

The IR-100 camera contains less than 100 Ci of Ir-192.

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