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Event Notification Report for February 23, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/22/2010 - 02/23/2010

** EVENT NUMBERS **


45574 45702 45707 45708

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General Information or Other Event Number: 45574
Rep Org: HYDROAIRE
Licensee: HYDROAIRE
Region: 3
City: CHICAGO State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SESHA GIRI
HQ OPS Officer: VINCE KLCO
Notification Date: 12/16/2009
Notification Time: 17:11 [ET]
Event Date: 09/29/2009
Event Time: 09:02 [CST]
Last Update Date: 02/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
TAMARA BLOOMER (R3DO)
PART 21 COORDINATOR (NRR)
RICHARD BARKLEY (R1DO)

Event Text

PART 21 INVOLVING A PUMP SHAFT COUPLING FAILURE

A service water pump failed during operation on 9/29/2009. Upon disassembly it was detected that a shaft coupling installed on a repaired service water pump failed while in service. The failed coupling was replaced with a new coupling of a different heat code. According to the manufacturer, the threaded coupling design was only supplied for Palisades.

* * * UPDATE FROM SESHA GIRI TO PETE SNYDER AT 1529 ON 2/22/10 * * *

HydroAire conducted a root cause analysis on the issue. They and their heat treat vendor, BodyCote, reviewed all of their safety related work records for the past three years and monitored heat treating of recent orders.

"Records showed that this anomaly occurred only on one piece and it is a random isolated incident."

The vendor believes that corrective actions that they and BodyCote have taken "should remove concerns in the future heat treatments and past review of records confirms adequacy of the heat treat at least for the past three years."

Notified R3DO (Stone) and Part 21 Group via email.

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General Information or Other Event Number: 45702
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY COMMUNITY HOSPITAL
Region: 1
City: TAMPA State: FL
County:
License #: 0549-3
Agreement: Y
Docket:
NRC Notified By: PHIL WEDDING
HQ OPS Officer: PETE SNYDER
Notification Date: 02/16/2010
Notification Time: 16:16 [ET]
Event Date: 02/16/2010
Event Time: [EST]
Last Update Date: 02/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT - MISPOSITIONED DOSE DURING MEDICAL TREATMENT

The following information was received from the State via e-mail:

"The two reported cases are single channel MammoSite patients. The errors resulted from erroneously placing the dwell position approximately 2 to 2.5 cm proximal to the correct position. The error was not noticed until 2/14/10 during a document review for [the second] patient after [the eighth] fraction. The last two fractions for [the second] patient were corrected. It appears that about 50% of the correct treatment volume received at least 50% of the prescribed dose. Some parts of the planned volume received greater than 700%. Also there are volumes that are not included in the planned treatment volume that exceed approximately 300% to 400% of the prescribed dose. The proximal skin received a small sliver of dose at the 125% the prescribed dose.

"First patient's treatment had been completed in January before the error was noticed. Probably 25% of the planned volume received the prescribed dose or higher. Probably 25% of the planned volume received 25% or less than of the prescribed dose. A large volume outside the planned treatment volume exceeded the prescribed dose. The maximum proximal skin dose was at approximately 220% of the prescribed dose. The desired dose was 340 cGy/fx * 10. Both doctors and patients have been notified.

"Health effects, if any, are still being determined. The licensee will send a written report on this incident."

The State of Florida is investigating. The isotope involved is 9.76 Curies of Ir-192.

Florida Incident Number: FL 10-027.

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: 45707
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH-STRATA, INC.
Region: 4
City: MURRIETA State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/17/2010
Notification Time: 18:52 [ET]
Event Date: 02/12/2010
Event Time: [PST]
Last Update Date: 02/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
TERRENCE REIS (FSME)
MEXICO (via)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was received via e-mail:

"A CPN moisture density gauge (model MC3, serial # M330506989) was reported to have been stolen over the recent four day weekend from a construction site in Hesperia, between Main St. and Smoke Tree Lane. The gauge was reportedly taken with the transportation container, which was secured inside a locked construction trailer. The RSO believed that the authorized user had locked the transportation container [prior to] the period during which the gauge was stolen.

"The [theft of the] gauge was reported to the Hesperia Police in San Bernardino County. The RSO was informed by RHB [Radiologic Health Branch] that a reward should be offered for the return of the gauge. The RSO indicated he would discuss posting of a reward with the company insurance carrier."

The gauge contains a 10 mCi Cs-137 gamma source and a 50 mCi Am-241/Be neutron source.

California Incident No: 5010-021710


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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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General Information or Other Event Number: 45708
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L-00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/18/2010
Notification Time: 10:58 [ET]
Event Date: 12/10/2008
Event Time: [CST]
Last Update Date: 02/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE STUCK IN CATHETER TUBE

The following information was obtained from NMED:

"The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence."

The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report.

Texas Report Number: I-8590

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Thursday, March 29, 2012