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Event Notification Report for March 2, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/01/2010 - 03/02/2010

** EVENT NUMBERS **


45599 45716 45720 45721 45735

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General Information or Other Event Number: 45599
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: GEORGIA PACIFIC CONSUMER DIVISION
Region: 4
City: CAMAS State: WA
County:
License #: WN-I0228-1
Agreement: Y
Docket:
NRC Notified By: BRANDIN KETTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/30/2009
Notification Time: 19:02 [ET]
Event Date: 12/30/2009
Event Time: [PST]
Last Update Date: 03/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE - STUCK SHUTTER ON FIXED DENSITY METER

The following was received via email:

"A fixed gauge licensee operating a paper mill in Camas, Washington, reported that the shutter mechanism of an Ohmart Vega fixed gauge, Model Number SH-F1B-0, containing a 100 mCi sealed source of Cesium 137 failed to close during a routine six-month shutter check.

"The Radiation Safety Officer reported the gauge is mounted on a vertical section of six-inch piping and is still functioning correctly as a density meter. The device is not part of any lockout or confined space entry permit and there is currently no safety hazard potential for exposure to radiation associated with the failure of the shutter mechanism.

"The environment where the gauge is mounted is susceptible to messy process conditions which allows water and lime-mud to accumulate on the fixed gauge. This appears to have contributed to the failure of the shutter mechanism. The manufacturer's representative was called by the licensee and has scheduled a visit to the facility to make corrective repairs."

Report #: WA090097

* * * UPDATE FROM BRANDIN KETTER TO HOWIE CROUCH VIA EMAIL ON 3/1/10 @ 1526 HRS. EST * * *

"On February 25, 2010, service representatives from Ohmart Vega replaced the shutter mechanism with a new shutter closing this incident."

Notified R4DO (Cain) and FSME EO (McIntosh).

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General Information or Other Event Number: 45716
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON State: KY
County: FAYETTE
License #:
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: DAN LIVERMORE
Notification Date: 02/23/2010
Notification Time: 13:56 [ET]
Event Date: 02/23/2010
Event Time: 09:45 [CST]
Last Update Date: 02/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO WRONG LOCATION

A gamma knife treatment prescribed to be administered to the left side of a patient was instead administered to the patient's right side. The scheduled 30 minute, 90 Gray procedure was terminated after 1.4 minutes when the administering physician detected the error. It is estimated that 4% of the prescribed dose was administered to the wrong area.

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: 45720
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ALCOA WORLD ALUMINA
Region: 4
City: POINT COMFORT State: TX
County:
License #: 05189
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/24/2010
Notification Time: 11:11 [ET]
Event Date: 02/19/2010
Event Time: [CST]
Last Update Date: 02/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK PROCESS GAUGE SHUTTER

The following information was received from the State of Texas via email:

"On February 23, 2010, at 1500 hours, the [State of Texas] was notified by the licensee that the operating mechanism for the shutter shielding device on a Thermo Fisher model 5201 nuclear gauge had failed. The gauge is normally operated with the shielding for the source in the open position. The licensee stated that the current condition of the gauge poses no additional health risk to individuals. The gauge contains a Cesium (Cs)-137 source with an original activity of 100 milliCuries. The gauge is located 10 feet off of the ground and is accessed using a ladder to a platform. The area has been posted to prevent anyone from performing maintenance in the area. The licensee has contacted the manufacturer to repair the gauge. [State of Texas] will provide additional information as it is obtained."

TX Report I-8713

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Hospital Event Number: 45721
Rep Org: CHRISTIANA CARE HEALTH SYSTEM
Licensee: CHRISTIANA CARE HEALTH SYSTEM
Region: 1
City: WILMINGTON State: DE
County:
License #: 07-1215302
Agreement: N
Docket:
NRC Notified By: LARRY SIMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/24/2010
Notification Time: 12:56 [ET]
Event Date: 02/23/2010
Event Time: 11:00 [EST]
Last Update Date: 02/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WAYNE SCHMIDT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

POTENTIAL MEDICAL EVENT FROM DOSAGE DELIVERED TO DIFFERENT LOCATION THAN PRESCRIBED

"[The patient] completed her prescribed 5 day, 10fx [High Dose Rate] HDR Brachytherapy to the left breast on January 22, 2010, utilizing a multi-lumen mammosite catheter device. On Feb 22, 2010, in follow-up, the patient complained about skin reddening on the external breast, outside of the mammosite catheter insertion site. The medical physicist involved in the treatment planning process was notified about the unusual finding, who upon investigating the treatment and the plan used to deliver the radiation treatment, found that an incorrect measurement resulted in placement of the radioactive source 10 cm away from the intended position, thereby delivering the prescribed dose to a portion of the unintended area. Majority of the dose was delivered in air, but a significantly high dose was delivered to a small volume of the skin distal to the connector end of the catheter, which could have caused the skin reaction.

"Description of circumstances that led to the event: On Thursday, January 14 at 1130, [the patient] was brought to the HDR suit for CT simulation and the needed measurements. Following the CT scan of the left breast, the physicist went in the room with the source position simulator (a dummy source wire with the exact length of the actual live source cable) to measure the treatment distance for each catheter (distance to the tip of the catheter). A transfer tube was connected to the proximal end of each catheter and dummy cable was fed through the same till it could not go any further. This point is understood as the tip of the closed end catheter. While the dummy cable was being fed, the physicist felt resistance at 115.2 cm, which he recorded as the distance to the tip of the catheter. He then repeated the same measurement for the other three catheters and found that the distance of resistance was the same. All four lumens were measured and the distances were recorded. This multi-lumen mammosite catheter was the first one to be used on a patient and therefore the physicist assumed that this is the correct distance for this device, although other devices similar to this device have different treatment distances. The physicist did not exert extra pressure on the dummy cable fearing the rupture /malfunction of the catheters.

"There were two representatives from the manufacturer present, for proctoring, as this was the first case of the multi-lumen mammosite catheter. The physicist expressed his concern about the unusual treatment distance to one of the representatives, who said that the distance sounded right.

"The measured distances were entered in the plan as the position of the first dwell position of the radiation source for each catheter. The treatment plan was generated and sent to the treatment console for storage and treatment execution that next week. The planning system cannot detect any errors in the treatment distance, as long as the distance is within the length of the closed system.

"The patient returned for her first treatment on the morning of Monday, January 18, and started with treatments, twice a day for five days. There were no warnings or error messages from the treatment console and the treatments were delivered as planned.

"The radiation oncologist reported that the mammosite multi-lumen catheter had no unusual aspects or appearance at either insertion at surgery or at extraction after the last treatment fraction.

"Discovery of the error: Soon after the physician's follow-up meeting with the patient, Monday, February 22, 2010, the physicist was informed about the unusual skin reaction on the patient, on February 22, 2010. The physicist immediately began investigating the treatment records and the treatment plan. He then tried to measure the treatment distance on a sample mammosite multi-lumen device which the manufacturer had provided, as a test device, with the same source position simulator and encountered a similar resistance at the exact same distance. But when exerted more pressure on the source cable, it advanced further and the distance turned out to be 125.2, which was 10 cm longer than the measurement done on the patient. This observation led him to conclude that the patient did not receive the treatment at the intended area, but at 10 cm proximal to the catheter tip, which included some skin and tissue of the external breast medial to the entry point of the device where the skin reaction is. The physicist recalled similar resistance on the dummy source cable on other occasions, which leads to a possible fault with source position simulator assembly. It was also possible that the lumens were kinked at some point inside, where the housing of the lumens was bent (to facilitate wound dressing), thereby causing resistance for the advancing of the dummy source cable.

"A treatment plan was generated that night representing what happened and the following conclusions were made upon review by physics staff that next morning, February 23, 2010, regarding the treatment of the unintended tissue and skin:

"a. An average dose of 1700 cGy was delivered to approximately 100 cc of the unintended breast tissue.

"b. About 7.5 cc of the skin and underlying tissue received a high maximum dose of 6800 cGy (possibly the area of skin reaction)

"c. 35 cc of the intended breast tissue received an average dose of 340 cGy (10% of the total prescribed dose)

"Recommendations:

"1. The physicist should make a list of treatment distances for all standard applicators including partial breast treatment devices and catheters.

"2. Include a therapist or a nurse in the process of all patient measurements and have them double-check the patient measurements.

"3. Acquire a new source position simulator assembly and a set of transfer tubes.

"4. Make a second measurement of the treatment distance on all patient catheters prior to the first treatment."

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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Other Nuclear Material Event Number: 45735
Rep Org: COVIDIEN
Licensee: COVIDIEN
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 0204206-01
Agreement: N
Docket:
NRC Notified By: JIM SCHUH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/01/2010
Notification Time: 10:47 [ET]
Event Date: 03/01/2010
Event Time: 09:15 [CST]
Last Update Date: 03/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN GIESSNER (R3DO)
ANGELA MCINTOSH (FSME)
DENNIS ALLSTON (ILTA)

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

Event Text

TECHNETIUM GENERATOR LOST IN TRANSIT

Covidien was shipping a Molybdenum/Technetium generator to Bermuda on 2/12/2010. It was being transshipped in Atlanta for air delivery to Bermuda on one of Delta Airlines twice weekly flights. On 2/14/2010, the shipment was bumped to the next flight and on 2/18/2010 it was again bumped. The recipient was contacted and declined the shipment. Delta was contacted and stated that they could no longer locate the shipment.

The initial activity was 3 Ci of Mo-99m which would have decayed to 41 mCi on 3/1/2010.

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

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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Thursday, March 29, 2012