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Event Notification Report for September 29, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/28/2010 - 09/29/2010

** EVENT NUMBERS **


46272 46273 46275 46278 46285

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General Information or Other Event Number: 46272
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MERCY ST VINCENT MEDICAL CENTER
Region: 3
City: TOLEDO State: OH
County:
License #: 02120490000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/02/2004
Event Time: [EDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - UNREPORTED MEDICAL PROSTATE THERAPY UNDERDOSES DISCOVERED DURING AUDIT

The following information received via email is historical and was discovered/reported to the State of Ohio on 04/27/2010:

"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [NMED Item Number: 100113 - Ohio Agreement State Report EN #45750]

"On 12/2/04 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [107.4 Gray actually delivered] to the prostate. A post implant dose calculation showed a underdose to the prostate greater than 20% of the prescribed dose; however, the licensee determined the dose to be clinically adequate. No further therapy was planned at that time. [Ohio NMED Item # OH100012]

"On 12/14/04 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [66.27 Gray actually delivered] to the prostate. Post implant dosimetry showed a low dose distribution to the base of the prostate, which was not felt to be clinically significant. No further therapy was recommended at that time, since the patient also received external beam radiotherapy. [Ohio NMED Item # OH100013]

"On 7/3/07 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [101.82 Gray actually delivered] to the prostate. A post implant dose calculation showed a underdose to the prostate greater than 20% of the prescribed dose; however, the licensee determined the dose to be clinically adequate. There was limited dose distribution at the gland base. No further therapy was planned at that time. [Ohio NMED Item # OH100014]

"On 1/11/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [101.7 Gray actually delivered] to the prostate. A post implant dose calculation revealed a suboptimal dose distribution to the base of the prostate gland. No further therapy was planned at that time. [Ohio NMED Item # OH100015]

"On 7/14/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [57.4 Gray actually delivered] to the prostate. Following the final dosimetry testing in 2005, the patient and the referring urologist were notified of a clinically suboptimal dose to the base of the prostate. Post implant prostate volume on which the dosimetry was calculated was 40% greater than the intraoperative prostate volume. Thus, dosimetry was inaccurate due to gland edema. The patient and the referring urologist opted for close monitoring of the prostate and PSA levels without additional therapy. No further therapy was planned at that time. [Ohio NMED Item # OH100016]

"On 4/17/07 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [58.6 Gray actually delivered] to the prostate. Seed implant was utilized as a boost to the prostate gland following IMRT. Post implant dosimetry showed a suboptimal dose distribution at the base; however, satisfactory dose was observed about the mid gland where biopsy proven adenocarcinoma was present. No further therapy was planned at that time. [Ohio NMED Item # OH100017]

"On 9/23/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [79.4 Gray actually delivered] to the prostate. The patient received external beam radiation therapy (4500cGy) and seed implant was utilized as a boost to the prostate gland following IMRT. Post implant dosimetry indicated a clinically satisfactory dose distribution. No further therapy was planned at that time. [Ohio NMED Item # OH100018]"

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: 46273
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TIFFIN MERCY HOSPITAL
Region: 3
City: TIFFIN State: OH
County:
License #: 02120750001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/10/2008
Event Time: [EDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - UNREPORTED MEDICAL PROSTATE THERAPY UNDERDOSE DISCOVERED DURING AUDIT

The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010:

"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [See EN # 46272]

"On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray [104.76 Gray actually delivered] to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose."

Ohio NMED Item # OH100019.

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: 46275
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UTAH INSPECTION
Region: 4
City: UINTAH-OURAY RESERVATION State: UT
County:
License #: UT 2400357
Agreement: Y
Docket:
NRC Notified By: MARIO BETTOLO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 20:31 [ET]
Event Date: 09/19/2010
Event Time: 11:30 [MDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE NOT FULLY RETRACTED

The following report was received via fax:

"Event Location: QEP Ironhorse Gas facility plant near Bonanza Utah on Uintah-Ouray reservation land.

"Event Description: While conducting Industrial Radiography operations with a SPEC-150 camera, Serial # 816, the guide tube detached from the fitting used to attach the guide tube to the camera. The Ir-192 pigtail source was being retracted at the time. The source was not fully retracted when the guide tube fell away. The radiographers were unable to fully retract the source since the pigtail was at a ninety degree angle to the cable. The camera was approximately 25' in the air located on pipe rigging. The radiographers appropriately determined a 2mR/hr boundary and secured the area. Upon examination through binoculars, the RSO determined that the source was still secured to the cable. He reset his pocket dosimeter and, using a man lift, was lifted up to near the back of the camera. He used a 4' long grabber tool to gently lift the pigtail, allowing it to be retracted into the camera. He measured 190 mRem on the pocket dosimeter and sent in his film badge for immediate processing. The film badge showed a reading of 260 mRem for the period of time from September 1, 2010 to September 19, 2010. The RSO examined the camera and tube and determined that the tube pulled out of the crimping on the fitting. At the time of the incident the licensee had a total of five employees present at the location. Three currently qualified radiographers (including the RSO) and two currently qualified radiography assistants."

Utah report UT-10-0004.

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General Information or Other Event Number: 46278
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SPACE SCIENCE SERVICES, INC.
Region: 1
City: ORLANDO State: FL
County:
License #: 140-2
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/24/2010
Notification Time: 17:24 [ET]
Event Date: 09/22/2010
Event Time: [EDT]
Last Update Date: 09/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following report was received via e-mail:

"During the last radiographic exposure on 9/22/10 the source did not fully retract. The workers did not do a survey and did not have their rate alarms turned on. They noticed that their dosimeters were off scale and discovered the problem. The film badges were processed on 9/24/10 by Landauer and found the assistant radiographer received 0.742 Rem and the lead [radiographer] received 114.4 Rem. Since they were both together this is questionable. Landauer reports the lead's badge shows an uneven surface reading which is an indication it has been damaged by dropping. Licensee calculations show 0.750 REM for both. The lead has been sent for a blood test. Licensee will send a written report. Florida is investigating."

The camera contained a 71 Ci Ir-192 source.

Florida report number: FL10-101

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Power Reactor Event Number: 46285
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ALAN MODZELEWSKI
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/28/2010
Notification Time: 15:04 [ET]
Event Date: 09/28/2010
Event Time: 11:30 [EDT]
Last Update Date: 09/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MEL GRAY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION - FAULTY ALARM ACTUATION

"At 1130 hrs. on September 28, 2010, the site was notified by Wayne County, New York of a single siren activation at 0620 hrs. for approximately 2 minutes. The single siren activation was not related to any condition or event at Ginna Station.

"The NRC Resident Inspector has been informed of the activation."

A maintenance crew is currently investigating the cause of the spurious activation.

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