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Event Notification Report for May 17, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/16/2011 - 05/17/2011

** EVENT NUMBERS **


46842 46843 46851

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Agreement State Event Number: 46842
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: DECATUR MEMORIAL HOSPITAL
Region: 3
City: DECATUR State: IL
County:
License #: IL-01410-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 05/11/2011
Notification Time: 17:11 [ET]
Event Date: 09/27/2006
Event Time: [CDT]
Last Update Date: 05/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE PASSEHL (R3DO)
JAMES DANNA (FSME)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERENT THAN PRESCRIBED DOSE

The following information was received by e-mail:

"The Director of Oncology Services at Decatur Memorial Hospital contacted the Agency [state] to give a preliminary notification of a medical event that happened in September 2006. Following the receipt of additional training by their oncologists regarding medical event criteria, they began to conduct a retrospective review of past prostate cancer treatments that have been performed at their facility since 2002. A particular case was readily notable when the comparison of dose intended vs. dose received was made. Using 81 I-125 seeds, the prescribed dose to the target (D100) was 132.5 Gray, the delivered dose was 32.5 Gray which is only 24.5 percent of the intended dose. However the review showed all seeds intended to be implanted were successfully placed under guided ultrasound and post operative x-ray imaging showed all seeds to be within the target volume. Subsequent follow-ups with the patient over the past 5 years have shown a significant reduction in PSA levels, no evidence of recurrent cancer and no adverse side effects to the bladder, rectum, urethra or other associated dysfunction for the now 87 year old patient. At the time of implant, there were no notes in the surgical file to suggest a change in shape or size of the prostate which would suggest pre-treatment planning performed was invalid. Routine CT imaging conducted at 30 days post treatment as part of the follow-up process showed the prostate had expected swelling present. When dosimetry calculations were performed using the increase in volume, the total delivered dose value for the intended treatment site fell, resulting in the criteria for a medical event being met. The attending oncologist does not intend to notify the patient of this recent discovery. The doctor believes that such a notification would be against his medical judgment and would do unnecessary harm to the patient in this instance considering the success of the treatment.

"The responsible oncologists and the rest of the treatment team were interviewed by the [Illinois Emergency Management] Agency yesterday afternoon regarding additional details of this event and planned actions. The team indicated that [they] would continue review of the 240 cases but didn't believe that any changes to its current program were warranted at this time based on this one observation. Anecdotally, none of the physicians could remember any of their patients having adverse or unexpected effects during subsequent follow-ups. Nor had any [patients] required additional or supplemental treatment of any kind (i.e. hormonal, surgery, external beam, additional seeds) for recurrent cancer. [The team] couldn't rule out that a similar medical event requiring reporting wouldn't be discovered as they continued their review."

Illinois Event: IL11053

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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Agreement State Event Number: 46843
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: INEOS USA LLC
Region: 4
City: ALVIN State: TX
County:
License #: 01422
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 05/12/2011
Notification Time: 11:29 [ET]
Event Date: 05/11/2011
Event Time: [CDT]
Last Update Date: 05/12/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - OPERATING MECHANISM FAILED ON GAUGE

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

"On May 12, 2011, the Agency [state] was notified that the operating mechanism on an Ohmart Model SHLM-BR-2 nuclear gauge containing 1,000 milliCuries of Cesium (Cs) 137 had failed. The operating mechanism consists of two rods. The source is mounted on one rod and the other rod is used to move the source into and out of the source holder. The pin used to connect the two rods together broke so the source can not be manipulated. The source is currently located inside the vessel in its normal operating position. There is no increased risk of radiation exposure to any individual. The licensee is making arrangements to have the gauge repaired. The cause for the failure is still being investigated. Additional information will be provided as it is received in accordance with SA-300."

TX Incident Number I-8846

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Fuel Cycle Facility Event Number: 46851
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKLEFORD
HQ OPS Officer: VINCE KLCO
Notification Date: 05/13/2011
Notification Time: 12:39 [ET]
Event Date: 05/13/2011
Event Time: 09:00 [EDT]
Last Update Date: 05/13/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
EUGENE GUTHRIE (R2DO)
BRITTAIN HILL (NMSS)
FUELS OUO GRP EMAIL ()

Event Text

SHIPPING CONTAINER CONTAMINATION LEVEL EXCEEDS THE SURFACE CONTAMINATION LIMITS

The following information was received by e-mail:

"Empty [Model] LR-230 shipping containers received from off-site where one (1) LR-230 had removable surface contamination above limits for alpha/beta activity on the outer surface of the container (~7,800 dpm/100 sq cm alpha and 13,300 dpm/100 sq cm beta). The LR-230 shipping containers are used to transport uranyl nitrate (<5.0 wt % U-235). Contamination was not related to container integrity. Contamination appears to be related to minor drips during unloading. Areas have been successfully decontaminated.

"There were no actual or potential safety consequences to workers, the public, or the environment."

The licensee notified the NRC Resident Inspector.

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