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Event Notification Report for July 26, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/25/2011 - 07/26/2011

** EVENT NUMBERS **


47071 47074 47082 47083

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 47071
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/19/2011
Notification Time: 10:05 [ET]
Event Date: 07/12/2011
Event Time: 11:00 [EDT]
Last Update Date: 07/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RON ZELAC (FSME)
ERIC DUNCAN (R3DO)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED TREATMENT TO INCORRECT ORGAN

"Approximately four (4) weeks prior to the therapy, patient was scanned for extrahepatic shunting through injection of 99mTc MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.

"On Tuesday July 12, 2011, at 11:00 AM the patient was treated with 0.977 GBq of 90Y TheraSphere per protocol. Interventional Radiologist properly placed catheter. A second interventional Radiologist confirmed the catheter placement.

"On Tuesday July 12, 2011 at 6 PM, post procedure scan identified significant activity in the duodenum. Initial estimate indicates 0.117 GBq had shunted into the duodenum approximately 12% of the administered activity. An initial estimate indicates dose to duodenum is approximately 110 Gy.

"The asymptomatic patient was discharged with follow up contacts for possible intervention as a result of the dose to the duodenum. Patient has been notified. Referring physician has been notified.

"Literature search indicates patient may have developed vascularization post-scan, pretreatment.

"An inspector from the Department [Ohio Bureau of Radiation Protection] will conduct an inspection the week of July 25, 2011."

Ohio Event Report Number: 2011-014

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.

* * * RETRACTION FROM MARK LIGHT TO VINCE KLCO ON 7/19/11 AT 1326 EDT * * *

Based on further review by the licensee, the patient's organ in question did not receive the above referenced dose.

Notified the R3DO(Duncan) and FSME (Zelac).

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Agreement State Event Number: 47074
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: INVISTA SARL
Region: 4
City: LA PORTE State: TX
County:
License #: L05719
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/20/2011
Notification Time: 13:12 [ET]
Event Date: 04/07/2011
Event Time: [CDT]
Last Update Date: 07/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
RON ZELAC (FSME)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

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

"On July 19, 2011, the Agency [Texas Department of Health] received a call from the licensee's Radiation Safety Officer reporting that during a routine inspection on April 7, 2011, the shutter handle on an Ohmart/Vega Gauge model SHLG-1 broke off. The gauge serial number is 0678GK and contains 300 mCi of Cs-137. The gauge failed in the normally open position. The gauge was subject to condensation from a steam leak from above which caused the handle to rust. A vendor shut the gauge shutter on June 30, 2011. The gauge will be removed for disposal since the tank is no longer used. The failure did not create any additional exposure to any individual. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-8872

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Agreement State Event Number: 47082
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BRAZOS VALLEY INSPECTION SERVICES, INC
Region: 4
City: BRYAN State: TX
County:
License #: 02859
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/21/2011
Notification Time: 08:38 [ET]
Event Date: 07/20/2011
Event Time: [CDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
RON ZELAC (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY CAMERA LOCKING MECHANISM

The following information was received via facsimile:

"On July 20, 2011, the Agency [Texas Department of Health] was notified by the licensee that they had completed radiography operations at a field site using a INC IR-100 radiography camera containing an 82 curie iridium-192 source and retracted the source to its fully shielded position. The radiographer surveyed the camera and found the readings to be normal. When he disconnected the drive cable from the source pigtail, he found that the pigtail was no longer protruding from the back of the camera, it was now flush with the rear of the device. The shipping plug and the front dust cover were placed on the camera. The camera is being returned to the manufacturer for repair. Additional information will be provided as it is received. The licensee believes that the locking device that holds the pigtail in place inside the camera has failed. The serial number for the camera is 4590."

Texas Incident Report Number: I-8873

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Agreement State Event Number: 47083
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSAL ENGINEERING SCIENCES, INC.
Region: 1
City: FT. PIERCE State: FL
County:
License #: 1136-12
Agreement: Y
Docket:
NRC Notified By: CHARLES E. ADAMS
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/21/2011
Notification Time: 12:42 [ET]
Event Date: 07/20/2011
Event Time: [EDT]
Last Update Date: 07/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISURE DENSITY GAUGE

The following report was received via email from the State of Florida:

"An accident caused damage to a moisture density gauge at a work site on the Kissimmee River Restoration/CSX Bridge project. The operator of a large earthmoving vehicle lost control and ran over a parked truck with the gauge sitting on the tailgate. The truck & contents were mangled and buried under the earthmoving vehicle. The tech was not injured. A 15 foot area was roped off around the accident site. When the gauge was recovered it appeared to have some damage to the top housing. Survey readings were elevated to around 40-50 mR/hr at one foot. Using shielding, the gauge was transported to the Troxler office in Orlando for repair. Licensee sent a written report to this office. This office will take no further action on this incident."

The device is a Troxler Model No. 3440 S/N 37720 with two sources; 9.0 mCi Cs-137 and 44 mCi Am-241/Be.

Florida Incident No.: FL-11-062

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Thursday, March 29, 2012