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Event Notification Report for February 4, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/03/2015 - 02/04/2015

** EVENT NUMBERS **


50756 50760 50761 50762 50763 50764 50765 50766 50770 50784

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Non-Agreement State Event Number: 50756
Rep Org: DANBURY HOSPITAL
Licensee: DANBURY HOSPITAL
Region: 1
City: DANBURY State: CT
County:
License #: 06-08544-01
Agreement: N
Docket:
NRC Notified By: RUTH SHANLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/23/2015
Notification Time: 14:52 [ET]
Event Date: 01/07/2015
Event Time: [EST]
Last Update Date: 02/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS EVENTS RESOURCE (EMAI)

Event Text

RECEIVED DOSE DIFFERED FROM PRESCRIBED DOSE OF I-125

On December 17, 2014, a patient had a 123 microCurie I-125 seed implanted in her breast as part of a treatment plan for non-palpable breast cancer. The treatment plan was to remove the seed after 5 days.

Due to illness, the patient was unable to return to the hospital to have the seed removed until January 7, 2015. This resulted in the patient receiving an 83.6 cGy exposure versus the prescribed 18.4 cGy exposure.

The prescribing physician and the patient were notified. No permanent damage due to the exposure is expected.

The licensee coordinated this report with NRC Region 1 Senior Health Physicist Penny Lanzisera.

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.

* * * UPDATE FROM RUTH SHANLEY TO CHARLES TEAL AT 1529 EST ON 2/3/15 * * *

The licensee called to report two additional patients whose dose exceeded 50 cGy.

The first patient was not medically cleared for the procedure. The patient received 57.9 cGy instead of the prescribed dose after 5 days of 21.8 cGy of I-125.

The second patient refused to undergo the procedure until genetic testing was completed. The patient received 54 cGy instead of the prescribed dose after 5 days of 20.3 cGy of I-125.

The licensee will modify their procedures to wait until patients are medically cleared and wait until all other testing is done prior to undergoing the procedure.

Notified R1DO (DeFrancisco) and NMSS Events Notifications via email.

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Non-Agreement State Event Number: 50760
Rep Org: BIOSTORAGE TECHNOLOGIES, INC
Licensee: BIOSTORAGE TECHNOLOGIES, INC
Region: 3
City: INDIANAPOLIS State: IN
County: MARION
License #: 13-32622-01
Agreement: N
Docket:
NRC Notified By: THOMAS SCHUMACHER
HQ OPS Officer: DANIEL MILLS
Notification Date: 01/26/2015
Notification Time: 11:11 [ET]
Event Date: 12/31/2014
Event Time: [EST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BILLY DICKSON (R3DO)
NMSS EVENT NOTIFICAT (EMAI)

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

Event Text

LOST RADIOACTIVE MATERIAL INADVERTENTLY INCINERATED

The licensee lost 9 vials of Carbon 14 (each vial containing 2 mCi). It was later determined that the vials were mistakenly disposed of with a large amount of non-radioactive medical waste on 12/31/2014. The medical waste and all 9 vials were incinerated on 1/7/2015 by Stericycle in Clinton, IL.

The licensee has instituted corrective actions including more robust labelling to identify radioactive material.

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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Agreement State Event Number: 50761
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TEAM INDUSTRIAL SERVICES, INC.
Region: 4
City: HAMMOND State: KS
County:
License #: 21-B875
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/26/2015
Notification Time: 12:30 [ET]
Event Date: 01/24/2015
Event Time: [CST]
Last Update Date: 01/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
BARRY WRAY (ILTA)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - ATTEMPTED THEFT OF RADIOGRAPHIC EQUIPMENT

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

"The Team Industrial office in Wichita was broken into. They have video evidence of attempt to access the licensed material of concern. All material is accounted for. Missing items include UT equipment, computers, vehicle keys (vehicles were not taken), files were ransacked including the sensitive information files. Unknown at this time if sensitive information was taken.

"Police notified."

Kansas Case Number: KS150001

* * * UPDATE FROM JAMES HARRIS TO JEFF HERRERA ON 01/28/2015 AT 1327 EST * * *

The following updated information was provided by the Kansas Department of Health and Environment via email:

The Kansas Department of Health and Environment provided additional detail regarding the event and the items stolen. Radioactive material was not stolen as a result of the break in attempt(s). Local law enforcement and FBI were notified and investigated the event. Additional corrective actions were taken by the licensee to secure sensitive materials and equipment. A reward has not been offered for return of the stolen items. A detailed list of the missing items has been provided to the Wichita police department.

Notified R4DO (Vasquez), ILTAB (Wray) and NMSS Events Notification (email).

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Agreement State Event Number: 50762
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FEDERAL MAINTENANCE, INC. D/B/A FEDERAL ENGINEERING AND TEST
Region: 1
City: POMPANO BEACH State: FL
County:
License #: 1933-1
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 12:58 [ET]
Event Date: 01/23/2015
Event Time: 10:30 [EST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE DAMAGED AT CONSTRUCTION SITE

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

"A Troxler Gauge Model No. 3440 was run over by a Bobcat tractor on a road construction site around 1030 EST [on 1/23/15] . The source was retracted when the gauge was hit. [The Florida State] Inspector arrived on scene and found gauge on truck tail gate. The gauge had been moved to tail gate before calling [the State]. [The State] Inspector surveyed the ground where gauge was hit and read background readings. Other readings: 6ft from gauge 23 uR/hr, gauge handle 71 uR/hr, top of gauge housing 13.3 mR/hr, source door 8.44 mR/hr. The guide rod and housing were broken but source was secure and there was no leakage of radiation. The gauge released to owner to be returned for repair. No further action will be taken on this incident."

This incident occurred at the intersection of S. Andrews and SE 30th St, Ft. Lauderdale, Fl.

Troxler Gauges, Model No. 3440, have a Cs-137 source not exceeding 9 mCi and a Am-241 source not exceeding 44 mCi.

Florida Incident Number: FL15-001

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Agreement State Event Number: 50763
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: FOX NDE, LLC
Region: 4
City: ODESSA State: TX
County:
License #: L06411
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 15:17 [ET]
Event Date: 01/25/2015
Event Time: [CST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA WITH STUCK SOURCE

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

"On January 26, 2015, the licensee notified the Agency [State of Texas] that on January 25, 2015, one of its industrial radiography crews had experienced a source disconnect. The crew was using a QSA Delta 880 exposure device (SN: 12916) containing a 98.5 curie iridium-192 source. After the first exposure of the day, the crew was unable to retract the source and it was determined that it was in the collimator. Barriers were extended. The licensee's site radiation safety officer (SRSO), who is authorized to perform source retrieval, responded. (The SRSO) was unable to get the source to slide back down the guide tube and had to use pliers to remove the collimator to recover the source and complete the retrieval. None of the 4 radiographers present at the site exceeded doses of 30 millirem according to their self-reading pocket dosimeters. The SRSO's self-reading pocket dosimeter indicated a whole body dose of 73 millirem. [The SRSO's] dosimetry badge is being sent for immediate processing. The SRSO's dose to both hands is being calculated. [The SRSO] affixed pocket dosimeters to both hands, but two of the 3 times he handled the source guide tube or collimator, they went off-scale. No member of the public received any exposure as a result of this event. The SRSO reported he consulted with the manufacturer and thoroughly inspected the equipment. [The SRSO] found no issues. [The SRSO] reported, he attempted, unsuccessfully, to replicate the disconnect. Based on [the SRSO's] findings, the camera was put back into use and not removed from service."

Texas Incident #: I - 9271

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Agreement State Event Number: 50764
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AMC THEATRE, SAN JOSE
Region: 4
City: SAN JOSE State: CA
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/26/2015
Notification Time: 17:20 [ET]
Event Date: 08/15/2014
Event Time: [PDT]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
ILTAB (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TRITIUM EXIT SIGN

The following information was obtained from the State of California via facsimile:

"On 01/22/15, RHB [California Radiologic Health Branch] was notified of a stolen tritium exit sign from an AMC Theatre in San Jose, CA. The police report No. 142273216 filed by the AMC theatres on 08/15/14 stated the following: 'The management was doing a walkthrough of the building on 08/15/14 at AMC Saratoga 14. In theatre No. 13, the manager noticed one of the exit signs missing.'

"The model, S/N or the activity of the exit sign is unknown. RHB will be contacting AMC theatres and the Ultimate Lighting Source (vendor) to get further details."

California Report Number: 5010-012215

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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Agreement State Event Number: 50765
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: FLORIDA BUREAU OF RADIATION SERVICES
Region: 1
City: ATLANTA State: GA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 17:09 [ET]
Event Date: 01/26/2015
Event Time: [EST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
BARRY WRAY (ILTA)

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

Event Text

AGREEMENT STATE REPORT - STOLEN DOSE CALIBRATOR SOURCES

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

"Georgia Radioactive Materials Program discovered through a Law Enforcement List Server that 2 Co-57 sources and 1 Cs-137 source (what appear to be Dose Calibrator Sources as indicated in the example photo provided by LE) were stolen from a vehicle at or around Atlanta Hartsfield Airport.

"Activities of the sources are: The 2 Co-57 are 2.47 mCi and .365 mCi sources. The Cs-137 is a .232 mCi source.

"The individual transporting the sources was from Florida [Florida Department of Radiation Services]. Florida Radiation Control has been notified and Atlanta FBI has been notified.

"Updates to follow when more information is available."

State of Georgia Event Report 1-26-2015.

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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Agreement State Event Number: 50766
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: REED ENGINEERING GROUP, INC.
Region: 4
City: ABILENE State: TX
County:
License #: L04343
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/26/2015
Notification Time: 18:55 [ET]
Event Date: 01/26/2015
Event Time: [CST]
Last Update Date: 01/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM ANDREWS (R4DO)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

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

"On January 26, 2015, the licensee notified the Agency [State of Texas] that one of its technicians had left a temporary job site in Fort Worth and after traveling approximately 30 minutes toward another job site, he realized the tailgate was down [and the gauge was missing]. When he left the first site, he had left the Humboldt 5001EZ moisture/density gauge (SN: 3613), containing one 10 millicurie cesium-137 source and one 40 millicurie americium-241/beryllium source, on the tailgate and not secured in the back of the vehicle. The technician returned to the site and looked for the gauge. Other construction workers at the site did produce the carrying case and the lock that had been on it, the standard block, and the flattening plate but not the gauge. The licensee is notifying local law enforcement and will return to the site in the morning with reward offer. Further information will be provided as it is obtained in accordance with SA-300."

Texas Report Number: I-9272

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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Agreement State Event Number: 50770
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CANCER CENTER OF GAITHERSBURG MARYLAND
Region: 1
City: GAITHERSBURG State: MD
County:
License #: 31-385-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2015
Notification Time: 14:49 [ET]
Event Date: 01/26/2015
Event Time: 14:30 [EST]
Last Update Date: 01/28/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"On 1/27/15 at 0830 EST, [Maryland Department of the Environment (MDEP) personnel] discussed preliminary findings [with the licensee] regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO [Radiation Safety Officer]. The initial notification came to [the Maryland] RHP [Radiological Health Program] on 1/26/15 at 1600 EST.

"The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878.

"The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR [High Dose Rate].

"The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose.

"[The Licensee] stated no history of previous medical incidents.

"The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray.

"Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur.

"The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed.

"Present at the therapy - Oncologist, Medical Physicist, and Therapist.

"[The Medical Physicist] stated that the licensee will re-examine all quality assurance oversight for HDR therapies.

"Preliminary consideration for corrective actions: All new treatment plans will be given new identities [and] the licensee will explore ways to delete previous treatment plans.

"The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day.

"[The Medical Physicist] was informed that RHP will investigate the incident."

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.

* * * UPDATE FROM ALAN JACOBSON TO JEFF HERRERA ON 01/28/2015 AT 0828 EST * * *

The following information was provided by the State of Maryland via email:

The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci.

Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email).

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Part 21 Event Number: 50784
Rep Org: OPERATION TECHNOLOGY, INC./ETAP
Licensee: OPERATION TECHNOLOGY, INC./ETAP
Region: 4
City: IRVINE State: CA
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: NAZAN ROSHDIEH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/03/2015
Notification Time: 14:44 [ET]
Event Date: 01/23/2015
Event Time: [PST]
Last Update Date: 02/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)
ROBERT HAAG (R2DO)
LAURA KOZAK (R3DO)
GEOFFREY MILLER (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 REPORT - ERROR IDENTIFIED IN POWER SYSTEM ANALYSIS SOFTWARE

The vendor identified an error in their power system analysis ETAP software (releases 11.0.0N to 12.6.0N) that could result in an inaccurate analysis result. A letter explaining the errors, and the way to avoid the errors, was submitted to the user community on January 23, 2015. A software revision correcting the errors is scheduled for release in February 2015.

Page Last Reviewed/Updated Wednesday, February 04, 2015
Wednesday, February 04, 2015