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Event Notification Report for July 30, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/29/2015 - 07/30/2015

** EVENT NUMBERS **


51245 51248 51249 51251 51252

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Agreement State Event Number: 51245
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STERIGENICS US, LLC
Region: 4
City: HAYWARD State: CA
County:
License #: 6268-01
Agreement: Y
Docket:
NRC Notified By: KENT PENDERGAST
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/21/2015
Notification Time: 20:06 [ET]
Event Date: 07/21/2015
Event Time: 00:11 [PDT]
Last Update Date: 07/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE RACK PNEUMATIC CYLINDER FAILURE

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

"On 07/21/15, the Sterigenics Corporate RSO [Radiation Safety Officer] contacted [California - Radiologic Health Branch] RHB-Sacramento office, via an email and telephone, to report the following event in accordance with [10CFR]36.83(a)(4). [The licensee's] email stated the following:

"Last night, at approximately [0011] PDT, at the Sterigenics Hayward Facility (Radioactive materials License 6268-1), the pneumatic cylinder used to raise one of the two source racks (Hoist #1) failed to function as designed. The failure did not cause a stuck source, nor was there any risk of exposure to any individual as a result of this failure. The source did return to the down position in the pool as designed, however, the pneumatic cylinder experienced a failure and a broken flange and is not operable.

"[The licensee] will review, in detail, the cause of this failure and implement appropriate corrective action including any necessary changes in maintenance and equipment and report these changes to [the State of California] in writing, within 30 days, as required by 10CFR36.83(b).

"In the interim, the facility will not commence operations until repairs are completed to the hoist and approval to commence operations is granted by the Corporate RSO and Corporate Engineering.

"[The licensee RSO] further stated that there is no emergency or current issue. A corporate engineer will arrive in San Francisco by [1400 PDT] on 7/21/15, to work on the irradiator. The facility is staffed 24/7 and will notify RHB before resuming any operations.

"[California] RHB will be following up with the licensee."

The irradiator is in safe mode and the licensee will be investigating the reason for the failure.

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Agreement State Event Number: 51248
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINE MEDICAL CENTER
Region: 1
City: PORTLAND State: ME
County:
License #: ME-05611
Agreement: Y
Docket:
NRC Notified By: JEAN GESLIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/22/2015
Notification Time: 11:22 [ET]
Event Date: 06/05/2015
Event Time: [EDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF I-125 SEED

The following report was provided by the Maine Radiation Control Program via email:

"Maine Medical Center (MMC) reported the loss of an I-125 localization seed (39209B-5-12) that contained an activity of 3.4 MBq (92 Ci). The seed was discovered lost during an inventory performed on 6/5/2015. The seed was still in the inventory log, but was not physically present. A nuclear medicine technologist searched the hot laboratory, mammography, and ultrasound areas, but the seed was not found. MMC continued to search for the seed for several weeks. There is no evidence that the seed was implanted into a patient. MMC believes that the seed was inadvertently placed into the trash in the hot laboratory. Corrective actions included providing additional training to personnel."

Maine Event Report: ME150003

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: 51249
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TWINING, INC.
Region: 4
City: SACRAMENTO State: CA
County:
License #: 7782-34
Agreement: Y
Docket:
NRC Notified By: KENNETH FUREY
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/22/2015
Notification Time: 11:21 [ET]
Event Date: 07/21/2015
Event Time: [PDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following was received from the State of California via Email:

"A CPN thin layer density gauge, serial #1228, was run over by a dump truck that was spreading sand at a paving project on Highway 12 at Terminous Road in San Joaquin County, CA. The source was not breached and remained intact. The gauge was taken to Pacific Nuclear and a leak test disclosed no removable contamination. The California Code of Regulations, Title 17, Section 30350.3 states that the licensee shall immediately notify the Department by telephone and subsequently, within 30 days, by confirmation letter if the licensee knows or has reason to believe that a sealed source has been ruptured. This incident is being reported to the NRC as information only."

California 5010 number: 072115

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Agreement State Event Number: 51251
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: RADIOTHERAPY CLINICS OF GEORGIA
Region: 1
City: LAWRENCEVILLE State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/22/2015
Notification Time: 15:20 [ET]
Event Date: 07/17/2015
Event Time: [EDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE FOR SKIN CANCER

The following report was received via e-mail:

"1. A patient received an [Ir-192] HDR treatment using a skin applicator on the nose. This treatment is used to treat skin cancer.

"2. The physician's written directive specified a dose to the tumor volume, and a maximum tumor dose of 130 percent of the prescribed dose. The total dose was delivered in 8 fractions.

"3. The patient's course of treatment proceeded to conclusion. On recent follow-up exam, the patient's skin reaction was more than usual for this type of treatment, so the physician asked physics to review the plan.

"4. This review indicated the tumor volume maximum dose exceeded the prescribed 130 percent by more than 50 percent."

The date, time, and dose prescribed/received were not given in the report.

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: 51252
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: RADIOTHERAPY CLINICS OF GEORGIA
Region: 1
City: CONYERS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/22/2015
Notification Time: 15:20 [ET]
Event Date: 07/01/2015
Event Time: [EDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - VAGINAL CATHETER SLIPPED DURING TREATMENT

The following report was received via e-mail:

"An incident has come to light at [the licensee's] Conyers clinic. A patient was treated with a vaginal cylinder at the beginning of July, 2015. The treatment was delivered in 3 fractions. On a recent follow-up exam, the patient presented with a single mark on the skin of the upper inner thigh on both legs. The radiation oncologist felt these marks were consistent with radiation dermatitis. A review of the patient's treatment plan and treatment records showed no errors had occurred.

"[The licensee's] current thinking is that the only plausible explanation is that the catheter which contains the source wire was not securely locked inside the vaginal cylinder and partially slipped out during treatment.. If this occurred, the most proximal dwell position could have fallen on the skin of the upper thigh.

"[The Georgia Radioactive Materials Program] is continuing to investigate."

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.

Page Last Reviewed/Updated Thursday, July 30, 2015
Thursday, July 30, 2015