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Event Notification Report for October 1, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/30/2015 - 10/01/2015

** EVENT NUMBERS **


50472 51416 51417 51418 51419 51420

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 50472
Rep Org: MONONGALIA GENERAL HOSPITAL
Licensee: MONONGALIA GENERAL HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: MARK PERNA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/19/2014
Notification Time: 13:56 [ET]
Event Date: 09/19/2014
Event Time: [EDT]
Last Update Date: 09/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

BRACHYTHERAPY PATIENT RECEIVED 54% OF PRESCRIBED DOSE

The authorized user determined that, due to scar tissue from a previous procedure, the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.

The investigation into the event is ongoing.

* * * RETRACTION FROM MARK PENA TO HOWIE CROUCH AT 1458 EDT ON 9/30/15 * * *

Upon investigation of the details surrounding the event, it was determined that the patient received greater than 80% of prescribed activity. Therefore, this event no longer meets any regulatory reporting criteria and is being retracted.

Notified R1DO (Bower) and NMSS Events Resource via email.

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: 51416
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EXXONMOBIL OIL CORPORATION
Region: 4
City: TORRANCE State: CA
County:
License #: 0113-19
Agreement: Y
Docket:
NRC Notified By: JOJI ORTEGO
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2015
Notification Time: 15:03 [ET]
Event Date: 09/21/2015
Event Time: [PDT]
Last Update Date: 09/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED SOURCE HOUSING

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

"On Sept. 21, 2015, [the] RSO [Radiation Safety Officer for] ExxonMobil contacted Los Angeles County Radiation Management regarding an equipment malfunction to one of the two sources in Vessel #5C31, found during routine maintenance. [Source information]; cesium-137, Model 7063 K-ray; SN: 29456B; 500 milliCuries. Per [the RSO], the source housing was damaged and was left in its normal operating position. Using a Ludlum Model 3, 44-6 beta gamma probe, the background radiation was measured at approx. 0.02 mR/hr and the radiation rate at 1 meter from the source is 0.06 mR/hr. The service company has been contacted and repair/replacement will be performed as soon as possible."

California Report 5010#: 092115

* * * UPDATE FROM JOSEPHINE ORTEGA TO JOHN SHOEMAKER AT 1437 EDT ON 9/23/15 * * *

The following information was excerpted from a updated report received from the State of California via email:

"The shutter was stuck in the open position as used during its normal operating position. Using a Ludlum Model 3, 44-6 beta gamma probe, the background radiation was measured at approx. 0.02 mR/hr and the dose rate at 1 meter in areas outside of the vessel that could be occupied is approx. 0.06 mR/hr. The dose rate obtained in the path of the beam after passing thru two vessel walls is approx. 0.6 mR/hr. The vessel walls are 1 inch thick steel and the vessel diameter is approximately 8 feet."

Notified R4DO (Pick) and NMSS_Events_Notification via email.

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Agreement State Event Number: 51417
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. THOMAS MORE HOSPITAL AND PROGRESSIVE CARE
Region: 4
City: CANON CITY State: CO
County:
License #: CO 397-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2015
Notification Time: 17:22 [ET]
Event Date: 09/22/2015
Event Time: [MDT]
Last Update Date: 09/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION EVENT

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

"On September 22, 2015, during a routine inspection at Colorado licensee St. Thomas More Hospital and Progressive Care (license CO 397-01), [Colorado State] inspectors noted multiple areas with contamination. Upon further investigation, the inspectors learned a patient earlier in the day was undergoing a diagnostic test involving nebulized Tc-99m DTPA for a lung scan. The patient began coughing and pulled off the mask during administration and coughed, spreading the contamination in the diagnostic area. The patient began to require elevated levels of medical care and nursing staff and nuclear medicine staff may have been contaminated while caring for the patient. Arrangements were made to transfer the patient to a different medical facility via helicopter. The second facility was notified and nuclear medicine technologists surveyed the helicopter and patient upon arrival with no contamination found.

"Reporting requirement: 10 CFR 30.50(b)(3); Colorado Part 4, Section 4.52.2.4

"Cause and corrective action: patient intervention. St. Thomas More has closed the affected areas to allow for decay. Surveys will be performed in affected areas prior to re-opening for additional patients.

"A full report of investigation and evaluations will follow within the next 30 days.

"Incident identification: CO15-I15-27"

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 51418
Rep Org: UNIV OF VT MEDICAL CENTER
Licensee: UNIV OF VT MEDICAL CENTER
Region: 1
City: BURLINGTON State: VT
County:
License #: 44-10187-03
Agreement: N
Docket:
NRC Notified By: MARLEEN MOORE
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/23/2015
Notification Time: 12:09 [ET]
Event Date: 09/23/2015
Event Time: 10:00 [EDT]
Last Update Date: 09/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL UNDERDOSE DURING SIRSPHERE ADMINISTRATION

"SirSphere administration to [the patient] on Wednesday Sept 23, 2015.

"[The patient] was prescribed, with appropriate written directives, 0.27 GBq and 0.29 GBq to segments in the posterior and anterior right lobe of the liver. Paperwork for determination of the activities and volumes are available.

"The SirSpheres were received on Sept 22, 2015, calibrated for 1800 [EDT] on Sept 23, 2015. The two doses were prepared between 0900 and 0930 AM on Wed Sept 23, 2015. The procedure used is attached as are the worksheets for verification of activity. No unusual behavior was observed (e.g. clumping or unusual settling of the spheres).

"The posterior right lobe treatment was given first. The system was set up with D5W for the agitating solution and contrast in a three way set up for the contrast flush. The interventional radiologist administered in the method that has been used for all prior, successful, administrations. [The radiologist] reports that he did not encounter any difference in resistance in the syringe, nor did [medical center staff] note any difference in the appearance of the solution flowing through the three way stopcock. The administration was completed and the residual immediately checked using the method of pre vs post assay of delivery vial then delivery vial and associated tubing. The post reading was initially higher than the pre. The vial and tubing was carefully put onto a plastic backed pad and it was determined that there were higher readings from the vicinity of the three way stopcock.

"This patient was scheduled for two infusions due to their vasculature, and after much discussion it was decided, based on our prior success with treatments, to proceed with the second but pay very close attention to whether there were some spheres that were backed up at the three way. In the past, [medical center staff] have been able to dislodge such an occurrence by gentle knocking of the three way prior to the clearing of the vial with air. A new administration set was installed and the administration proceeded. Frustratingly, it was immediately apparent that some of the spheres were clumping at the three way but that some had passed through and were then in the patient. With gentle knocking of the stopcock, it was possible to dislodge many of the spheres. However, the after reading again showed that there was a measurable amount of activity that had stuck somewhere in the delivery tubing.

"Because the pre and post readings are so dependent on the presence of the plastic for both stopping the electrons and production of Bremmstrahlung, it was not possible to get any type of accurate assessment of the activity remaining. However, it was possible to evaluate the last three Sirsphere post Brem SPECT scans, determine a counts/administered activity, and evaluate that number. For the three patients the values were acceptably comparable, that this calibration value was then used to determine the activity present for the after study Brem scan on today's patient. This gave an estimate of approximately 70% of the written directive.

"Please note that this report is a preliminary report and an updated will be forwarded as this is reviewed by all concerned and also further evaluations performed."

The licensee will contact the manufacturer to troubleshoot the issue, and will notify the patient, prescribing physician, and NRC Region 1.

* * * RETRACTION FROM MARLEEN MOORE TO HOWIE CROUCH AT 1613 EDT ON 9/29/15 * * *

Based on re-analysis of the data, and with concurrence of USNRC Region I DNMS Inspector (Nguyen), it was determined that the patient received between 82% and 90% of the prescribed dose. Based on this information, this event no longer meets the reporting criteria and is being retracted by the licensee.

Notified R1DO (Bower) and NMSS Events Resource (email).

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: 51419
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: PROFESSIONAL SERVICES INDUSTRIES
Region: 1
City: MEMPHIS State: TN
County:
License #: R-79242-B20
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/23/2015
Notification Time: 15:26 [ET]
Event Date: 09/21/2015
Event Time: 16:37 [CDT]
Last Update Date: 09/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

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

"On September 21, 2015, a moisture density gauge, belonging to Professional Services Industries, was run over at the Memphis International Airport. No contamination was reported by the licensee. The rods were still attached and shutter was in the closed position. The gauge was a Troxler Model 3430 (S/N # 31540) containing an 8 mCi Cs-137 sealed source and a 40 mCi Am-241 source in the base of the gauge. The licensee is making arrangements with manufacturer to package and ship the device. A follow-up report will be submitted upon receipt of further information."

Tennessee State Event Report ID NO: TN-15-144.

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Agreement State Event Number: 51420
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: WHITEMAN, REQUARDT & ASSOCIATES (WRA) LLP
Region: 1
City: LYNCHBURG State: VA
County:
License #: 680-572-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/23/2015
Notification Time: 15:59 [ET]
Event Date: 09/02/2015
Event Time: [EDT]
Last Update Date: 09/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ROBERT BUNCH (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOST PORTABLE MOISTURE/DENSITY GAUGE

The following report was received from the Commonwealth of Virginia via email:

"On September 22nd at 1749 EDT. [The Commonwealth of Virginia Department of Health] received a call from the Virginia Emergency Operations Center, stating that the RSO [Radiation Safety Officer] from WRA [the licensee, Whitman, Requardt & Associates] was calling to report a missing gauge. [Virginia Department of Health] contacted the [licensee's] RSO who then informed [Virginia Department of Health] that one of their gauges was lost in shipment. [Virginia Department of Health] requested the RSO send an email detailing the event.

"On August 12th, WRA shipped a Troxler 3411B gauge (S/N: 5374), containing 9 mCi of Cs-137 and 44 mCi of Am-241, to Northeast Technical Services (NETS) for calibration. On September 1st, WRA was contacted by NETS that the calibration was completed and the gauge was being shipped back. On September 15th, WRA contacted NETS to say they had not received the gauge. On September 22nd, NETS contacted WRA to inform them that [the common shipper] was unable to locate the gauge and considered it to be unlikely recovered.

"NETS supplied [Virginia Department of Health] with the tracking number which indicated the gauge was picked up on September 1st, sent to the York, PA facility, then the Greencastle, PA facility. The results then say on September 2nd, the gauge was sent to the Winchester, VA facility and unloaded.

"On September 23rd, [Virginia Department of Health] contacted the [common shipper's] facility in Winchester, VA and spoke with the site manager. The manager stated that the gauge was not on the truck when it arrived at this facility on September 2nd, and that an 'All Points Bulletin' (APB) was submitted. [Virginia Department of Health] then contacted the Greencastle, PA facility and spoke to the OS&D/Customer Service Representative regarding the loss of this gauge. [Virginia Department of Health] discussed what actions had been taken to locate the gauge and supplied them with an email containing pictures of the transportation case and the gauge.

"At 1458 EDT on September 23rd, an APB from the Greencastle, PA facility was created and submitted to [the common shipper's] staff. They have checked the truck that was used on September 1st, and the gauge was not found in the truck. They are speaking with the driver of this truck and showing him pictures of the gauge and case.

"Currently, [the common shipper] is looking through the Greencastle, PA facility and contacting the Pittsburgh, PA facility regarding the gauge. The Greencastle OS&D/Customer Service Representative stated they will provide daily updates regarding the search.

"The Pennsylvania RMP [Radioactive Materials Program] has been notified and made aware of this event.

"The Virginia RMP will provide updates as they become available.

"There is no public health or safety impact at this time."

Commonwealth of Virginia Event Report ID No.: VA-15-11

* * * UPDATE FROM MIKE WELLING TO CHARLES TEAL ON 9/24/15 AT 1156 EDT * * *

"On September 24th, it was discovered that the portable gauge was delivered to another Virginia licensee who also had sent a portable gauge to NETS for service. The gauge was returned to [common carrier] who is shipping it back to NETS to inspect. The gauge will then be sent to WRA.

"The investigation at [Common Carrier] is on-going with regards to how it was delivered to the wrong licensee."

Notified R1DO (Welling). Notified ILTAB (Johnson) and NMSS_Events_Notification via email.

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.

Page Last Reviewed/Updated Thursday, October 01, 2015
Thursday, October 01, 2015