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Event Notification Report for March 25, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/24/2016 - 03/25/2016

** EVENT NUMBERS **


51794 51796 51797 51798 51799 51820 51821

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Agreement State Event Number: 51794
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: COMMON CARRIER
Region: 4
City: LAPORTE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/16/2016
Notification Time: 13:11 [ET]
Event Date: 03/16/2016
Event Time: [CDT]
Last Update Date: 03/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - PACKAGE CONTAINING SOURCES LOST THEN FOUND

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

"The Agency [Texas Department of State Health Services] was notified by a manager for a common carrier of radioactive material that a package had fallen out of the transport vehicle. The package was found by a member of the public on a highway [when he] swerved to miss hitting the package. The person collected the package and called the number on the package. The number was to the manufacturer of the source. The radiation safety officer (RSO) for the company met the member of the public to collect the package. The RSO completed a survey of the package and performed leak testing. The container was a type B package containing two Ir-192 sources, SN29629G and 29630G, joint activity of 8,188.8Gbq (>100 curies each) with transport index of 1.2. The package outer shipping box was damaged although the type B container was in good condition and was not leaking. The sources are currently at the manufacturer's location in storage. The sources were enroute to the manufacturer's Baton Rouge location when the container fell out of the transport vehicle onto the freeway. The details of the time frame the member of the public had the package in their possession is being confirmed and details of the time the package was on the freeway is being acquired. Investigation into this event is ongoing and details will be provided in accordance with SA 300 guidelines."

Texas Incident No.: I-9387

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Non-Agreement State Event Number: 51796
Rep Org: BOTSFORD CANCER CENTER
Licensee: BOTSFORD CANCER CENTER
Region: 3
City: FARMINGTON HILLS State: MI
County:
License #: 21-08892-01
Agreement: N
Docket:
NRC Notified By: MISBAH GULAM
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 16:19 [ET]
Event Date: 03/16/2016
Event Time: 14:30 [EDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

BRACHYTHERAPY DOSE LESS THAN PRESCRIBED DUE TO EQUIPMENT MALFUNCTION

The following was received from the licensee via email:

"Medical Event on a Prostate HDR [high dose rate brachytherapy] Fraction #2. The patient was previously treated to Fraction #1 2 weeks earlier without any issue.

"A patient was under spinal anesthesia for a treatment to the prostate to a prescribed dose of 13.5 Gy. The plan called for 19 interstitial catheters to the 30 cc prostate gland. The V100 of the prostate was expected to be 99.75% (100% dose of 13.5 Gy covered 99.75% of the prostate volume). All coverage and critical organ sparing criteria were met and physician approved the plan.

"However during treatment and after completion of 9 catheters the treatment console reported an error (and subsequently retracted the source after 2 dwell positions were treated of the 10th catheter). The error code 9 message was source has moved from dwell position and a reset of the treatment console was required.

"[The medical physicist] went inside the treatment room with the survey meter to ensure the source indeed retracted and transfer tube and applicator appropriately connected. Which they were. Attempts were made to continue with the treatment as the error code direction was cancel the error and try again.

"However, the afterloader would not resume treatment and the treatment console reported an another error code 117 error during check out-drive in channel (driving out the check cable).

"Several attempts were made with help of Elekta field service and phone support to troubleshoot the issue as the message on the treatment console with these errors is that if the problem persists, contact your local Elekta service representative. Troubleshooting continued afterwards with the field service engineer coming on site. We were later informed by the engineer that parts had to be ordered to resolve the issue and that they would arrive early the next morning.

"The procedure was eventually halted due to the service issue and patient was sent to recovery and family informed.

"[The licensee is] now assessing what dose was delivered.

"The total treatment time called for 386.6 s. However, only 158.5 s was treated. On the treatment planning system using the catheters and dwell positions and time of 158.5 s the v100 to the prostate is showing as 12.52% (100% of the dose of 13.5 Gy covered 12.52% of the prostate volume) of the partially treated procedure. There was no excessive dose anywhere i.e. to critical structures, just lack thereof to the intended treatment volume of the prostate. The dosimetrist is working with the plan to put on dose points near treated catheters to provide us further details.

"[The licensee] wanted to take the appropriate direction going forward in regards to documentation, reporting and planning for treatment for the patient on a subsequent date. The machine issue initially occurred at approximately [1430 EDT on 3/16/16]. Service on the unit is ongoing so exact details of the repair are not yet available. Remaining prostate patients scheduled for this week been rescheduled for a later date."

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: 51797
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GEO CONCEPTS
Region: 1
City: ASHBURN State: VA
County:
License #: VA 45-25467-0
Agreement: Y
Docket:
NRC Notified By: AL JACOBSON
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 16:54 [ET]
Event Date: 03/16/2016
Event Time: [EDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED

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

"March 16, 2016 about 1600 [EDT]: [The GeoConcepts field representative] notified [the licensee's Radiation Safety Officer] (RSO) of the incident and that the gauge had been damaged. [The field representative] informed [the RSO] that a John Deere Dozer 700 had back up over the gauge. [The field representative], had just completed taking a compaction and moisture test. When the site foreman called to [the field representative] to ask about failing test results, [the field representative] placed the trigger lock back onto the gauge and walked over to the site foreman who was approximately 8-10 feet from where the gauge was located. The John Deere Dozer 700 operator was grading soil and placing it onto an onsite stockpile. The John Deere Dozer 700 operator proceeded to back up, in the vicinity of the gauge. When [the field representative] noticed the operator in close proximity to the gauge, he began to try and get the operators' attention. The operator was not able to see [the field representative's] attempts to gain his attention nor was he able to hear [the field representative] or the site foreman. At that time, the gauge was struck by John Deere 700, which resulted in cracking of the gauge case and breaking of the source rod.

"March 16, 2016 about 1620: The RSO called the assistant CS [Construction Site] manager and RSO, INC., to inform them of the incident and to immediately get RSO, Inc. to the site and address the issue. [The assistant CS manager] also placed a call to NRC and was informed to call Maryland NRC to notify them of the incident.

"March 16, 2016 about at 1630: The RSO, left our Ashburn [VA] office for the project in Maryland. [The RSO] arrived onsite at 1730 [EDT] to meet [the representative] of RSO Inc. RSO Inc. proceeded to perform a leak test and take readings of surrounding areas and construction equipment. [The source did not leak and there were no reports of radiation exposures.]

"March 16, 2016 about 1700: The RSO Inc. representatives were able to retract the source rod into the gauge case shielding. They packaged the gauge back into the carrying case; [The licensee's RSO] took the gauge back to the Ashburn office to secure it.

"March 17, 2016: The RSO, picked up the gauge and transported it to NETS (North East Technical Services), for the gauge to be disposed."

The gauge is a Humboldt model number 5001 EZ, serial number 4704.

The licensee is licensed in the Commonwealth of Virginia, VA License #45-25467-01 and MD Material License # MD-13-020-01.

Maryland Case Number: 1654

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Agreement State Event Number: 51798
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: HESEK & KEPES RADIATION ONCOLOGY
Region: 1
City: PLANT CITY State: FL
County:
License #: 4302-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 17:33 [ET]
Event Date: 03/15/2016
Event Time: [EDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received from Florida via email:

"On Tuesday March 15, 2016, a patient being treated for skin cancer on the right side of his mandible using a Valencia applicator was treated using the plan time from another patient who is being treated for the left leg also using a Valencia applicator. The short fall difference in time was 8.2 seconds, meaning that the patient treated for the right mandible was given 3.2% less radiation than what was correctly calculated for.

"As a plan of action, the patient as well as the attending physician will be notified of the occurrence, and a 'time-out' policy will be implemented for all HDR [high does rate brachytherapy] treatments to ensure that the correct patient, date of birth, patient number, plan number, date of the plan, and treatment location are being treated prior to the actual treatments. A policy will be formally drafted to this effect and placed into the departmental policy and procedures manual.

"[The prescribing physician] will decide whether or not to make up the short fall in the treatment dose after consultation with the patient."

Florida Incident # FL16-043

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: 51799
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ALPHA-OMEGA SERVICES, INC.
Region: 4
City: VINTON State: LA
County:
License #: LA-10025-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/17/2016
Notification Time: 17:28 [ET]
Event Date: 03/15/2016
Event Time: [CDT]
Last Update Date: 03/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE SOURCE SHIPMENT IN EXCESS OF LICENSED QUANTITY

The following was received from Louisiana via email:

"On 03/16/2016, the RSO for A&O [Alpha Omega] called in a report of a HDR [high does rate brachytherapy] source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025.

"[The RSO] was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care.

"A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at [1700 EDT] on 03/15/2016 to report the error.

"The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier"

A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated.

Louisiana incident # LA-160005

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Power Reactor Event Number: 51820
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: PAUL RHODES
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/24/2016
Notification Time: 08:58 [ET]
Event Date: 03/24/2016
Event Time: 02:11 [EDT]
Last Update Date: 03/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT DALEY (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM VENTILATION DECLARED INOPERABLE

"At approximately 0211 [EDT], on March 24, 2016, both control room ventilation filtration trains were declared inoperable in accordance with Technical Specification 3.7.10, Condition B, due to a control room boundary door not being fully closed. Following routine security rounds, the door was unable to be fully closed due to the door's locking bolts not retracting back into the door body, causing interference between the door and door frame.

"Mitigating actions have been implemented that ensure control room envelope (CRE) occupant radiological exposures will not exceed limits, and CRE occupants are protected from chemical and smoke hazards. Repairs to the door are currently in progress.

"Technical Specification 3.7.10 allows control room boundary doors to be opened intermittently, under administrative control for preplanned activities, provided the doors can be rapidly restored to the design condition. Previous evaluations of the door not being fully closed for a limited time concluded no loss of safety function had existed.

"This condition had no impact on the health and safety of the public.

"The NRC Resident Inspector has been notified."

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Non-Agreement State Event Number: 51821
Rep Org: CASTLEROCK GEOTECHNICAL ENGINEERING
Licensee: CASTLEROCK GEOTECHNICAL ENGINEERING
Region: 4
City: BOZEMAN State: MT
County:
License #: 25-29229-01
Agreement: N
Docket:
NRC Notified By: ANDREW TILSKALUS
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/24/2016
Notification Time: 11:10 [ET]
Event Date: 03/23/2016
Event Time: 14:45 [MDT]
Last Update Date: 03/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICA (E-MA)

Event Text

TROXLER DENSITY GAUGE DAMAGED BY SOIL COMPACTOR

While preparing to take a soil density measurement, a soil compactor operator backed up and ran over the Troxler density gauge, damaging the casing of the density gauge. The gauge was examined and inspected and the top of the case was cracked, however, the plunger and source appeared to be intact. The gauge was isolated and returned to its protective case. The gauge was subsequently sent for leak testing to Qual-Tech in Idaho Falls. The gauge has been quarantined and isolated pending the results of the leak testing.

Density gauge information: Troxler model 3430 containing Am-241 - 40 milliCuries and Cs-137 - 8 milliCuries

Page Last Reviewed/Updated Friday, March 25, 2016
Friday, March 25, 2016