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Event Notification Report for March 28, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/25/2016 - 03/28/2016

** EVENT NUMBERS **


51796 51797 51798 51799 51802 51803 51804 51805

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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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Agreement State Event Number: 51802
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GEOTECHNICAL CONSULTANTS, INC.
Region: 3
City: WESTERVILLE State: OH
County:
License #: 31210250023
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/18/2016
Notification Time: 09:12 [ET]
Event Date: 03/16/2016
Event Time: 07:30 [EDT]
Last Update Date: 03/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - NUCLEAR DENSITY GAUGE DAMAGED ON A CONSTRUCTION SITE

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

"At approximately 1315 [EDT] on 3/16/16, ODH [Ohio Department of Health] was notified that a licensee had a nuclear density gauge run over on a construction site. The incident occurred at about 0730 that morning. The licensee's technician instructed site personnel to stay 20 feet from the damaged gauge and contacted the RSO [Radiation Safety Officer] via telephone. The RSO arrived on site at approximately 0810 and determined that both sources were intact within the gauge housing. Readings attained around the damaged gauge with a radiation monitor and indicated normal levels. The gauge was placed back in the case and additional readings were [obtained] from the soil at the accident location with negative results. The gauge was then transported to a licensed service provider for inspection and storage. The service provider inspected the gauge and performed a leak test which indicated that the sources were not leaking.

"Investigation is ongoing."

Sealed Source Gauge. Manufacturer: QSA GLOBAL, Model Number: X.2084, Serial Number: A-7879, 0.050 Ci Am/Be-241 source and Model Number: X.8, Serial Number: C-7879, 0.010 Ci Cs-137 source.

Ohio: Item Number: OH160001

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Agreement State Event Number: 51803
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ACUREN INSPECTION, INC.
Region: 4
City: LaPorte State: TX
County:
License #: LA-7072-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/18/2016
Notification Time: 10:44 [ET]
Event Date: 03/02/2016
Event Time: 12:30 [CDT]
Last Update Date: 03/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE - RADIOGRAPHY CAMERA SOURCE UNABLE TO BE RETRACTED

The following was received from the State of Louisiana via email:

"On March 17, 2016, Acuren Inspection, Inc. notified LDEQ [Louisiana Department of Environmental Quality] during a telephone discussion, about a source retrieval on March 2, 2016, but did not use our 24-hour hotline number for these types of notifications within the regulatory guidelines prescribe time limits of 24 hours. The event occurred at Exxon Mobil Baton Rouge, 4045 Scenic Hwy., Baton Rouge, LA.

"The source could not be retracted due to a crimped guide tube. The total amount of Ir-192 for the industrial radiography camera was 64.7 Ci. The camera was:

"QSA Global: 880D, S/N: D4022, Curies: 64.7, Source S/N: 27719G."

Louisiana Event Report Identification Number: LA160006

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Agreement State Event Number: 51804
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PENN STATE HERSHEY MEDICAL CENTER
Region: 1
City: HERSHEY State: PA
County:
License #: PA-0127
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/18/2016
Notification Time: 11:43 [ET]
Event Date: 03/15/2016
Event Time: [EDT]
Last Update Date: 03/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received from Pennsylvania via email:

"On March 15, 2016 a written directive for 18.1 mCi of yttrium-90 (Y-90) was written by the authorized user (AU) and referring physician for this procedure. The entire content of the syringe was injected and the residual activity in the vial measured 13.3 mCi, or 73.5% of the prescribed dose. No harm is expected to the patient.

"A different AU wrote the initial written directive based on incorrect dose calculation. The discrepancy was not realized until after the administration was completed.

"A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt."

PA Incident # PA160010

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: 51805
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSAL TECHNICAL EQUIPMENT, INC
Region: 1
City: COLLINGDALE State: PA
County:
License #: PA-0187
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DANIEL MILLS
Notification Date: 03/18/2016
Notification Time: 14:48 [ET]
Event Date: 03/17/2016
Event Time: [EDT]
Last Update Date: 03/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - ABANDONED RADIUM 226 SOURCE FOUND

The following was received from Pennsylvania via email:

"Lost or abandoned licensed material in a quantity greater than or equal to 1000 times the Appendix C quantities in part 20, reportable as per 10 CFR 20.2201(a)(1)(i).

"A new owner of a facility in Collingdale, Pennsylvania came across a locked room that contained an old lead pig, stamped with a label stating radium-226, 100 mg. The owner contacted Ecology Services, a local radioactive waste management company, who confirmed a dose rate outside the pig. Ecology Services called the Department [PA Bureau of Radiation Protection].

"The previous occupant of this facility, Universal Technical Equipment Inc., was licensed by the Department (PA-0187) to possess up to 110 mCi of Ra-226 sealed sources and contracted the removal of the radium source. The Certificate of Disposition documentation was submitted to the Department for license termination. The license was ultimately terminated on January 14, 2015.

"[PA Bureau of Radiation Protection] Southeast regional inspectors visited the facility today, March 18, 2016, and verified there is a source within the locked pig. A smear test revealed no leakage was detected on the outside of the pig. The source remains in a secured and locked location. More information will be provided upon receipt."

PA incident # PA160011

Page Last Reviewed/Updated Monday, March 28, 2016
Monday, March 28, 2016