Event Notification Report for May 31, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/30/2017 - 05/31/2017
Non-Agreement State
Event Number: 52780
Rep Org: KARMANOS CANCER INSTITUTE
Licensee: KARMANOS CANCER INSTITUTE
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: DONG HWA PARK
Licensee: KARMANOS CANCER INSTITUTE
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/01/2017
Notification Time: 12:25 [ET]
Event Date: 05/31/2017
Event Time: 12:45 [EDT]
Last Update Date: 06/01/2017
Notification Time: 12:25 [ET]
Event Date: 05/31/2017
Event Time: 12:45 [EDT]
Last Update Date: 06/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MEDICAL EVENT - PATIENT RECEIVED LESS DOSE THAN PRESCRIBED
"On May 31, 2017, the licensee's gamma knife model 'C' failed during treatment delivery. The couch retracted from the treatment position at 1245 [EDT] due to a clutch malfunction. Three out of five shots were delivered to the single planned lesion. The prescribed volume received a dose of 15 Gy versus the prescribed 20 Gy. Due to uncertainty regarding repair, the fixation frame was removed from the patient's head. Repair was completed at 1845 [EDT]."
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.
"On May 31, 2017, the licensee's gamma knife model 'C' failed during treatment delivery. The couch retracted from the treatment position at 1245 [EDT] due to a clutch malfunction. Three out of five shots were delivered to the single planned lesion. The prescribed volume received a dose of 15 Gy versus the prescribed 20 Gy. Due to uncertainty regarding repair, the fixation frame was removed from the patient's head. Repair was completed at 1845 [EDT]."
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.
Agreement State
Event Number: 52786
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: GEODESIGN, INC.
Region: 4
City: WILSONVILLE State: OR
County:
License #: WN-I0542-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: DONG HWA PARK
Licensee: GEODESIGN, INC.
Region: 4
City: WILSONVILLE State: OR
County:
License #: WN-I0542-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/02/2017
Notification Time: 19:59 [ET]
Event Date: 05/31/2017
Event Time: 00:00 [PDT]
Last Update Date: 06/02/2017
Notification Time: 19:59 [ET]
Event Date: 05/31/2017
Event Time: 00:00 [PDT]
Last Update Date: 06/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL OKEEFE (R4DO)
DANIEL COLLINS (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
NEIL OKEEFE (R4DO)
DANIEL COLLINS (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - PORTABLE GAUGE OPERATOR HANDLED UNSHIELDED SOURCE
The following report was received from the State of Washington via email:
"An operator of a portable moisture/density gauge touched and directly handled the unshielded source.
"Here is how the event occurred: A worker knelt down next to a portable moisture/density gauge and pulled it up, tilted it back, and stuck his face toward the source rod. He then extended the source rod out of the gauge housing and into the air. He then took his left hand and rubbed the source rod clean with his bare hand.
"This event was observed by a manager from Oregon Radiation Protection Services, who then reported the event to the Washington State Department of Health for investigation.
"Incident Number: WA-17-014"
The portable moisture/density gauge is a Troxler 3430 containing 0.333 GBq (9 mCi) of Cs-137 and 1.628 GBq (44 mCi) of Am-241/Be.
The following report was received from the State of Washington via email:
"An operator of a portable moisture/density gauge touched and directly handled the unshielded source.
"Here is how the event occurred: A worker knelt down next to a portable moisture/density gauge and pulled it up, tilted it back, and stuck his face toward the source rod. He then extended the source rod out of the gauge housing and into the air. He then took his left hand and rubbed the source rod clean with his bare hand.
"This event was observed by a manager from Oregon Radiation Protection Services, who then reported the event to the Washington State Department of Health for investigation.
"Incident Number: WA-17-014"
The portable moisture/density gauge is a Troxler 3430 containing 0.333 GBq (9 mCi) of Cs-137 and 1.628 GBq (44 mCi) of Am-241/Be.