Event Notification Report for November 06, 2017

FITNESS FOR DUTY PROGRAM VULNERABILITY

"It was determined that a licensed employee was not placed in an additional Fitness-For-Duty (FFD) testing program as directed by the MRO (Medical Review Officer). Upon discovery, the individual was subsequently tested . . . and determined Fit-For-Duty per 10 CFR 26 requirements.

"This event is being reported pursuant to 10 CFR 26.719(b)(4).

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - DOSE GREATER THAN 50 REM DELIVERED AT A SITE NOT INTENDED FOR TREATMENT

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

"On Friday, November 10, 2017, ODH [Ohio Department of Health] received notification that a cancer patient may have received a dose greater than 50 rem at a site not intended for treatment. A follow-up call was made on Monday November 13, 2017. The licensee stated they believe the Elekta Flexitron (model 136149A02) remote afterloader software package used an incorrect catheter model during the first treatment fraction. The error was discovered while preparing the second fraction.

"ODH will be sending an inspector to investigate the event this week.

"See licensee initial description below:

"A patient was planned to be treated with HDR [High Dose Rate] brachytherapy for GYN [Gynocology] cancer with three fractions. The HDR treatment was planned with a single curved catheters through a Tandem and Cylinder. A dosimetrist preformed a CT based treatment plan for the first fraction. During planning, the dosimetrist did not digitize the catheter correctly. A physicist checked the HDR plan in a hurry and failed to detect the incorrect reconstructed catheter shape in the planning software. During the treatment delivery, the delivery system translated the incorrectly reconstructed catheter as a linear catheter, resulting in the treatment length from the intended 9.0 cm to 15.7 cm. On the second fraction, a new plan was created based on the CT of the day. The dosimetrist did the digitization correctly this time. During the planning check (a routine process), the physicist noticed the differences between the two plans and discovered the error on the first fraction treatment."

Remote afterloader HDR
Device: ELEKTA
Model Number: 136149A02

Sealed Source Brachytherapy
Source: IR-192
Model Number: 136147

Ohio Event Number: OH170008

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 REPORT - STUCK SHUTTER

The following information was received from the State of Texas by email:

"On November 6, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that a shutter was stuck in the closed position. The Ronan SA1 shutter was closed for maintenance on a hopper and failed to reopen. The gauge contains a 50 millicurie Cesium-137 source. The Licensee stated a service company has been contacted to repair the gauges in the next few days. No individual received significant exposure to radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9519

AGREEMENT STATE REPORT - LEAKING CESIUM-137 SOURCE

The following information was received from the State of Georgia via email:

"[The Radiation Safety Officer] of Phoenix Technology reported a leaking cesium-137 source from one of their clients (Myers Cardiology). During a source change out on November 6, 2017, it was noted that the old source was leaking. The activity of the leaking source is 203 microCuries, and the leak test results are 26 nanoCuries. The leaking source was placed inside a protective pig and inside a plastic bag labeled as a damaged source. The source has been sent to Pinestar Technologies in Pennsylvania for proper disposal."

Source Manufacturer: IPL
Source Model No.: MED-3550
Source Serial No.: 986-15-17

Georgia Item Number: GA170001

AGREEMENT STATE REPORT - STUCK SHUTTERS ON FIXED NUCLEAR GAUGES

The following was excerpted from an email received from the state of South Carolina:

"On January 5, 2018, the licensee called [South Carolina Department of Health and Environmental Control] to provide notification of stuck shutters on 2 sets of three-rod Berthold Model LB300L fixed gauging devices. The shutters were stuck in the open position. The gauging devices contain Co-60 in amounts of 0.11, 0.41, and 1.81 milliCuries in one and 0.189, 0.5, and 1.50 milliCuries in the other. The [licensee's] Radiation Safety Officer found the shutter stuck in the open position on November 6, 2017 and the licensee notified the State on January 5, 2018. The licensee called Berthold to come out to evaluate corrective measures on the shutter mechanisms. Berthold technicians came to the plant on December 19, 2017. After being informed of proper procedures on reporting requirements, the licensee stated that a written report will be sent within 30 days of the event.

"Updates to this event will be made through the NMED system."