Event Notification Report for December 12, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/11/2022 - 12/12/2022
EVENT NUMBERS
56270
56270
Agreement State
Event Number: 56270
Rep Org: Texas Dept of State Health Services
Licensee: Methodist Hospital
Region: 4
City: Houston State: TX
County:
License #: L 00457
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Adam Koziol
Licensee: Methodist Hospital
Region: 4
City: Houston State: TX
County:
License #: L 00457
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Adam Koziol
Notification Date: 12/13/2022
Notification Time: 13:10 [ET]
Event Date: 12/12/2022
Event Time: 00:00 [CST]
Last Update Date: 12/13/2022
Notification Time: 13:10 [ET]
Event Date: 12/12/2022
Event Time: 00:00 [CST]
Last Update Date: 12/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - EQUIPMENT FAILURE TO HOUSE SOURCE
The following information was provided by the Texas Department of State Health Services via email:
"On December 12, 2022, the licensee reported that following a cardiac brachytherapy procedure the source train containing strontium-90 sources could not be fully retracted into the safe position. The device was placed into the emergency shielding box by a staff member. There was no exposure to the patient and there was no overexposure, based on calculations, to the individual who handled the device. The individual's ring and whole body dosimeters will be sent for processing to confirm. A manufacturer's representative responded later in the day and secured the sources into the fully shielded position and assessed the cause. He believed the hemostasis valve had been tightened a little too tight which caused a kink in the catheter that prevented the retraction.
"Device: Novoste Brachytherapy device manufactured by Best Vascular, model A-1000 series, SN: 87690
"Sources: 40 millimeter source train containing 16 Strontium-90 sealed sources with original activity of 34.88 millicuries (June 2002), source manufacturer AEA, model SICW.2, train SN: ZA-706.
"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident No.: 9971
Texas NMED No.: TX220040
The following information was provided by the Texas Department of State Health Services via email:
"On December 12, 2022, the licensee reported that following a cardiac brachytherapy procedure the source train containing strontium-90 sources could not be fully retracted into the safe position. The device was placed into the emergency shielding box by a staff member. There was no exposure to the patient and there was no overexposure, based on calculations, to the individual who handled the device. The individual's ring and whole body dosimeters will be sent for processing to confirm. A manufacturer's representative responded later in the day and secured the sources into the fully shielded position and assessed the cause. He believed the hemostasis valve had been tightened a little too tight which caused a kink in the catheter that prevented the retraction.
"Device: Novoste Brachytherapy device manufactured by Best Vascular, model A-1000 series, SN: 87690
"Sources: 40 millimeter source train containing 16 Strontium-90 sealed sources with original activity of 34.88 millicuries (June 2002), source manufacturer AEA, model SICW.2, train SN: ZA-706.
"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident No.: 9971
Texas NMED No.: TX220040