Page Last Reviewed/Updated Friday, January 31, 2020
Event Notification Report for April 22, 2008
General Information or Other Event Number: 44143
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
City: TULSA State: OK
License #: OK-05860-01
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JOHN KNOKE Notification Date: 04/16/2008
Event Time: 14:00 [CDT]
JEFFREY CLARK (R4)
BILL VON TILL (FSME)
A patient at the Oklahoma State University Medical Center in Tulsa, Oklahoma was undergoing prostate treatment. The treatment was to implant 187 Pd-103 seeds (1.5 microCuries each) into the patient. The seeds were injected using a MIC gun which was manufactured by TheraGenics in Buford, Georgia. During the procedure it was observed that one of the seeds was sheared off with only 5% of the seed showing. The patient is believed to have the other 95% of the open seed inside his body. The radiation oncologist was present when this event happened. The patient was surveyed and his radiation levels were 0.46 mr/hr, which is within normal levels. The patient was not informed as yet, but should be by the attending physician. The half life of Pd-103 is 17 days, and most likely will be defused throughout the body.
* * * UPDATE ON 4/17/2008 AT 1036 FROM MIKE BRODERICK TO MARK ABRAMOVITZ * * *
The State provided the following information via email:
"At about 2:00 PM on April 16, a patient was receiving 187 Pd-103 seeds for prostate therapy. The seeds were Theragen Model 200 of 1.5 microCuries each, manufactured by Theragenics, in Buford, Georgia, and purchased from Bard in Georgia. After injecting the seeds, the facility discovered one end of a Pd-103 seed in the 'mic' cartridge that had been used to hold the seeds. Only about 5% of the seed was present, and it is assumed the other 95% was injected into the patient. The piece found was leaking radioactivity. Surveys with a calibrated meter showed that the patient met the criteria for unrestricted release. The licensee plans to ask the referring physician to notify the patient. The licensee speculates that a malfunction in the mic gun caused the seed to be out of alignment when the cartridge was inserted or removed, leading to the clipping of the end, but this is highly preliminary, and the result of speculation rather than definite findings. The licensee will do an investigation. The licensee has temporarily stopped doing prostate implants. DEQ will send investigators to the site."
Notified FSME (Burgess) and the R4DO (Clark).
* * * UPDATE ON 4/17/2008 AT 1536 FROM MIKE BRODERICK TO JASON KOZAL * * *
"There was a miscommunication between the state and the facilities, average strength for the Pd-103 sources involved in this event is 1.5 milliCuries, rather than 1.5 microCuries. The licensee has informed the patient of the event. The mic gun involved has been taken out of service. It is also considered possible the cartridge holding the sources was flawed, but the cartridges were disposed of as biomedical waste immediately after the surgery and will not be available to be checked. The licensee informs [the state] that the cartridges are generally covered in blood after one of these procedures, and such cartridge disposal is typical. The licensees are holding the mic gun until a state inspector arrives for an investigation, after which it will be returned to the manufacturer for evaluation."
Notified FSME (Von Till) and R4DO (Miller).
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.
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: TEAM INDUSTRIAL SERVICES
City: MILWAUKEE State: WI
License #: 079-2005-01
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: PETE SNYDER Notification Date: 04/17/2008
Event Time: [CDT]
LAURA KOZAK (R3)
RADIOGRAPHY CAMERA MALFUNCTION
This "incident occurred on April 15, 2008 at about 8:20 PM at a new [non-nuclear] power plant under construction. Team Industrial Services was performing industrial radiography on Unit 1. The radiography was being performed on elevation 807 on a header approximately 4 foot off of the roof of the boiler.
"According to statements from the crew, they had exposed the source on their first shot of the pipe weld, and approximately 15 seconds into the shot they heard what they thought was the guide tube and collimator faillng off the pipe to the roof of the boiler. They then went to retract the source back into the exposure device and encountered an obstruction preventing the source from being retracted into a secured position in the exposure device. They attempted [to retract the source] three times with no success.
"The industrial radiographer contacted the facility radiation safety officer and advised him that he had a source he could not retract back into the exposure device. The industrial radiographer extended the radiation safety boundaries above and below the area. The Radiation Safety Officer (RSO) advised [the radiographer] that he was on his way to the site.
"The RSO arrived at the site at approximately 9:00 PM. At this time an initial assessment was made and a decision was made to bring in two more trained technicians to assist with boundary control and retrieval of the sealed source. After arrival of the extra technicians, a plan for retrieval was discussed with all technicians, including the Corporate Radiation Safety Officer.
"The industrial radiographer stated that his pocket dosimeter had gone 'off scale.' This means that he could have received a dose of at least 200 millirems of radiation. At this time he was advised that he would not be assisting with the retrieval but he continued to assist with boundary control. The licensee has estimated that the industrial radiographer received 630 mR.
"At approximately 11:35 PM, the shielding of the source and attempt to repair the guide tube commenced. Four lead shot bags were placed over the end of the guide tube where the sealed source was known to be. The radiation levels were reduced to 15 millirems per hour at five feet from the source under the lead shot bags. The RSO then approached the guide tube with a pair of pliers, located the distortion in the guide tube and rounded it with the pliers. He then returned to the crank assembly and retracted the source successfully back into the exposure device. The RSO is estimated to have received 32 mR from conducting the repair.
"A determination was made that there was not an equipment failure, it was a result of the guide tube falling from the pipe to the root of the boiler that damaged the guide tube resulting in the obstruction. Boundaries were maintained throughout the incident to ensure that at no time any member of the general public could enter the incident area.
"DHFS plans to investigate this incident on the next inspection (to be conducted in the near future)."
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ARDAMAN & ASSOCIATES, INC.
City: HIALEAH State: FL
License #: 3456-2
NRC Notified By: CHARLES E. ADAMS
HQ OPS Officer: JASON KOZAL Notification Date: 04/17/2008
Event Time: [EDT]
WAYNE SCHMIDT (R1)
ILTAB (VIA E-MAIL) ()
This material event contains a "Less than Cat 3" level of radioactive material.
AGREEMENT STATE - LOST TROXLER GAUGE
The licensee provided the following information via email:
After completing a job a Troxler Moisture Density Gauge (Model number 3430, Serial Number 34618) was loaded into the back of the licensee's truck and not secured. The unsecured gauge fell out of the truck in transit from the job site. The licensee discovered the gauge missing and notified supervision.
The licensee notified the local police department and is actively searching for the gauge. The licensee plans to offer a reward for return of the missing gauge. The State of Florida is further investigating the incident.
* * * UPDATE FROM ADAMS TO CROUCH (VIA EMAIL) ON 04/21/08 @ 1334 EDT * * *
"Florida incident FL08-060 which was reported and occurred on April 17, 2008 involved a lost Troxler gauge. It was recovered today. A gentleman found it at the intersection of 40th St. and 38th Ave. in Coral Gables on Thursday, the day it was lost. He finally called the licensee today and the licensee took possession of it about 10:30 this morning. It is undamaged."
Notified R1DO (White) and FSME EO (Burgess).
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
Facility: SURRY
Region: 2 State: VA
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: HUNTER SCHILL
Event Time: 22:16 [EDT]
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
KATHLEEN O'DONOHUE (R2)
UNIT 1 MANUAL REACTOR TRIP DUE TO MAIN TURBINE VIBRATIONS
"While ramping the Unit 1 Turbine following a forced unit outage, vibrations on the number 4 bearing increased to 13.9 mils. The ramp was stopped and a rapid load reduction was initiated. Due to sustained vibrations (>14.1 mils) after ramping the turbine down, the Unit 1 reactor was manually tripped. Unit 1 has been stabilized at Hot Shutdown.
"All three auxiliary feedwater pumps automatically initiated as designed on low-low steam generator level following the trip. Currently RCS temperature is being maintained stable at 547 degrees. All systems functioned as required following the reactor trip. There were no radiation releases due to this event, nor were there any personnel injuries or contamination events. This event is being reported in accordance with 10 CFR 50.72 (b)(2)(iv) and 10 CFR 50.72 (b)(3)(iv)."
Upon exiting the refueling outage in 11/07 the main turbine had a vibration issue of about 11 or 12 mils. Decay heat is being removed via the steam dumps to the condenser. Unit 2 was not affected during this event. Offsite power was lined up normally.
The licensee notified the NRC Resident Inspector.
Facility: INDIAN POINT
Region: 1 State: NY
NRC Notified By: NICK LIZZO
JOHN WHITE (R1)
2 M/R Y 37 Power Operation 0 Hot Standby
MANUAL REACTOR TRIP DUE TO LOWERING STEAM GENERATOR WATER LEVEL
"On April 21 2008, at approximately 1123 hours, during power ascension from a scheduled refueling outage, Unit 2 experienced an inadvertent main turbine runback. The runback initiated for unknown reasons from an initial reactor power of approximately 37%. As a result of the runback, operators observed decreasing steam generator levels and initiated a manual reactor trip at 1125 hours. As a result of the reactor trip, the auxiliary feedwater pumps actuated on a low steam generator level as designed. Prior to the runback, one of two main feedwater pumps was operating. The unit is stable and in Mode 3. Operators closed the main steam isolation valves as a result of indications of lowering RCS temperature. A 4-hour non-emergency notification is provided for a reactor trip while critical and 8 hour non-emergency notification is provided for a valid actuation of the auxiliary feedwater system."
All rods inserted as expected. Decay heat is being removed by AFW through the atmospheric steam dumps. Offsite power is in a normal configuration.