| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
8/1/2018 - 8/2/2018 ** EVENT NUMBERS ** |
| Agreement State | Event Number: 53516 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County: LOS ANGELES
License #: 0059-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: BRIAN LIN | Notification Date: 07/19/2018
Notification Time: 02:04 [ET]
Event Date: 07/17/2018
Event Time: 10:00 [PDT]
Last Update Date: 07/19/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES) | Event Text AGREEMENT STATE REPORT - RECEIVED DOSE GREATER THAN PRESCRIBED DOSE
The following information was obtained from the state of California via email:
"A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am [PDT]. The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018."
California report no.: 5010-071718
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: 53523 | Rep Org: OK DEQ RAD MANAGEMENT
Licensee: DBI, INC.
Region: 4
City: TULSA State: OK
County:
License #: OK-32174-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONG HWA PARK | Notification Date: 07/24/2018
Notification Time: 13:40 [ET]
Event Date: 07/23/2018
Event Time: 20:00 [CDT]
Last Update Date: 07/24/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION
The following report was received via e-mail:
"At approximately [2000 hrs. CDT] last night (July 23) a crew working at the DBI, Inc. facility in Tulsa had a casting they were shooting fall on the guide tube, crushing it, so that the source (28 Ci of Ir-192) could not be retracted. The RSO [Radiation Safety Officer] was notified and responded to the scene. DBI is licensed to perform source recoveries which they successfully did. As far as we [Oklahoma Department of Environmental Quality] know right now, there were no over-exposures as a result of this incident. [The state of Oklahoma] will provide details on the equipment involved when we have them." |
| Power Reactor | Event Number: 53533 | Facility: MILLSTONE
Region: 1 State: CT
Unit: [] [] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: NICOLAOS KOSTOPOULOS
HQ OPS Officer: THOMAS KENDZIA | Notification Date: 08/02/2018
Notification Time: 13:09 [ET]
Event Date: 08/02/2018
Event Time: 09:00 [EDT]
Last Update Date: 08/02/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
ANNE DeFRANCISCO (R1DO) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text OFFSITE NOTIFICATION DUE TO RELEASE OF POSSIBLE TRITIUM BEARING WATER
The following was received via telephone and email notification from Millstone Power Station:
Millstone Power Station Unit 3, identified that the underground pipe to the Condensate Surge Tank had leaked greater than 100 gallons of water that included trace amounts of tritium to the ground. The effected piping is inside the protected area and has been isolated and drained.
No tritium has been detected in any monitoring wells outside of the Protected Area. There is no threat to employees or the public or impact to drinking water.
The Connecticut Department of Energy and Environmental Protection, and the towns of Waterford and East Lyme were notified at approximately 1300 [EDT] on August 2, 2018.
The licensee notified the NRC Resident Inspector. | |