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Event Notification Report for April 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/24/2019 - 4/25/2019

** EVENT NUMBERS **
 
53879 53952 54003 54006 54007 54024

Agreement State Event Number: 53879
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK   State: AR
County:
License #: ARK-0001-02110
Agreement: Y
Docket:
NRC Notified By: ANGIE HALL
HQ OPS Officer: THOMAS KENDZIA		 Notification Date: 02/15/2019
Notification Time: 17:07 [ET]
Event Date: 02/13/2019
Event Time: 07:24 [CST]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 4/25/2019

EN Revision Text: AGREEMENT STATE REPORT - DOSE DELIVERED WAS LESS THAN PRESCRIBED

The following was received from the Arkansas Department of Health, Radiation Control Program (the Department) via email:

"The treatment prescribed activity was for 0.54 GBq (14.5 mCi) on February 13, 2019. The calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter Terumo-Progreat Microcatheter (2.0 French Catheter). The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST].

"The Department performed exposure surveys of the connector confirming activity stuck at the connector site. The connector site read the highest and in that concentrated area, reading 430 mR/hr, on February 15, 2019, at approximately 1415 [CST].

"There were no spills and/or contamination during this event.

"The licensee notified the manufacturer and the manufacturer will be performing an investigation on the tubing and radiopharmaceutical/sealed sources. The licensee is continuing to investigate the root cause and is preparing an initial fifteen day written report.

"The Department is waiting on information from the manufacturer(s) and licensee for further investigation. The Department will update this report when the licensee provides additional information."

Arkansas Event AR-2019-001

* * * UPDATE AT 1516 EST ON 3/7/19 FROM ANGIE HALL TO JEFF HERRERA * * *

The following update was received from the Arkansas Department of Health, Radioactive Materials Program via email:

"The Department [Arkansas Department of Health] received a Y-90 TheraSphere Glass Microsphere patient therapy misadministration notification on February 14, 2019 from a medical licensee. The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST]. The Department has received the required initial fifteen day report from the Licensee.

"The Y-90 TheraSphere therapy prescribed activity was for 0.54 GBq (14.6 mCi) on February 13, 2019. The Y-90 TheraSphere calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter. The catheter used was a Terumo-Progreat Microcatheter (2.0 French Catheter). This dose resulted in a 54.34 Gy exposure instead of the intended 143 Gy exposure.

"The Licensee performs Y-90 TheraSphere therapies on a regular basis. The Licensee's physician/Authorized User and colleagues state that they have never had this issue before. The Authorized User states that 54.34 Gy is still a therapeutic dose. A patient CT follow-up scan will be performed to evaluate the therapy dose effectiveness.

"The Department verified activity stuck at the connector site via exposure surveys with a Fluke ion chamber survey meter (reading 430 mR/hr) on February 15, 2019 at approximately 1415 [CST].

"The Licensee notified the Manufacturer and the Manufacturer will be performing an investigation on the tubing and on the radioactive sealed sources.

"There were no spills and/or contamination during this event.

"The Department is waiting on information from the Licensee regarding the Manufacturer's investigation. The Department will update this report when the Licensee provides additional information.

"Corrective Actions: In Process by Licensee and Manufacturer."

Notified the R4DO (Werner), NMSS Events (via email).

* * * UPDATE FROM ANGIE HALL TO HOWIE CROUCH VIA EMAIL ON 4/24/19 AT 1708 EDT * * *

"The Department received a report on April 24, 2019 (dated April 4, 2019) from the Licensee regarding the Y-90 TheraSphere misadministration.

"The Department requested additional information on April 24, 2019, regarding the information provided by the Licensee. The request includes clarification from the manufacturer's report and the Licensee's corrective actions.

"The Department will update this report when the Licensee provides additional information."

Notified R4DO (Young) and NMSS Events (via email).


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.

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53952
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL CORPORATION
Region: 1
City: BRADDOCK   State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED		 Notification Date: 03/22/2019
Notification Time: 14:22 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 4/25/2019

EN Revision Text: AGREEMENT STATE REPORT - FAILED MOISTURE GAUGE SHUTTER

The following was received from the Commonwealth of Pennsylvania via e-mail:

"The licensee reported that on March 21, 2019, the Berthold Technologies Model LB-7 410 moisture gauge containing 300 milliCuries of americium-241 was not able to operate as designed; the shutter locking mechanism cylinder was able to be pulled out of the gauge. The gauge was being removed from the east side of #3 Blast Furnace to the storage area at the Blast Furnace spares building. A service provider was already scheduled on site to observe removal and transport of the gauge. A contract employee working with the service provider stated that the cylinder was able to be pulled out of the gauge. The cylinder was never fully removed, but if it was, this would allow the shutter to be manually opened or closed. The cylinder locking device was depressed by the service provider employee and it is currently in that condition. The shutter can't be moved with the cylinder depressed. The gauge is currently locked in the storage area at the Blast Furnace spares building.

All work was performed using ALARA principles and at no point were employees exposed to excess levels of radiation. Survey results indicated no abnormal amounts of radiation in the area before, during, or after the removal of the device. Berthold has been contact for repair or replacement."

PA Event Report ID No: PA19001

* * * RETRACTION FROM THE JOHN CHIPPO TO CATY NOLAN ON 4/24/19 AT 1059 EDT * * *

The following was received via fax:

"A follow-up interview and review of the operation of the locking mechanism was conducted with the contract employee. It was determined that the contract employee was unfamiliar with the operation of the locking mechanism at the time of the removal and that the cylinder never was able to be pulled out of the gauge. Based on this investigation, it has been determined that there was not a failure of the locking mechanism or shutter during the removal of the gauge on March 21, 2019. Therefore, this event should be retracted from NMED."

Notified R1DO (Lilliendahl) and NMSS Events (via email).

Agreement State Event Number: 54003
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: REPLOGLE ENTERPRISES
Region: 1
City: HENRY   State: TN
County:
License #: GL #708
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: MARK ABRAMOVITZ		 Notification Date: 04/16/2019
Notification Time: 15:27 [ET]
Event Date: 05/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 04/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST GENERALLY LICENSED TESTING DEVICE

The following report was received via e-mail:

"On January 11, 2018, FHL Industries, LLC, acquired Replogle Hardwood Flooring out of bankruptcy. The new owners were unaware of a generally licensed hazardous testing device from previous ownership. During a search of the facility during April 2018, FHL concluded the device was missing. FHL has no intentions of acquiring another radioactive testing device.

"Isotope and activity: Am-241, 0.03 mCi; Cm-244, 13.0 mCi
Manufacturer: Asoma Instruments
Model: 100
SN: 1537"

Tennessee Event: TN-18-089

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Agreement State Event Number: 54006
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TSI LABORATORIES INC.
Region: 4
City: VICTORIA   State: TX
County:
License #: RAM-L04767
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ		 Notification Date: 04/17/2019
Notification Time: 12:22 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On April 16, 2019, the licensee notified the Agency that one of its Humboldt model 5001-C moisture/density gauges (SN: 2076), containing 40 milliCuries americium-241/beryllium (SN: 47-6041) and 10 milliCuries of cesium-137 (SN: 40-6862), had been run over and damaged by a dump truck at a temporary job site in Danbury, Texas. While a density test was being performed and the cesium source was extended into the ground, a dump truck backed up into the test area. The technician had to jump out of the way. The truck tire ran over and shattered the housing on one side of the gauge. The source was retracted, with some difficulty, into its shielded position. Radiation surveys indicated the shielding was intact. However, the technician reported that the source rod could be pulled completely out of the top of the housing. With the source in the normal shielded position, the gauge was placed inside its transport case and returned to the licensee's facility. The licensee is making arrangements for repair/disposal. There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident: 9675

Agreement State Event Number: 54007
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER BOSWELL MEDICAL CENTER
Region: 4
City: SUN CITY   State: AZ
County:
License #: 07-138
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: MARK ABRAMOVITZ		 Notification Date: 04/17/2019
Notification Time: 12:52 [ET]
Event Date: 04/17/2019
Event Time: 00:00 [MST]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TRITIUM EXIT SIGNS DISMANTLED

The following report was received via e-mail:

"The Department [Arizona Department of Health Services] received notification from the licensee that they dismantled 24 tritium exit signs by removing the outer glass and aluminum housing, and then releasing the glue that held the glass ampules onto the inner plastic. The licensee said they were attempting to reduce the cost of shipping the signs for disposal. The Department has requested additional information and continues to investigate the event.

"The Licensee is:

Arizona License Number- 07-138
Banner Boswell Medical Center
10401 Thunderbird Blvd
Sun City, Arizona 85351"

Arizona Incident: 19-005

None of the vials were damaged and the wipe tests were all negative.

Power Reactor Event Number: 54024
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT TATRO
HQ OPS Officer: JEFF HERRERA		 Notification Date: 04/24/2019
Notification Time: 10:40 [ET]
Event Date: 04/23/2019
Event Time: 12:56 [CDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY		 Person (Organization):
CALE YOUNG (R4DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY REPORT - ALGORITHM USED FOR RANDOM TESTING EXCLUDED A POPULATION OF INDIVIDUALS

"On April 23, 2019, at 12:56 Central Time, South Texas Project Nuclear Operating Company (STPNOC) identified a programmatic failure, degradation, or discovered vulnerability of the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program."

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Wednesday, March 24, 2021