Event Notification Report for August 01, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/31/2013 - 08/01/2013
Agreement State
Event Number: 49237
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: IOWA HEALTH - DES MOINES
Region: 3
City: DES MOINES State: IA
County:
License #: 0310-1-77-HDR
Agreement: Y
Docket:
NRC Notified By: LEO WARDROBE
HQ OPS Officer: PETE SNYDER
Licensee: IOWA HEALTH - DES MOINES
Region: 3
City: DES MOINES State: IA
County:
License #: 0310-1-77-HDR
Agreement: Y
Docket:
NRC Notified By: LEO WARDROBE
HQ OPS Officer: PETE SNYDER
Notification Date: 08/05/2013
Notification Time: 13:14 [ET]
Event Date: 08/01/2013
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2013
Notification Time: 13:14 [ET]
Event Date: 08/01/2013
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JULIO LARA (R3DO)
FSME EVENT RESOURCE (EMAI)
JULIO LARA (R3DO)
FSME EVENT RESOURCE (EMAI)
AGREEMENT STATE REPORT - WRONG FRACTIONAL DOSE ADMINISTERED TO PATIENT
The licensee reported the administration of a 700 cGy fractional dose instead of the 500 cGy prescribed fractional dose to a patient during GYN treatment on 8/1/13. The 700 cGy fraction was prepared for another patient. The isotope involved was Ir-192.
The fraction was the second of a three fraction total dose of 1500 cGy. The final fraction will be adjusted so that the total dose to the patient is 1500 cGy. The prescribing physician had been informed. The patient will be informed of the adjustment prior to administration of the final fraction on 8/8/13.
There are no anticipated adverse consequences to the patient. The cause is under investigation and the licensee is still discussing potential corrective actions.
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.
The licensee reported the administration of a 700 cGy fractional dose instead of the 500 cGy prescribed fractional dose to a patient during GYN treatment on 8/1/13. The 700 cGy fraction was prepared for another patient. The isotope involved was Ir-192.
The fraction was the second of a three fraction total dose of 1500 cGy. The final fraction will be adjusted so that the total dose to the patient is 1500 cGy. The prescribing physician had been informed. The patient will be informed of the adjustment prior to administration of the final fraction on 8/8/13.
There are no anticipated adverse consequences to the patient. The cause is under investigation and the licensee is still discussing potential corrective actions.
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 !!!!!
Fuel Cycle Facility
Event Number: 49231
Facility: B&W NUCLEAR OPERATING GROUP, INC.
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: KENNY KIRBY
HQ OPS Officer: STEVE SANDIN
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: KENNY KIRBY
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/01/2013
Notification Time: 12:00 [ET]
Event Date: 08/01/2013
Event Time: 09:00 [EDT]
Last Update Date: 08/05/2013
Notification Time: 12:00 [ET]
Event Date: 08/01/2013
Event Time: 09:00 [EDT]
Last Update Date: 08/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
MICHAEL F. KING (R2DO)
GORDON BJORKMAN (NMSS)
FUELS GRP via email
MICHAEL F. KING (R2DO)
GORDON BJORKMAN (NMSS)
FUELS GRP via email
EXTERNAL RADIATION LEVELS ON SHIPMENT EXCEEDED 2MR/HR LIMIT FOR UNMONITORED EXPOSURES
"The conditions for reporting under the requirements of 10 CFR 20.1906(d) have been met. QWI 14.1.10, Classification & Notification Criteria for Unusual Incidents Radiation Protection section - for shipments, bases reporting requirements on receipt of a shipment with radiation or contamination levels in excess of 10 CFR 20.1906(d). This requirement was exceeded and an NRC report is required. The truck cab sleeping area (normally occupied space) dose rate of 5.4 mrem/hr is greater than the allowable limit of 2.0 mrem/hr. The carrier drivers (2) state that they do not have dosimetry.
"Immediate actions that have been taken:
- The area was secured.
- Confirmatory measurements were taken.
- Digital photographs have been taken.
- The shipper has been notified.
- A review of the associated regulations was performed.
- The carrier has been notified.
- The truck has been unloaded and released."
The shipment contained Am241/Be sources sent from QSA Global in Burlington, MA for use in refurbishing sources, typically well-logging. The estimated departure time/date was 0800 EDT on 07/31/13 with estimated arrival time/date of 0800 EDT on 08/01/13. The driver team consisted of two (2) individuals during the 24-hour transit time. The shipment was off-loaded and secured following the receipt rad survey.
The licensee notified the shipper, the carrier, the Commonwealth of Virginia and informed the NRC Resident Inspector.
* * * RETRACTION FROM TONY ENGLAND TO PETE SNYDER AT 1702 EDT ON 8/5/13 * * *
"This event has been reported to the Commonwealth of Virginia under Event Number VA-13-04. The material involved in this event is regulated under Commonwealth of Virginia License."
Notified R2DO (King), R1DO (Trapp), FSME Event Resource (email), and FUELS OUO (email).
"The conditions for reporting under the requirements of 10 CFR 20.1906(d) have been met. QWI 14.1.10, Classification & Notification Criteria for Unusual Incidents Radiation Protection section - for shipments, bases reporting requirements on receipt of a shipment with radiation or contamination levels in excess of 10 CFR 20.1906(d). This requirement was exceeded and an NRC report is required. The truck cab sleeping area (normally occupied space) dose rate of 5.4 mrem/hr is greater than the allowable limit of 2.0 mrem/hr. The carrier drivers (2) state that they do not have dosimetry.
"Immediate actions that have been taken:
- The area was secured.
- Confirmatory measurements were taken.
- Digital photographs have been taken.
- The shipper has been notified.
- A review of the associated regulations was performed.
- The carrier has been notified.
- The truck has been unloaded and released."
The shipment contained Am241/Be sources sent from QSA Global in Burlington, MA for use in refurbishing sources, typically well-logging. The estimated departure time/date was 0800 EDT on 07/31/13 with estimated arrival time/date of 0800 EDT on 08/01/13. The driver team consisted of two (2) individuals during the 24-hour transit time. The shipment was off-loaded and secured following the receipt rad survey.
The licensee notified the shipper, the carrier, the Commonwealth of Virginia and informed the NRC Resident Inspector.
* * * RETRACTION FROM TONY ENGLAND TO PETE SNYDER AT 1702 EDT ON 8/5/13 * * *
"This event has been reported to the Commonwealth of Virginia under Event Number VA-13-04. The material involved in this event is regulated under Commonwealth of Virginia License."
Notified R2DO (King), R1DO (Trapp), FSME Event Resource (email), and FUELS OUO (email).
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 49243
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: BABCOCK & WILCOX
Region: 1
City: LYNCHBURG State: VA
County:
License #: VA-680-028-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: DONG HWA PARK
Licensee: BABCOCK & WILCOX
Region: 1
City: LYNCHBURG State: VA
County:
License #: VA-680-028-1
Agreement: Y
Docket:
NRC Notified By: MIKE WELLING
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/06/2013
Notification Time: 11:04 [ET]
Event Date: 08/01/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/01/2013
Notification Time: 11:04 [ET]
Event Date: 08/01/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/01/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1DO)
MICHAEL F. KING (R2DO)
FSME EVENTS RESOURCE (EMAI)
BRIAN SMITH (NMSS)
FUELS GRP via email
JAMES TRAPP (R1DO)
MICHAEL F. KING (R2DO)
FSME EVENTS RESOURCE (EMAI)
BRIAN SMITH (NMSS)
FUELS GRP via email
AGREEMENT STATE REPORT - EXTERNAL RADIATION LEVELS ON SHIPMENT EXCEEDED 2MR/HR LIMIT FOR UNMONITORED EXPOSURES
The following information was received from the Commonwealth of Virginia via facsimile:
"On Thursday, August 1st, a shipment was being received by B&W from QSA Global, Inc. During the receipt survey, readings indicated 5.4 mrem/hr in the cab of the truck. The sources were received and leak tests were performed indicating no leakage. B&W contacted the Virginia Radioactive Materials Program (RMP) who then contacted the Massachusetts RMP.
"B&W also reported the event to the NRC Operations Center on August 1st. A discussion to retract the event as this shipment occurred under the Virginia license was held on Friday 8/2 but the final determination was not made until Monday 8/5 to retract the NRC report. A decision was agreed upon for the Virginia RMP to report the event to the NRC Ops Center.
"The Massachusetts RMP contacted QSA Global, Inc. A preliminary investigation indicates that a QSA Global, Inc. employee did not perform the proper survey before the sources were shipped.
"The [contract carrier] consultant was contacted and made aware of this event. The [contract carrier] has begun an investigation into the event.
"There was no adverse effect to public health and safety from this event.
"Media attention: Yes"
VA Event Report ID Number: VA-13-04
* * * RETRACTION FROM MIKE WELLING (VIA EMAIL) TO HOWIE CROUCH AT 1513 EDT ON 10/1/13 * * *
The following retraction was submitted by the Commonwealth of Virginia via email:
"On August 1st, a shipment from QSA Global using [a common carrier] was received at Babcock & Wilcox. During the receipt, a survey indicated readings >2 mrem/hr in the cab. An investigation was performed by the Massachusetts Radioactive Materials Program, during which they spoke with QSA and [the carrier]. Based upon this investigation, it has been determined that the shipment was not an exclusive shipment and all DOT regulations were met.
"This event is being retracted based upon the investigation results."
Notified R1DO (Joustra), NMSS EO (Bjorkman), Fuels Group (via email) and FSME Events Resource (via email).
The following information was received from the Commonwealth of Virginia via facsimile:
"On Thursday, August 1st, a shipment was being received by B&W from QSA Global, Inc. During the receipt survey, readings indicated 5.4 mrem/hr in the cab of the truck. The sources were received and leak tests were performed indicating no leakage. B&W contacted the Virginia Radioactive Materials Program (RMP) who then contacted the Massachusetts RMP.
"B&W also reported the event to the NRC Operations Center on August 1st. A discussion to retract the event as this shipment occurred under the Virginia license was held on Friday 8/2 but the final determination was not made until Monday 8/5 to retract the NRC report. A decision was agreed upon for the Virginia RMP to report the event to the NRC Ops Center.
"The Massachusetts RMP contacted QSA Global, Inc. A preliminary investigation indicates that a QSA Global, Inc. employee did not perform the proper survey before the sources were shipped.
"The [contract carrier] consultant was contacted and made aware of this event. The [contract carrier] has begun an investigation into the event.
"There was no adverse effect to public health and safety from this event.
"Media attention: Yes"
VA Event Report ID Number: VA-13-04
* * * RETRACTION FROM MIKE WELLING (VIA EMAIL) TO HOWIE CROUCH AT 1513 EDT ON 10/1/13 * * *
The following retraction was submitted by the Commonwealth of Virginia via email:
"On August 1st, a shipment from QSA Global using [a common carrier] was received at Babcock & Wilcox. During the receipt, a survey indicated readings >2 mrem/hr in the cab. An investigation was performed by the Massachusetts Radioactive Materials Program, during which they spoke with QSA and [the carrier]. Based upon this investigation, it has been determined that the shipment was not an exclusive shipment and all DOT regulations were met.
"This event is being retracted based upon the investigation results."
Notified R1DO (Joustra), NMSS EO (Bjorkman), Fuels Group (via email) and FSME Events Resource (via email).