Event Notification Report for August 05, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/04/2015 - 08/05/2015
EVENT NUMBERS
51312512885128951290512925129951326
Agreement State
Event Number: 51312
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NEWELL RECYCLING SOUTHEAST
Region: 1
City: PHENIX CITY State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: NEWELL RECYCLING SOUTHEAST
Region: 1
City: PHENIX CITY State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2015
Notification Time: 09:09 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/12/2015
Notification Time: 09:09 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - Sr-90 SOURCE FOUND AT RECYCLING FACILITY
The following report was received via fax:
"On August 5, 2015, while investigating a collection of naturally occurring radioactive material (NORM) at Newell Recycling Southeast facility in Phenix City, AL, representatives from the Alabama Office of Radiation Control identified what appeared to be a very old gauge containing radioactive material. Initial field analysis measurements identified the isotope as Sr-90.
"A follow-up visit on August 7, 2015 by Alabama Office of Radiation Control personnel confirmed the source of radiation to be a very old device containing a sealed Sr-90 source. Maximum radiation levels of 1500 mR/hr (beta + gamma) and 300 mR/hr (gamma only) at the port opening were measured. The device was secured and placed in storage at the facility. A leak test was performed and the results are pending.
"The origin of the device is unknown. There are no identifying marks on the device. The Alabama Office of Radiation Control continues to investigate to determine the make, model and serial number. It is assumed that the device is a very old, generally licensed device that was abandoned, lost or stolen in the past."
Alabama Incident 15-36
The following report was received via fax:
"On August 5, 2015, while investigating a collection of naturally occurring radioactive material (NORM) at Newell Recycling Southeast facility in Phenix City, AL, representatives from the Alabama Office of Radiation Control identified what appeared to be a very old gauge containing radioactive material. Initial field analysis measurements identified the isotope as Sr-90.
"A follow-up visit on August 7, 2015 by Alabama Office of Radiation Control personnel confirmed the source of radiation to be a very old device containing a sealed Sr-90 source. Maximum radiation levels of 1500 mR/hr (beta + gamma) and 300 mR/hr (gamma only) at the port opening were measured. The device was secured and placed in storage at the facility. A leak test was performed and the results are pending.
"The origin of the device is unknown. There are no identifying marks on the device. The Alabama Office of Radiation Control continues to investigate to determine the make, model and serial number. It is assumed that the device is a very old, generally licensed device that was abandoned, lost or stolen in the past."
Alabama Incident 15-36
Non-Agreement State
Event Number: 51288
Rep Org: ADVANCE TESTING COMPANY, INC
Licensee: ADVANCE TESTING COMPANY INC
Region: 1
City: CAMPBELL HALL State: NY
County:
License #: 31-31284-01
Agreement: Y
Docket:
NRC Notified By: MARK CLARK
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ADVANCE TESTING COMPANY INC
Region: 1
City: CAMPBELL HALL State: NY
County:
License #: 31-31284-01
Agreement: Y
Docket:
NRC Notified By: MARK CLARK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/05/2015
Notification Time: 10:02 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/07/2015
Notification Time: 10:02 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/07/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAMAGED PORTABLE MOISTURE DENSITY GAUGE
The licensee reported that a portable moisture density gauge was damaged, by a dump truck, during a road paving project in Glastonbury, CT. The gauge case and keypad were damaged however, the sources are in the stored/safe position. There is no indication of leakage and no radiation exposures have occurred. The licensee has stored the gauge in their secure location pending further evaluation. The gauge is an Instrotek Model 3500 gauge containing 11mCi Cs-137 and 44 mCi Am/Be sources.
* * * UPDATE PROVIDED BY MARK CLARK TO JEFF ROTTON AT 1258 EDT ON 08/07/2015 * * *
Licensee called to correct initial report. The damaged gauge was actually a Troxler 3440, Serial number 18428 and not an Instrotek model 3500. Reported activity of sources remains the same.
Notified R1DO (Burritt) and NMSS Events Notification Group via email.
The licensee reported that a portable moisture density gauge was damaged, by a dump truck, during a road paving project in Glastonbury, CT. The gauge case and keypad were damaged however, the sources are in the stored/safe position. There is no indication of leakage and no radiation exposures have occurred. The licensee has stored the gauge in their secure location pending further evaluation. The gauge is an Instrotek Model 3500 gauge containing 11mCi Cs-137 and 44 mCi Am/Be sources.
* * * UPDATE PROVIDED BY MARK CLARK TO JEFF ROTTON AT 1258 EDT ON 08/07/2015 * * *
Licensee called to correct initial report. The damaged gauge was actually a Troxler 3440, Serial number 18428 and not an Instrotek model 3500. Reported activity of sources remains the same.
Notified R1DO (Burritt) and NMSS Events Notification Group via email.
Power Reactor
Event Number: 51289
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JONATHAN PRYOR
HQ OPS Officer: JEFF ROTTON
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JONATHAN PRYOR
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/05/2015
Notification Time: 16:22 [ET]
Event Date: 08/05/2015
Event Time: 12:52 [EDT]
Last Update Date: 08/05/2015
Notification Time: 16:22 [ET]
Event Date: 08/05/2015
Event Time: 12:52 [EDT]
Last Update Date: 08/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ART BURRITT (R1DO)
ART BURRITT (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
MOMENTARY LOSS OF SECONDARY CONTAINMENT
"Nine Mile Point Unit 1 (NMP1) experienced a momentary loss of Secondary Containment due to both Reactor Building (RB) airlock doors being opened at the same time.
"At 1252 [EDT] on 08/05/15, both RB airlock doors were opened simultaneously for less than 5 seconds. This resulted in Secondary Containment being declared inoperable (TS 3.4.3). Secondary Containment was restored to operable when the doors were closed.
"The event is reportable in accordance with 10 CFR 50.72(b)(3)(v)(c), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'
"The condition has been entered into the station's corrective action program and the NRC Resident Inspector has been notified."
The licensee also notified the State of New York Public Service Commission.
"Nine Mile Point Unit 1 (NMP1) experienced a momentary loss of Secondary Containment due to both Reactor Building (RB) airlock doors being opened at the same time.
"At 1252 [EDT] on 08/05/15, both RB airlock doors were opened simultaneously for less than 5 seconds. This resulted in Secondary Containment being declared inoperable (TS 3.4.3). Secondary Containment was restored to operable when the doors were closed.
"The event is reportable in accordance with 10 CFR 50.72(b)(3)(v)(c), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.'
"The condition has been entered into the station's corrective action program and the NRC Resident Inspector has been notified."
The licensee also notified the State of New York Public Service Commission.
Power Reactor
Event Number: 51290
Facility: SALEM
Region: 1 State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN MCHUGH
HQ OPS Officer: DONG HWA PARK
Region: 1 State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN MCHUGH
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/05/2015
Notification Time: 18:51 [ET]
Event Date: 08/05/2015
Event Time: 15:38 [EDT]
Last Update Date: 08/05/2015
Notification Time: 18:51 [ET]
Event Date: 08/05/2015
Event Time: 15:38 [EDT]
Last Update Date: 08/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ART BURRITT (R1DO)
ART BURRITT (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP ON LOW REACTOR COOLANT FLOW
"This 4-hour and 8-hour notification is being made to report that Salem Unit 2 had an unplanned automatic reactor trip. The trip occurred because the 2H 4kV infeed breaker tripped on over current protection which deenergized the 2H 4kV group bus resulting in a reactor trip on reactor coolant flow due to the loss of the 21 reactor coolant pump [RCP]. The 21 RCP remains unavailable. The cause of the over current protection trip on the 2H 4kV infeed breaker is unknown at this time.
"All control rods inserted on the reactor trip. All ECCS [emergency core cooling systems] and ESF [engineered safety feature] systems functioned as expected. The auxiliary feed pumps started as expected.
"Salem Unit 2 is currently in Mode 3. Reactor coolant system pressure is at 2235 psig and temperature is 547 degrees Fahrenheit with decay heat removal via the main steam dumps and auxiliary feedwater systems. Unit 2 has no active technical specification action statements in effect requiring a lower mode of operation due to the transient.
"The 22 auxiliary building supply fan was tagged for maintenance prior to this event and has no adverse impact of the post trip plant response or stabilization. There was no major secondary equipment tagged for maintenance prior to the event. There were no personnel injuries as a result of this event.
"There is no physical evidence of damage to the 2H 4kV bus based on visual observations and thermography."
Normal offsite power is available to the site. There is no effect on Unit 1.
The licensee has notified the NRC Resident Inspector and will notify the Lower Alloways Creek Township Police Department.
"This 4-hour and 8-hour notification is being made to report that Salem Unit 2 had an unplanned automatic reactor trip. The trip occurred because the 2H 4kV infeed breaker tripped on over current protection which deenergized the 2H 4kV group bus resulting in a reactor trip on reactor coolant flow due to the loss of the 21 reactor coolant pump [RCP]. The 21 RCP remains unavailable. The cause of the over current protection trip on the 2H 4kV infeed breaker is unknown at this time.
"All control rods inserted on the reactor trip. All ECCS [emergency core cooling systems] and ESF [engineered safety feature] systems functioned as expected. The auxiliary feed pumps started as expected.
"Salem Unit 2 is currently in Mode 3. Reactor coolant system pressure is at 2235 psig and temperature is 547 degrees Fahrenheit with decay heat removal via the main steam dumps and auxiliary feedwater systems. Unit 2 has no active technical specification action statements in effect requiring a lower mode of operation due to the transient.
"The 22 auxiliary building supply fan was tagged for maintenance prior to this event and has no adverse impact of the post trip plant response or stabilization. There was no major secondary equipment tagged for maintenance prior to the event. There were no personnel injuries as a result of this event.
"There is no physical evidence of damage to the 2H 4kV bus based on visual observations and thermography."
Normal offsite power is available to the site. There is no effect on Unit 1.
The licensee has notified the NRC Resident Inspector and will notify the Lower Alloways Creek Township Police Department.
Agreement State
Event Number: 51292
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: VIDANT MEDICAL CENTER
Region: 1
City: GREENVILLE State: NC
County:
License #: 074-1457-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: JEFF ROTTON
Licensee: VIDANT MEDICAL CENTER
Region: 1
City: GREENVILLE State: NC
County:
License #: 074-1457-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/06/2015
Notification Time: 12:22 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/06/2015
Notification Time: 12:22 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/06/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO ADMINISTRATION OF HIGHER DOSE THAN PRESCRIBED
The following information was provided by the State of North Carolina via email:
"Pitt County Memorial Hospital, Inc. dba Vidant Medical Center (License No. 074-1457-1) had a medical event occur yesterday afternoon [08/05/2015]. In brief, a patient with a low GFR [Glomerular Filtration Rate] was being treated for thyroid carcinoma. The original plan was to give the patient 50 mCi of I-131, which was received, assayed and ready for the Radiologist's approval.
"The Radiologist on site was not the original Radiologist who planned the treatment for this patient. The physician onsite felt that with the low GFR (score to indicate kidney function) a lower dose, 35 mCi, would be prudent and a second order was placed with the radiopharmacy.
"Around 1200 EDT, the dose was received, assayed and ready for administration. The Radiation Safety Representative identified the patient as required and discussed the home-going instructions with the patient prior to the administration. After the patient acknowledged the instructions, the Radiation Safety Representative went to the hot lab, confirmed the written directive, identified an assayed dose with the patient's name on it (of which there were two), failed to confirm the activity on the pig and slip, and administered the dose.
"The error was not identified until the hot lab nuclear medicine technologist noted that the 35 mCi dose was still in the hot lab. The Radiologist and Radiation Safety Office was notified immediately. As of 1420 EDT, the referring physician was notified and patient was to be notified by the end of the day. At this time, it is not probable that there will be any health impact from the discrepancy.
"A NC Health Physicist will be doing a reactive inspection before the end of this week. The radiation safety team is conducting an investigation and will be filing a formal report (15-day report) by August 20, 2015."
NC NMED Report Identification number: NC150023
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 following information was provided by the State of North Carolina via email:
"Pitt County Memorial Hospital, Inc. dba Vidant Medical Center (License No. 074-1457-1) had a medical event occur yesterday afternoon [08/05/2015]. In brief, a patient with a low GFR [Glomerular Filtration Rate] was being treated for thyroid carcinoma. The original plan was to give the patient 50 mCi of I-131, which was received, assayed and ready for the Radiologist's approval.
"The Radiologist on site was not the original Radiologist who planned the treatment for this patient. The physician onsite felt that with the low GFR (score to indicate kidney function) a lower dose, 35 mCi, would be prudent and a second order was placed with the radiopharmacy.
"Around 1200 EDT, the dose was received, assayed and ready for administration. The Radiation Safety Representative identified the patient as required and discussed the home-going instructions with the patient prior to the administration. After the patient acknowledged the instructions, the Radiation Safety Representative went to the hot lab, confirmed the written directive, identified an assayed dose with the patient's name on it (of which there were two), failed to confirm the activity on the pig and slip, and administered the dose.
"The error was not identified until the hot lab nuclear medicine technologist noted that the 35 mCi dose was still in the hot lab. The Radiologist and Radiation Safety Office was notified immediately. As of 1420 EDT, the referring physician was notified and patient was to be notified by the end of the day. At this time, it is not probable that there will be any health impact from the discrepancy.
"A NC Health Physicist will be doing a reactive inspection before the end of this week. The radiation safety team is conducting an investigation and will be filing a formal report (15-day report) by August 20, 2015."
NC NMED Report Identification number: NC150023
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: 51299
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WELLSTAR KENNESTONE HOSPITAL
Region: 1
City: MARIETTA State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF ROTTON
Licensee: WELLSTAR KENNESTONE HOSPITAL
Region: 1
City: MARIETTA State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/07/2015
Notification Time: 15:58 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/11/2015
Notification Time: 15:58 [ET]
Event Date: 08/05/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GEORGIA AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO OVEREXPOSURE
The following information was provided by the State of Georgia via email:
"The [Georgia] Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015.
"Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by [greater than] 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015.
"The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy."
* * * UPDATE AT 0808 EDT ON 8/11/2015 FROM TRAVIS CARTOSKI TO MARK ABRAMOVITZ * * *
The following information was received via e-mail:
"First fraction delivered was 300 cGy
Second faction delivered was 300 cGy
Third fraction delivered was 900 cGy, should have been 300 cGy
Total dosed received 1500 cGy
"On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU [Authorized User] that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy).
"On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec.
"The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015."
Notified the R1DO (Powell) and NMSS Events Resource (via e-mail).
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 following information was provided by the State of Georgia via email:
"The [Georgia] Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015.
"Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by [greater than] 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015.
"The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy."
* * * UPDATE AT 0808 EDT ON 8/11/2015 FROM TRAVIS CARTOSKI TO MARK ABRAMOVITZ * * *
The following information was received via e-mail:
"First fraction delivered was 300 cGy
Second faction delivered was 300 cGy
Third fraction delivered was 900 cGy, should have been 300 cGy
Total dosed received 1500 cGy
"On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU [Authorized User] that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy).
"On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec.
"The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015."
Notified the R1DO (Powell) and NMSS Events Resource (via e-mail).
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: 51326
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: H & H X-RAY SERVICES
Region: 4
City: WEST MONROE State: LA
County:
License #: LA-2970-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: JEFF ROTTON
Licensee: H & H X-RAY SERVICES
Region: 4
City: WEST MONROE State: LA
County:
License #: LA-2970-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/17/2015
Notification Time: 15:10 [ET]
Event Date: 08/05/2015
Event Time: 12:45 [CDT]
Last Update Date: 08/17/2015
Notification Time: 15:10 [ET]
Event Date: 08/05/2015
Event Time: 12:45 [CDT]
Last Update Date: 08/17/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE RETRIEVAL
"The crew [for H&H X-Ray Services] was x-raying pipe at a temporary job site in Elm Grove, LA. Due to the configuration, the camera was above the guide tube and the source and guide tube were on a surface below. The camera slipped and fell approximately 18 inches and landed on the guide tube and crimped the guide tube not allowing the source to be returned to the shielded position. A survey indicated the source was still in the guide tube. The boundaries were maintained until the RSO and his assistant arrived to perform the retrieval. Following the source retrieval procedure, the source was placed into a shielded source changer, QSA Global 650L, and returned to the company's West Monroe, LA storage location. Except for the guide tube, none of the equipment was damaged. Exposures to the crew and the retrieval crew were minimal.
"Reported to the LA Department of Environmental Quality 08/13/2015 at 1533 CDT.
"Exposure Device AEA/QSA Model 880 Delta, SR D2767, Source: 58 Ci Ir-192, Model A424-9, SN 18108G"
State Event Report ID No.: LA 150013
"The crew [for H&H X-Ray Services] was x-raying pipe at a temporary job site in Elm Grove, LA. Due to the configuration, the camera was above the guide tube and the source and guide tube were on a surface below. The camera slipped and fell approximately 18 inches and landed on the guide tube and crimped the guide tube not allowing the source to be returned to the shielded position. A survey indicated the source was still in the guide tube. The boundaries were maintained until the RSO and his assistant arrived to perform the retrieval. Following the source retrieval procedure, the source was placed into a shielded source changer, QSA Global 650L, and returned to the company's West Monroe, LA storage location. Except for the guide tube, none of the equipment was damaged. Exposures to the crew and the retrieval crew were minimal.
"Reported to the LA Department of Environmental Quality 08/13/2015 at 1533 CDT.
"Exposure Device AEA/QSA Model 880 Delta, SR D2767, Source: 58 Ci Ir-192, Model A424-9, SN 18108G"
State Event Report ID No.: LA 150013