Event Notification Report for December 20, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/19/2016 - 12/20/2016
EVENT NUMBERS
5245752448524495245052446
Agreement State
Event Number: 52457
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/22/2016
Notification Time: 12:46 [ET]
Event Date: 12/20/2016
Event Time: 00:00 [EST]
Last Update Date: 12/22/2016
Notification Time: 12:46 [ET]
Event Date: 12/20/2016
Event Time: 00:00 [EST]
Last Update Date: 12/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following report was received via fax:
"On December 20, 2016, a leak occurred during an administration of Yttrium-90 (Y-90) TheraSpheres to a patient, resulting in less than 80% of the prescribed dosage being administered. A total of about 8.99 millicurie of Y-90 activity was administered; or 34.6% of the prescribed 25.95 mCi activity. The prescribed dose was 17,470 rad (174.7 gray), with the leak resulting in a dose to the patient's liver of about 6,040 rad (60.4 Gy). The leak also caused contamination of the administration area, which was immediately and successfully decontaminated. As an under-dose, no immediate harmful effect to the patient resulted from the event. The referring physician and patient were made aware of the event during the procedure."
Pennsylvania event: PA-160040
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 report was received via fax:
"On December 20, 2016, a leak occurred during an administration of Yttrium-90 (Y-90) TheraSpheres to a patient, resulting in less than 80% of the prescribed dosage being administered. A total of about 8.99 millicurie of Y-90 activity was administered; or 34.6% of the prescribed 25.95 mCi activity. The prescribed dose was 17,470 rad (174.7 gray), with the leak resulting in a dose to the patient's liver of about 6,040 rad (60.4 Gy). The leak also caused contamination of the administration area, which was immediately and successfully decontaminated. As an under-dose, no immediate harmful effect to the patient resulted from the event. The referring physician and patient were made aware of the event during the procedure."
Pennsylvania event: PA-160040
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: 52448
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINEGENERAL MEDICAL CENTER
Region: 1
City: AUGUSTA State: ME
County:
License #: 11623 #30
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: HOWIE CROUCH
Licensee: MAINEGENERAL MEDICAL CENTER
Region: 1
City: AUGUSTA State: ME
County:
License #: 11623 #30
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 16:36 [ET]
Event Date: 12/20/2016
Event Time: 13:00 [EST]
Last Update Date: 01/03/2017
Notification Time: 16:36 [ET]
Event Date: 12/20/2016
Event Time: 13:00 [EST]
Last Update Date: 01/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING WRONG TREATMENT SITE
The following information was obtained from the state of Maine via facsimile:
"On 12/19/2016, patient was scheduled for initial verification and treatment with electrons of a right sided metastatic rib lesion of 5 fractions at 400cGy per fraction. Patient was also to be treated with photons to a spinal lesion. Patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment location tattoos were present for each of these sites. Failure to identify the correct treatment tattoo and confusion over the treatment note led to the patient being setup to the previous rib tattoo location and treated. A single fraction of 400 cGy was delivered to the previous treatment site. Following treatment, the physician suspected a setup error. Further review of treatment plan confirmed the error. The licensee has notified the patient.
"A review of causes of the event and corrective actions was initiated."
Maine Event Report ID No.: ME 16-002
* * * UPDATE AT 1704 EST ON 1/3/2017 FROM THOMAS HILLMAN TO MARK ABRAMOVITZ * * *
The following information was received via fax:
"On 12/19/2016, a patient initiated treatment to a right sided metastatic rib lesion with 12 MEV electrons. The patient was also treated with photons to a T9 spinal lesion. The patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site and a T2 spinal lesion. Each treatment site was marked with a small tattoo as is common in Radiation Oncology.
"The treating therapists incorrectly identified and set up the radiation treatment to the wrong rib tattoo. This was the patient's first radiation treatment of this course. Therefore, consistent with Radiation Oncology practice, a documented verification step in which the prescribing physician is present and verifies field setup prior to initiating treatment occurred. The physician also failed to identify that the radiation treatment was setup to the wrong tattoo. A single fraction of the intended 5 fractions of 400cGy was then delivered.
"Referencing SOM rules, PART X, THERAPEUTIC RADIATION MACHINES, a 'Medical Event' means 'the administration of an external beam radiation therapy dose: (1) Involving the wrong patient, wrong treatment modality, or wrong treatment site; or, .. 'The event is considered to meet the intent of 'wrong treatment site' under the rule and is being reported. An initial notification of the State occurred with 24 hours, as prescribed by the rule. This was followed up the same day with an email containing initial details of the event. This report constitutes the written report requirement under that rule required within 15 days of identification.
"Why the event occurred: The patient had previously been treated to two sites. The new treatment included two additional sites. Each treatment site is marked with a small tattoo. The appropriate treatment tattoo was misidentified. Patient was set up to the tattoo of the previously treated right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment setup information was available in the form of simulation photos and graphical treatment plan to adequately identify the appropriate treatment site. Available information was not accessed in the treatment room during set up of the patient.
"When the plan is brought up on the treatment machine, information is presented on the overhead monitors in the treatment room. This is limited to 3 photos (1 being patient race photo) and 256 characters of text. Prior to treatment, dosimetrists load all available simulation images into the electronic chart only assuring that the face photo is the first for each field. During initial therapist chart review the most informative photos are selected by the therapist to be presented in the room that they will find useful to setup the patient. This did not occur in this case. Two face photos and an ambiguous photo was present. This 1 photo when coupled with the note did not provide clear field setup direction.
"When a right rib tattoo was readily identified by the therapist they assumed that they were on the correct tattoo and chose to rely on the limited information that was presented on the overhead monitor. Comprehensive setup information was available in the simulation documentation, EMR and the graphical treatment plan available in the electronic medical record (EMR). This information was available on the in room EMR computer. It is understood by the therapist that the overhead monitor may not be able to convey all necessary setup information and routinely refer to the EMR. This physician routinely requests a hard copy print out of the setup of electron treatments so that the image can be compared to surface landmarks. The image print out is not requested by all physicians. A print out was not provided by the dosimetrist. When requested, the therapist did bring up the plan information on the in room EMR computer monitor for reference by the physician.
"The setup error was also not detected by the physician. Immediately following treatment the physician requested a print out of the patient setup from dosimetry and noted the error. A review of causes of the event and development or corrective actions was initiated.
"The effect on the patient: Due to the superficial nature of electrons the dose delivered to the wrong site will result in no appreciable impact on skin or underlying healthy tissues. The treatment dose can be made up in the remaining days of scheduled treatment safely providing full therapeutic dose to the target lesion.
"What improvements are needed to prevent recurrence; actions taken to prevent recurrence?
"The need to select the most informative images to be presented in the treatment room was added to a newly created comprehensive pre-treatment chart checklist. This step is required to be initialed by both the dosimetrist and therapist performing pre-treatment chart check.
"The need to select those photos as photo 1 and photo 2 in the EMR was reviewed with the dosimetrists, who were previously unaware of the functionality added approximately 1 year ago. The need to no longer add the face photo to the plan, which is now presented in the room automatically, was also shared.
"The need to review and configure the in-room field notes and photos, the need to utilize additional information in the EMR if the in-room note is unclear, and the need to reach out to the planning dosimetrist if treatment remains ambiguous was reemphasized with the therapist.
"The newly installed TrueBeam treatment machines allow electronic reference field images to be easily generated and taken through the field aperture even for clinical patient setups. A comparison of proximal bony anatomy at the treatment site to the reference derived from the planned treatment can performed at the treatment console to assure treatment of the correct location. Initial verification image guidance, common on most photon treatments, will now also be required for electron treatments.
"The prescription was titled Right 8th rib. The treatment plan was titled Right Inferior Rib. The dosimetrist considered inferior rib to be more descriptive and one more generally understood by staff than 8th rib. Consistency of prescription and plan name is weak potential barrier in this case, but in general consistency will serve to minimize potential for gross errors such as wrong body part and laterality issues. The verification of consistency of prescription and plan names was added to newly created comprehensive pre-treatment chart checklist.
"As of this date, Maine General has classified this as a Sentinel Event. As such, an independent Root Cause Analysis is planned by our Risk Management Department. That assessment is in progress and as yet no additional corrective actions have been identified.
"Event and corrective actions will be reviewed in the department Quality Committee.
"Notification of the patient: Event was reviewed with the patient by the physician on 12/20/16 prior to delivery of the next scheduled treatment. Patient was informed that an error had been made, that impact was negligible to the re-treated site, and that full therapeutic dose could be delivered safely to the intended site. A physician's note is available in the patients chart documenting that conversation.
"Conclusion: The root cause of the event is determined to be human error. The incorrect one of two right rib tattoos was identified and referenced for treatment setup. Contributing factors included limited in-room information to initially setup patient and failing to access readily available information if setup information was ambiguous. Corrective actions have been put in place to assure than in-room data presented on the overhead monitors ls present and as comprehensive as possible. The need to access additional information using the EMR or other resources when the setup is ambiguous was reemphasized with the staff.
"An additional barrier created to prevent repetition of the event is the addition of image guidance for all electron treatments during initial treatment verification. A comparison of proximal bony anatomy at the treatment site to the reference derived from the planned treatment can performed at the treatment console to assure treatment of the correct location."
Notified the R1DO (Dentel) and NMSS (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 obtained from the state of Maine via facsimile:
"On 12/19/2016, patient was scheduled for initial verification and treatment with electrons of a right sided metastatic rib lesion of 5 fractions at 400cGy per fraction. Patient was also to be treated with photons to a spinal lesion. Patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment location tattoos were present for each of these sites. Failure to identify the correct treatment tattoo and confusion over the treatment note led to the patient being setup to the previous rib tattoo location and treated. A single fraction of 400 cGy was delivered to the previous treatment site. Following treatment, the physician suspected a setup error. Further review of treatment plan confirmed the error. The licensee has notified the patient.
"A review of causes of the event and corrective actions was initiated."
Maine Event Report ID No.: ME 16-002
* * * UPDATE AT 1704 EST ON 1/3/2017 FROM THOMAS HILLMAN TO MARK ABRAMOVITZ * * *
The following information was received via fax:
"On 12/19/2016, a patient initiated treatment to a right sided metastatic rib lesion with 12 MEV electrons. The patient was also treated with photons to a T9 spinal lesion. The patient had previously been treated to a right sided rib lesion approximately 11 cm superior to the intended treatment site and a T2 spinal lesion. Each treatment site was marked with a small tattoo as is common in Radiation Oncology.
"The treating therapists incorrectly identified and set up the radiation treatment to the wrong rib tattoo. This was the patient's first radiation treatment of this course. Therefore, consistent with Radiation Oncology practice, a documented verification step in which the prescribing physician is present and verifies field setup prior to initiating treatment occurred. The physician also failed to identify that the radiation treatment was setup to the wrong tattoo. A single fraction of the intended 5 fractions of 400cGy was then delivered.
"Referencing SOM rules, PART X, THERAPEUTIC RADIATION MACHINES, a 'Medical Event' means 'the administration of an external beam radiation therapy dose: (1) Involving the wrong patient, wrong treatment modality, or wrong treatment site; or, .. 'The event is considered to meet the intent of 'wrong treatment site' under the rule and is being reported. An initial notification of the State occurred with 24 hours, as prescribed by the rule. This was followed up the same day with an email containing initial details of the event. This report constitutes the written report requirement under that rule required within 15 days of identification.
"Why the event occurred: The patient had previously been treated to two sites. The new treatment included two additional sites. Each treatment site is marked with a small tattoo. The appropriate treatment tattoo was misidentified. Patient was set up to the tattoo of the previously treated right sided rib lesion approximately 11 cm superior to the intended treatment site. Treatment setup information was available in the form of simulation photos and graphical treatment plan to adequately identify the appropriate treatment site. Available information was not accessed in the treatment room during set up of the patient.
"When the plan is brought up on the treatment machine, information is presented on the overhead monitors in the treatment room. This is limited to 3 photos (1 being patient race photo) and 256 characters of text. Prior to treatment, dosimetrists load all available simulation images into the electronic chart only assuring that the face photo is the first for each field. During initial therapist chart review the most informative photos are selected by the therapist to be presented in the room that they will find useful to setup the patient. This did not occur in this case. Two face photos and an ambiguous photo was present. This 1 photo when coupled with the note did not provide clear field setup direction.
"When a right rib tattoo was readily identified by the therapist they assumed that they were on the correct tattoo and chose to rely on the limited information that was presented on the overhead monitor. Comprehensive setup information was available in the simulation documentation, EMR and the graphical treatment plan available in the electronic medical record (EMR). This information was available on the in room EMR computer. It is understood by the therapist that the overhead monitor may not be able to convey all necessary setup information and routinely refer to the EMR. This physician routinely requests a hard copy print out of the setup of electron treatments so that the image can be compared to surface landmarks. The image print out is not requested by all physicians. A print out was not provided by the dosimetrist. When requested, the therapist did bring up the plan information on the in room EMR computer monitor for reference by the physician.
"The setup error was also not detected by the physician. Immediately following treatment the physician requested a print out of the patient setup from dosimetry and noted the error. A review of causes of the event and development or corrective actions was initiated.
"The effect on the patient: Due to the superficial nature of electrons the dose delivered to the wrong site will result in no appreciable impact on skin or underlying healthy tissues. The treatment dose can be made up in the remaining days of scheduled treatment safely providing full therapeutic dose to the target lesion.
"What improvements are needed to prevent recurrence; actions taken to prevent recurrence?
"The need to select the most informative images to be presented in the treatment room was added to a newly created comprehensive pre-treatment chart checklist. This step is required to be initialed by both the dosimetrist and therapist performing pre-treatment chart check.
"The need to select those photos as photo 1 and photo 2 in the EMR was reviewed with the dosimetrists, who were previously unaware of the functionality added approximately 1 year ago. The need to no longer add the face photo to the plan, which is now presented in the room automatically, was also shared.
"The need to review and configure the in-room field notes and photos, the need to utilize additional information in the EMR if the in-room note is unclear, and the need to reach out to the planning dosimetrist if treatment remains ambiguous was reemphasized with the therapist.
"The newly installed TrueBeam treatment machines allow electronic reference field images to be easily generated and taken through the field aperture even for clinical patient setups. A comparison of proximal bony anatomy at the treatment site to the reference derived from the planned treatment can performed at the treatment console to assure treatment of the correct location. Initial verification image guidance, common on most photon treatments, will now also be required for electron treatments.
"The prescription was titled Right 8th rib. The treatment plan was titled Right Inferior Rib. The dosimetrist considered inferior rib to be more descriptive and one more generally understood by staff than 8th rib. Consistency of prescription and plan name is weak potential barrier in this case, but in general consistency will serve to minimize potential for gross errors such as wrong body part and laterality issues. The verification of consistency of prescription and plan names was added to newly created comprehensive pre-treatment chart checklist.
"As of this date, Maine General has classified this as a Sentinel Event. As such, an independent Root Cause Analysis is planned by our Risk Management Department. That assessment is in progress and as yet no additional corrective actions have been identified.
"Event and corrective actions will be reviewed in the department Quality Committee.
"Notification of the patient: Event was reviewed with the patient by the physician on 12/20/16 prior to delivery of the next scheduled treatment. Patient was informed that an error had been made, that impact was negligible to the re-treated site, and that full therapeutic dose could be delivered safely to the intended site. A physician's note is available in the patients chart documenting that conversation.
"Conclusion: The root cause of the event is determined to be human error. The incorrect one of two right rib tattoos was identified and referenced for treatment setup. Contributing factors included limited in-room information to initially setup patient and failing to access readily available information if setup information was ambiguous. Corrective actions have been put in place to assure than in-room data presented on the overhead monitors ls present and as comprehensive as possible. The need to access additional information using the EMR or other resources when the setup is ambiguous was reemphasized with the staff.
"An additional barrier created to prevent repetition of the event is the addition of image guidance for all electron treatments during initial treatment verification. A comparison of proximal bony anatomy at the treatment site to the reference derived from the planned treatment can performed at the treatment console to assure treatment of the correct location."
Notified the R1DO (Dentel) and NMSS (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.
Power Reactor
Event Number: 52449
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KEVIN P. O'ROURKE
HQ OPS Officer: JEFF HERRERA
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KEVIN P. O'ROURKE
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/20/2016
Notification Time: 19:45 [ET]
Event Date: 12/20/2016
Event Time: 18:30 [EST]
Last Update Date: 12/20/2016
Notification Time: 19:45 [ET]
Event Date: 12/20/2016
Event Time: 18:30 [EST]
Last Update Date: 12/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES NOGGLE (R1DO)
JAMES NOGGLE (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
OFFSITE NOTIFICATION - RELEASE OF HYDROGEN GAS IN EXCESS OF THE REPORTABLE QUANTITY OF TEN POUNDS
"At 1830 EST on 20 December, 2016 the Massachusetts Department of Environmental Protection and the Plymouth Massachusetts Fire Department were notified of a Hydrogen release in accordance with plant procedures and 310CMR40.300, Massachusetts Contingency Plan Notification for Oil and Hazardous Material; Identification and Listing of Oil and Hazardous Material, due to a release of hydrogen gas to the environment exceeding the reportable quantity of ten pounds. The release, which is an expected part of a routine plant start-up was from the generator hydrogen cooling system.
"This event posed no danger to the health and safety of plant personnel or members of the general public.
"The NRC Resident Inspector has been notified."
"At 1830 EST on 20 December, 2016 the Massachusetts Department of Environmental Protection and the Plymouth Massachusetts Fire Department were notified of a Hydrogen release in accordance with plant procedures and 310CMR40.300, Massachusetts Contingency Plan Notification for Oil and Hazardous Material; Identification and Listing of Oil and Hazardous Material, due to a release of hydrogen gas to the environment exceeding the reportable quantity of ten pounds. The release, which is an expected part of a routine plant start-up was from the generator hydrogen cooling system.
"This event posed no danger to the health and safety of plant personnel or members of the general public.
"The NRC Resident Inspector has been notified."
Non-Agreement State
Event Number: 52450
Rep Org: INDIANA MICHIGAN POWER
Licensee: INDIANA MICHIGAN POWER
Region: 3
City: ROCKPORT State: IN
County:
License #: GL704402-21
Agreement: N
Docket:
NRC Notified By: STEVEN PFEISTER
HQ OPS Officer: HOWIE CROUCH
Licensee: INDIANA MICHIGAN POWER
Region: 3
City: ROCKPORT State: IN
County:
License #: GL704402-21
Agreement: N
Docket:
NRC Notified By: STEVEN PFEISTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/21/2016
Notification Time: 14:09 [ET]
Event Date: 12/20/2016
Event Time: 15:10 [CST]
Last Update Date: 12/21/2016
Notification Time: 14:09 [ET]
Event Date: 12/20/2016
Event Time: 15:10 [CST]
Last Update Date: 12/21/2016
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):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA
SHUTTER AND SHUTTER MECHANISM SEPARATED FROM SOURCE HOLDER
"On December 20, 2016 [at approximately] 1510 CST, a [level detector] nuclear source holder was found fallen off of its mounting on the unit 2 economizer hopper #49. The shutter mechanism and the shutter appear to have separated from the source holder. This occurred at the Indiana Michigan Power Rockport plant in Rockport, Indiana. The source holder is a Vega Americas Model SHLD-1-45, serial number: 7185CP. It is a 20 millicurie Cesium 137 source. The plant's general license number is GL704402-21. The radiation around the fallen source holder was tested and found to be a maximum of 35 millirem/hr at 1 foot in the source beam path. The radiation was tested at the 20 foot boundary where danger tape has been placed around the source holder and readings of 0.08 to 0.12 millirem/hr were noted. A nuclear technician from Vega Americas is currently on his way to the plant and we are planning to attempt to repair the source holder this evening [December 21].
"If we are unable to repair the source holder it will be prepared for shipping and will be sent back to Vega Americas' office in Cincinnati, Ohio for repair."
"On December 20, 2016 [at approximately] 1510 CST, a [level detector] nuclear source holder was found fallen off of its mounting on the unit 2 economizer hopper #49. The shutter mechanism and the shutter appear to have separated from the source holder. This occurred at the Indiana Michigan Power Rockport plant in Rockport, Indiana. The source holder is a Vega Americas Model SHLD-1-45, serial number: 7185CP. It is a 20 millicurie Cesium 137 source. The plant's general license number is GL704402-21. The radiation around the fallen source holder was tested and found to be a maximum of 35 millirem/hr at 1 foot in the source beam path. The radiation was tested at the 20 foot boundary where danger tape has been placed around the source holder and readings of 0.08 to 0.12 millirem/hr were noted. A nuclear technician from Vega Americas is currently on his way to the plant and we are planning to attempt to repair the source holder this evening [December 21].
"If we are unable to repair the source holder it will be prepared for shipping and will be sent back to Vega Americas' office in Cincinnati, Ohio for repair."
Agreement State
Event Number: 52446
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EAGLE NDT, LLC
Region: 4
City: POTH State: TX
County:
License #: 06176
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Licensee: EAGLE NDT, LLC
Region: 4
City: POTH State: TX
County:
License #: 06176
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2016
Notification Time: 12:49 [ET]
Event Date: 12/20/2016
Event Time: 00:00 [CST]
Last Update Date: 01/24/2017
Notification Time: 12:49 [ET]
Event Date: 12/20/2016
Event Time: 00:00 [CST]
Last Update Date: 01/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERAS DAMAGED IN BUILDING FIRE
The following information was obtained from the State of Texas via email:
"On December 20, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee's corporate radiation safety officer (CRSO) that a fire had occurred at their Poth, Texas location causing extensive damage to the building. The licensee reported that inside the building was its storage location for its radiography exposure devices. The storage location had ten QSA 880D cameras containing between 32.2 and 90.2 curies Ir-192. Dose rates five feet from the storage location after the fire was out were near normal.
"Once the licensee gained access to the storage location they discovered that at least two of the handles on the devices had been melted to some degree. The licensee removed all the cameras from the storage location and a radiation survey on each was completed. The licensee stated the measured dose rates were normal. It appears the integrity of the shielding was maintained, but could have been affected. The CRSO stated all cameras were being returned to the manufacturer for leak test and inspection.
"No licensee personnel or member of the general public were exposed to any significant levels of radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident # I-9452
* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1049 EST ON 12/23/16 * * *
The following report update was received from the State of Texas via email:
"On December 23, 2016, the Agency contacted the licensee to get an update on the status of the radiography exposure devices. The licensee stated ten exposure devices were involved in the event and all have been delivered to the manufacturers Houston, Texas location for leak test and inspection. The licensee stated the exposure device storage area has been surveyed and no contamination was found. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO(Hay) and NMSS_Events_Notification via email.
* * * UPDATE FROM TUCKER TO KLCO AT 1056 EST ON 12/28/16 * * *
The following information was received from the State of Texas via email:
"On December 28, 2016, the Agency was notified by the licensee that the state Fire Marshal determined the fire was an electrical short at a plug. Additional information will be provided as it is received IAW SA-300."
Notified R4DO (Drake) and NMSS_Events_Notification via email.
* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1151 EST ON 1/24/17 * * *
The following update information was received from the State of Texas via email:
"On January 19, 2017, the Agency received the written report from the licensee. Due to the nature of this event, the information is being provided directly to the HOO [NRC Headquarters Operations Officer]. The report included the report from the device manufacturer. The manufacturer's report states that due to the heat the devices were exposed to, none of the QSA 880 devices should be used to perform radiography work. In addition, the type 'B' containers could not be used as transportation containers for radioactive materials. The report also stated 12 cameras were involved in the fire, but only 10 had sources in them. All of the devices will be disposed of. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Rollins) and NMSS_Events_Notification (via email).
The following information was obtained from the State of Texas via email:
"On December 20, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee's corporate radiation safety officer (CRSO) that a fire had occurred at their Poth, Texas location causing extensive damage to the building. The licensee reported that inside the building was its storage location for its radiography exposure devices. The storage location had ten QSA 880D cameras containing between 32.2 and 90.2 curies Ir-192. Dose rates five feet from the storage location after the fire was out were near normal.
"Once the licensee gained access to the storage location they discovered that at least two of the handles on the devices had been melted to some degree. The licensee removed all the cameras from the storage location and a radiation survey on each was completed. The licensee stated the measured dose rates were normal. It appears the integrity of the shielding was maintained, but could have been affected. The CRSO stated all cameras were being returned to the manufacturer for leak test and inspection.
"No licensee personnel or member of the general public were exposed to any significant levels of radiation due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident # I-9452
* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1049 EST ON 12/23/16 * * *
The following report update was received from the State of Texas via email:
"On December 23, 2016, the Agency contacted the licensee to get an update on the status of the radiography exposure devices. The licensee stated ten exposure devices were involved in the event and all have been delivered to the manufacturers Houston, Texas location for leak test and inspection. The licensee stated the exposure device storage area has been surveyed and no contamination was found. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO(Hay) and NMSS_Events_Notification via email.
* * * UPDATE FROM TUCKER TO KLCO AT 1056 EST ON 12/28/16 * * *
The following information was received from the State of Texas via email:
"On December 28, 2016, the Agency was notified by the licensee that the state Fire Marshal determined the fire was an electrical short at a plug. Additional information will be provided as it is received IAW SA-300."
Notified R4DO (Drake) and NMSS_Events_Notification via email.
* * * UPDATE FROM ART TUCKER TO JOHN SHOEMAKER AT 1151 EST ON 1/24/17 * * *
The following update information was received from the State of Texas via email:
"On January 19, 2017, the Agency received the written report from the licensee. Due to the nature of this event, the information is being provided directly to the HOO [NRC Headquarters Operations Officer]. The report included the report from the device manufacturer. The manufacturer's report states that due to the heat the devices were exposed to, none of the QSA 880 devices should be used to perform radiography work. In addition, the type 'B' containers could not be used as transportation containers for radioactive materials. The report also stated 12 cameras were involved in the fire, but only 10 had sources in them. All of the devices will be disposed of. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Rollins) and NMSS_Events_Notification (via email).