Event Notification Report for July 17, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/16/2018 - 07/17/2018
EVENT NUMBERS
53516535115351255486
Agreement State
Event Number: 53516
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County: LOS ANGELES
License #: 0059-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: BRIAN LIN
Licensee: PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK State: CA
County: LOS ANGELES
License #: 0059-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: BRIAN LIN
Notification Date: 07/19/2018
Notification Time: 02:04 [ET]
Event Date: 07/17/2018
Event Time: 10:00 [PDT]
Last Update Date: 07/19/2018
Notification Time: 02:04 [ET]
Event Date: 07/17/2018
Event Time: 10:00 [PDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)
AGREEMENT STATE REPORT - RECEIVED DOSE GREATER THAN PRESCRIBED DOSE
The following information was obtained from the state of California via email:
"A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am [PDT]. The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018."
California report no.: 5010-071718
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following information was obtained from the state of California via email:
"A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am [PDT]. The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018."
California report no.: 5010-071718
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Power Reactor
Event Number: 53511
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: KARA STACY
HQ OPS Officer: DONG HWA PARK
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: KARA STACY
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/17/2018
Notification Time: 17:01 [ET]
Event Date: 07/17/2018
Event Time: 13:38 [EDT]
Last Update Date: 07/17/2018
Notification Time: 17:01 [ET]
Event Date: 07/17/2018
Event Time: 13:38 [EDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAIL)
REBECCA NEASE (R2DO)
FFD GROUP (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Under Construction | 0 | Under Construction |
| 4 | N | N | 0 | Under Construction | 0 | Under Construction |
NON-LICENSED CONTRACT SUPERVISOR TESTS POSITIVE ON FITNESS FOR DUTY TEST
"At 1338 [EDT] on July 17, 2018, Southern Nuclear Operating Company (SNC) determined a contractor supervisor confirmed positive for a controlled substance during a random Fitness-for-Duty (FFD) test. The employee's unescorted access to the plant has been suspended. The Resident Inspector has been notified."
"At 1338 [EDT] on July 17, 2018, Southern Nuclear Operating Company (SNC) determined a contractor supervisor confirmed positive for a controlled substance during a random Fitness-for-Duty (FFD) test. The employee's unescorted access to the plant has been suspended. The Resident Inspector has been notified."
Agreement State
Event Number: 53512
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: BRIAN LIN
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: BRIAN LIN
Notification Date: 07/17/2018
Notification Time: 17:54 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2018
Notification Time: 17:54 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - TOTAL DOSE DELIVERED DIFFERED FROM PRESCRIBED DOSE BY GREATER THAN 20 PERCENT
The following information was received from the state of Wisconsin via email:
"On July 17, 2018, the licensee identified a medical event where the total dose delivered differed from the prescribed dose by 20 percent or more. The licensee implanted 83 seeds containing Pd-103 for prostate brachytherapy. The prescribed dose to the prostate was 125 Gy; the dose delivered was 96.25 Gy. The dose received by the prostate (D90) was 77 percent of the intended dose. The patient has been notified. The implant occurred on June 8, 2018, and post-implant dosimetry was completed on July 17, 2018. The department will perform a site investigation to determine the root cause of this medical event."
Event Report ID No.: WI180011
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 received from the state of Wisconsin via email:
"On July 17, 2018, the licensee identified a medical event where the total dose delivered differed from the prescribed dose by 20 percent or more. The licensee implanted 83 seeds containing Pd-103 for prostate brachytherapy. The prescribed dose to the prostate was 125 Gy; the dose delivered was 96.25 Gy. The dose received by the prostate (D90) was 77 percent of the intended dose. The patient has been notified. The implant occurred on June 8, 2018, and post-implant dosimetry was completed on July 17, 2018. The department will perform a site investigation to determine the root cause of this medical event."
Event Report ID No.: WI180011
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: 55486
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: Earthwork Engineering Group
Region: 4
City: Albuquerque State: NM
County:
License #: NM-DM-378-10
Agreement: Y
Docket:
NRC Notified By: Michael Ortiz
HQ OPS Officer: Brian Lin
Licensee: Earthwork Engineering Group
Region: 4
City: Albuquerque State: NM
County:
License #: NM-DM-378-10
Agreement: Y
Docket:
NRC Notified By: Michael Ortiz
HQ OPS Officer: Brian Lin
Notification Date: 09/24/2021
Notification Time: 10:24 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/24/2021
Notification Time: 10:24 [ET]
Event Date: 07/17/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/22/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE
The following information was received via email:
"Earthwork Engineering Group (EEG) reported the loss and recovery of a moisture/density gauge (Seaman Nuclear model C-300, serial #21279) that contained a 1.48 GBq (40 mCi) Am-Be source (AEA Technologies model AMNV.997) and a 0.333 GBq (9 mCi) Cs-137 source (AEA Technologies model CDC.800).
"An EEG employee was contacted by personnel at a job site (believed to be a city inspector) in Albuquerque, New Mexico, on 7/17/2018. The EEG employee was informed that a gauge was left at the job site. The gauge had apparently fallen off the back of the truck. The employee immediately returned to the job site, secured the gauge, and placed it in the shipping container.
"The gauge was out of EEG's control for between 20 and 30 minutes. The gauge was inspected for cracks and leaks. No damage was observed. The employment of the involved employee was terminated for not securing the gauge as trained."
NMED Item No.: 180513
EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE
The following information was received via email:
"Earthwork Engineering Group (EEG) reported the loss and recovery of a moisture/density gauge (Seaman Nuclear model C-300, serial #21279) that contained a 1.48 GBq (40 mCi) Am-Be source (AEA Technologies model AMNV.997) and a 0.333 GBq (9 mCi) Cs-137 source (AEA Technologies model CDC.800).
"An EEG employee was contacted by personnel at a job site (believed to be a city inspector) in Albuquerque, New Mexico, on 7/17/2018. The EEG employee was informed that a gauge was left at the job site. The gauge had apparently fallen off the back of the truck. The employee immediately returned to the job site, secured the gauge, and placed it in the shipping container.
"The gauge was out of EEG's control for between 20 and 30 minutes. The gauge was inspected for cracks and leaks. No damage was observed. The employment of the involved employee was terminated for not securing the gauge as trained."
NMED Item No.: 180513