Event Notification Report for April 03, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/02/2019 - 04/03/2019
Agreement State
Event Number: 53978
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL OPERATING COMPANY
Region: 3
City: BRILLIANT State: OH
County:
License #: 31201420000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: CARDINAL OPERATING COMPANY
Region: 3
City: BRILLIANT State: OH
County:
License #: 31201420000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/04/2019
Notification Time: 15:19 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2019
Notification Time: 15:19 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FIXED GAUGE MISSING SHUTTER
The following report was received via e-mail:
"On 4/3/19, during preparation to conduct maintenance on a coal chute, workers prepared to isolate a gauge from service to prevent worker exposure to the beam. It was discovered that the gauge was missing its isolation shutter. The RSO [Radiation Safety Officer] and plant personnel conducted an extensive search and investigation of the missing shutter, but it could not be located. A six-month physical inventory of the facilities devices was conducted on 3/26/19 and 3/27/19 and there was no notation of any problems with this gauge on the inventory sheets. The gauge involved is a Texas Nuclear Model 5189 with a 20 mCi Cesium-137 source.
"The RSO and job supervisor held a discussion and decided that they could use the shutter from another Model 5189 gauge in the vicinity. The second gauge is used in a continuously operating process line and would have the shutter open for operations. The area around the second gauge will have signage and barricades installed to safely mark the area if future work activities will take place in that location. The shutter from the second gauge was placed on the first gauge and it was tagged out for maintenance of the coal chute. The second gauge remains in the open position during operation of the second process line.
"The RSO contacted ThermoFisher Scientific and discovered that because of the age of the gauge, replacement parts could not be obtained. They were provided with a list of third-party service providers to assist with proper repair or removal and disposal of the gauge. The licensee will explore options and inform ODH [Ohio Department of Health] of the actions to be taken."
Ohio Item Number: OH190005
The following report was received via e-mail:
"On 4/3/19, during preparation to conduct maintenance on a coal chute, workers prepared to isolate a gauge from service to prevent worker exposure to the beam. It was discovered that the gauge was missing its isolation shutter. The RSO [Radiation Safety Officer] and plant personnel conducted an extensive search and investigation of the missing shutter, but it could not be located. A six-month physical inventory of the facilities devices was conducted on 3/26/19 and 3/27/19 and there was no notation of any problems with this gauge on the inventory sheets. The gauge involved is a Texas Nuclear Model 5189 with a 20 mCi Cesium-137 source.
"The RSO and job supervisor held a discussion and decided that they could use the shutter from another Model 5189 gauge in the vicinity. The second gauge is used in a continuously operating process line and would have the shutter open for operations. The area around the second gauge will have signage and barricades installed to safely mark the area if future work activities will take place in that location. The shutter from the second gauge was placed on the first gauge and it was tagged out for maintenance of the coal chute. The second gauge remains in the open position during operation of the second process line.
"The RSO contacted ThermoFisher Scientific and discovered that because of the age of the gauge, replacement parts could not be obtained. They were provided with a list of third-party service providers to assist with proper repair or removal and disposal of the gauge. The licensee will explore options and inform ODH [Ohio Department of Health] of the actions to be taken."
Ohio Item Number: OH190005
Agreement State
Event Number: 53979
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: LA PORTE State: TX
County:
License #: RAM-L01774
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ACUREN INSPECTIONS INC.
Region: 4
City: LA PORTE State: TX
County:
License #: RAM-L01774
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/04/2019
Notification Time: 16:50 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2019
Notification Time: 16:50 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE
The following report was received via e-mail:
"On April 4, 2019, the Agency was notified by the licensee that one of their radiography crews was unable to retract a source on April 3, 2019, when a jig on a ladder fell on the source tube. The crew contacted the RSO [Radiation Safety Officer]. The RSO, an authorized source retriever, reported to the temporary job site in approximately 20 minutes and retrieved the source.
"No member of the general public received an exposure from this event. No additional information has been provided. The radiographers were to be interviewed on April 4, 2019. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident: 9670
* * * UPDATE ON 4/5/2019 AT 1222 EDT FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following information was received via e-mail:
"On April 5, 2019, the licensee provided the following information. The device was a QSA 880D exposure device containing a 62 curie iridium-192 source. The highest exposure received from this event to any of the individuals involved was to the individual who retrieved the source. [The RSO] received 370 millirem whole body dose and his right hand received 350 millirem. No individual exceeded any exposure limits due to this event. The exposure device has been returned to the manufacturer for service and the guide tube has been taken out of service. Additional information will be provided as it is received in accordance with SA-300."
Notified the R4DO (Kozal) and NMSS Events Notification (via e-mail).
The following report was received via e-mail:
"On April 4, 2019, the Agency was notified by the licensee that one of their radiography crews was unable to retract a source on April 3, 2019, when a jig on a ladder fell on the source tube. The crew contacted the RSO [Radiation Safety Officer]. The RSO, an authorized source retriever, reported to the temporary job site in approximately 20 minutes and retrieved the source.
"No member of the general public received an exposure from this event. No additional information has been provided. The radiographers were to be interviewed on April 4, 2019. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident: 9670
* * * UPDATE ON 4/5/2019 AT 1222 EDT FROM ART TUCKER TO MARK ABRAMOVITZ * * *
The following information was received via e-mail:
"On April 5, 2019, the licensee provided the following information. The device was a QSA 880D exposure device containing a 62 curie iridium-192 source. The highest exposure received from this event to any of the individuals involved was to the individual who retrieved the source. [The RSO] received 370 millirem whole body dose and his right hand received 350 millirem. No individual exceeded any exposure limits due to this event. The exposure device has been returned to the manufacturer for service and the guide tube has been taken out of service. Additional information will be provided as it is received in accordance with SA-300."
Notified the R4DO (Kozal) and NMSS Events Notification (via e-mail).
Agreement State
Event Number: 53996
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: CATY NOLAN
Licensee: PIEDMONT HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: CATY NOLAN
Notification Date: 04/12/2019
Notification Time: 13:21 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/30/2020
Notification Time: 13:21 [ET]
Event Date: 04/03/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION OF Y-90 THERASPHERES
The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:
On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.
There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).
The licensee will follow-up with a formal report.
* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/29/20 AT 1553 EDT * * *
The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis.
The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment.
NMED Item: 190182
Notified R1DO (Schroeder) and NMSS Events Notification (email).
* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 EDT * * *
The state of Georgia has amended the original report and the update from 4/29/20 as follows:
-the prescribed dose was 122 Gy
-the delivered dose was 78.8 Gy
-the difference is 64.5 percent.
This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database.
Notified R1DO (Schroeder) and NMSS Events Notification (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.
The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:
On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.
There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).
The licensee will follow-up with a formal report.
* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/29/20 AT 1553 EDT * * *
The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis.
The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment.
NMED Item: 190182
Notified R1DO (Schroeder) and NMSS Events Notification (email).
* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 EDT * * *
The state of Georgia has amended the original report and the update from 4/29/20 as follows:
-the prescribed dose was 122 Gy
-the delivered dose was 78.8 Gy
-the difference is 64.5 percent.
This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database.
Notified R1DO (Schroeder) and NMSS Events Notification (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.