Event Notification Report for August 09, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/08/2019 - 08/09/2019
Agreement State
Event Number: 54210
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: THEDACARE REGIONAL MEDICAL CENTER - APPLETON
Region: 3
City: APPLETON State: WI
County:
License #: 087-1014-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: CATY NOLAN
Licensee: THEDACARE REGIONAL MEDICAL CENTER - APPLETON
Region: 3
City: APPLETON State: WI
County:
License #: 087-1014-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: CATY NOLAN
Notification Date: 08/09/2019
Notification Time: 14:54 [ET]
Event Date: 08/09/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2019
Notification Time: 14:54 [ET]
Event Date: 08/09/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE TO PATIENT
The following was received from the Wisconsin Radiation Protection Section via email:
"On 8/9/19, the Department [State of Wisconsin Department of Health Services] was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit."
The patient will be notified.
Wisconsin Event Report ID: WI190009
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 was received from the Wisconsin Radiation Protection Section via email:
"On 8/9/19, the Department [State of Wisconsin Department of Health Services] was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit."
The patient will be notified.
Wisconsin Event Report ID: WI190009
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.
Non-Agreement State
Event Number: 54207
Rep Org: NVI
Licensee: NVI
Region: 4
City: GRADE State: LA
County:
License #: 17-29410-01
Agreement: Y
Docket:
NRC Notified By: KEITH GRIFFIN
HQ OPS Officer: OSSY FONT
Licensee: NVI
Region: 4
City: GRADE State: LA
County:
License #: 17-29410-01
Agreement: Y
Docket:
NRC Notified By: KEITH GRIFFIN
HQ OPS Officer: OSSY FONT
Notification Date: 08/09/2019
Notification Time: 10:09 [ET]
Event Date: 08/09/2019
Event Time: 07:25 [CDT]
Last Update Date: 08/09/2019
Notification Time: 10:09 [ET]
Event Date: 08/09/2019
Event Time: 07:25 [CDT]
Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
LOST RADIOGRAPHY CAMERA IN INTERNATIONAL WATERS
The following is a summary of a phone call from the licensee:
NVI (Non-Destructive and Visual Inspections) notified the NRC that a radiography camera with a less than 22 Ci Ir-192 source was lost when it fell into approximately 200 feet of international waters from an oil platform in South Pass Section 60-A. The camera (SPEC 150 Model 0605; Source SPEC G-60 S/N AC0160) was locked in the shielded position during setup when the radiographer slipped. The licensee does not plan to retrieve the device.
Additionally, the licensee notified NRC R-IV and the Bureau of Safety and Environmental Enforcement.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
The following is a summary of a phone call from the licensee:
NVI (Non-Destructive and Visual Inspections) notified the NRC that a radiography camera with a less than 22 Ci Ir-192 source was lost when it fell into approximately 200 feet of international waters from an oil platform in South Pass Section 60-A. The camera (SPEC 150 Model 0605; Source SPEC G-60 S/N AC0160) was locked in the shielded position during setup when the radiographer slipped. The licensee does not plan to retrieve the device.
Additionally, the licensee notified NRC R-IV and the Bureau of Safety and Environmental Enforcement.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)