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Event Notification Report for June 6, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/05/2014 - 06/06/2014

** EVENT NUMBERS **


50146 50148 50175

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Agreement State Event Number: 50146
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: WELDING TESTING SERVICES
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-3266-LO1
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: VINCE KLCO
Notification Date: 05/28/2014
Notification Time: 16:39 [ET]
Event Date: 05/28/2014
Event Time: 06:50 [CDT]
Last Update Date: 05/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME RESOURCES (EMAI)
BARRY WRAY (ILTA)
WILLIAM GOTT (IRD)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT- LOST AND FOUND LICENSED MATERIAL

The following information was received from the State of Louisiana by facsimile:

"Event Location: The radiography crew was at the MARATHON PETROLEUM COMPANY REFINERY, 4663 West Airline Highway, Garyville, LA, St. John the Baptist Parish. The crew was in the refinery to do radiography weld testing. The weather for the day was stormy and raining. The crew was in the vehicle waiting out the weather when a tornado ripped the darkroom off of the company vehicle and took the camera and source with the
darkroom.

"Event type: The lost/found gamma camera is an AMERSHAM, MODEL 880 DELTA, S/N4045 exposure device housing 39 Ci of Ir-192 AEA Technology sources, Model #A424-9, S/N # 1040C.

"The camera was located within the refinery boundary and appeared to be undamaged and the source remained in the shielded area. The camera was surveyed and only background radiation levels were detected. The camera was then transported to QSA Global on Langley Dr. in Baton Rouge, LA for leak tests, radioactive source and DU [Depleted Uranium] mechanical evaluation. [QSA Global] stated the device would be disassembled for the evaluation. If the results of the evaluation are negative, the equipment will be removed from service. The leak test results for radiation and DU were negative for removable contamination.

"Notifications: LDEQ [Louisiana Department of Environmental Quality] was notified of the lost/found radiography source in a QSA Global, Amersham Delta 880 gamma camera/source holder housing a 39 Ci Ir-192 source. The source exposure device was located within the refinery boundary. After a field evaluation, the exposure device was moved to QSA Global in Baton Rouge, LA for a professional mechanical evaluation. The results of the evaluation will determine if this equipment will be returned to service or remain out of service.

"Event Description: On May 28, 2014, [a senior trainer and business ops manager] called LDEQ and reported that a radiography crew dispatched to the Marathon Refinery in Garyville, LA had been hit by a tornado on the jobsite. The incident was at the Marathon Refinery, 4663 West Airline Highway in Garyville, LA. The tornado ripped the darkroom off of the truck with the gamma camera in the darkroom. After the storm had passed, the crew and the Marathon RSO surveyed the area in an attempt to locate the radiography source. The source and exposure device were located, field test/inspected for damage and radioactive contamination. When the equipment was deemed safe, it was transferred to QSA Global for a professional mechanical evaluation.

"ALL EQUIPMENT AND PERSONNEL APPEAR TO BE SAFE AND UNHARMED.

"LDEQ CONSIDERS THIS EVENT CLOSED."

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 50148
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: CANCER TREATMENT CENTERS OF AMERICA
Region: 1
City: NEWNAN State: GA
County:
License #: GA 1632-1
Agreement: Y
Docket:
NRC Notified By: DAVID CROWLEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/29/2014
Notification Time: 12:54 [ET]
Event Date: 05/27/2014
Event Time: [EDT]
Last Update Date: 05/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
FSME RESOURCES (E-MA (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL OVERDOSE

The following report was received via e-mail:

"Georgia Radioactive Materials Program (GA RMP) received a report yesterday (5/28/2014) of a medical event involving Nordion Y-90 TheraSpheres. The event occurred on 5/27/2014 at Cancer Treatment Centers of America (license #: GA 1632-1) - 600 Parkway North, Newnan GA 30265. GA RMP is tracking this under complaint number: 73962.

"GA RMP was notified on 5/28/2014 by the facility's RSO. The event was discovered after treatment while verifying dose delivered to dose prescribed. At that point it was noticed that the doctor had prescribed a 20% reduction for the patient than what is considered the treatment standard. The patient received 35.31 mCi of TheraSpheres as opposed to the physician prescribed amount of 26.73 mCi. The activity delivered deviated by ~32%. The dose consequence to the tumor was 65.32 Gy as opposed to the written directive's 49.45 Gy. The tumor was located in the patient's liver. Finally, the patient was notified of the overdose by the physician.

"The facility determined that the problem occurred in the treatment planning review process. The nuclear medicine technician performed the treatment plan review but verified with the standard treatment dose as opposed to the doctor prescribed dose. The facility is proposing a two person calculation sheet review for a corrective action in the future to avoid these sort of oversights. GA RMP will work with the facility to ensure these actions are sufficient to prevent reoccurrence.

"It is worth mentioning that other than delivering the wrong dose, there were no complications with the procedure. No shunting issues, unintended organs dosed, equipment malfunctions, or contaminations occurred.

"No outside agency notifications have been made other than this notification. GA RMP is responding at this time via telephonic investigation unless any additional doubt is raised on this event. We will follow up with more details and information to NMED as they become available."


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.

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Power Reactor Event Number: 50175
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JOHN LAUDENBACH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/05/2014
Notification Time: 17:20 [ET]
Event Date: 06/05/2014
Event Time: 16:01 [CDT]
Last Update Date: 06/05/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 89 Power Operation 89 Power Operation

Event Text

DISCHARGE CANAL RADIATION MONITORS REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"Planned preventive maintenance will render the discharge canal radiation monitors inoperable for both A and B trains. As a result, this represents a loss of emergency assessment capability and is reportable under 10 CFR 50.72 (b)(3)(xiii). The planned maintenance is expected to last two hours. During this time, the site Chemistry Department will be perform sampling as a compensatory measure. The health and safety of the public remains protected as the plant is operating in a normal condition.

"The NRC Resident Inspector was notified prior to removing the discharge canal radiation monitors from service."

Page Last Reviewed/Updated Friday, June 06, 2014
Friday, June 06, 2014