Event Notification Report for September 10, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/09/2015 - 09/10/2015
Agreement State
Event Number: 51389
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: BRIGHTON State: CO
County:
License #: CO 902-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: JOHN SHOEMAKER
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: BRIGHTON State: CO
County:
License #: CO 902-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/11/2015
Notification Time: 16:07 [ET]
Event Date: 09/10/2015
Event Time: 17:45 [MDT]
Last Update Date: 09/11/2015
Notification Time: 16:07 [ET]
Event Date: 09/10/2015
Event Time: 17:45 [MDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - INDUSTRIAL RADIOGRAPHY CAMERA SOURCE DISCONNECT
The following report was received from the State of Colorado via email:
"Event description: The Department [Colorado Department of Public Health and Environment] received a phone report from [licensee] on 09/11/15, at 0906 [MST]. It was reported that a source disconnect occurred on 09/10/15, at about 1745. At that time, the licensee RSO [Radiation Safety Officer], went out and retrieved the source according to procedures for source retrieval. The source was successfully retrieved, and no over exposure was reported.
"The Department [Colorado Department of Public Health and Environment] is preparing for a visit to investigate the event and is expecting a full report from the licensee within 30 days. No reported over exposure from this event."
No additional information on the Radiography Camera or source strength is available at this time.
Event Report ID No.: CO15-I15-26
The following report was received from the State of Colorado via email:
"Event description: The Department [Colorado Department of Public Health and Environment] received a phone report from [licensee] on 09/11/15, at 0906 [MST]. It was reported that a source disconnect occurred on 09/10/15, at about 1745. At that time, the licensee RSO [Radiation Safety Officer], went out and retrieved the source according to procedures for source retrieval. The source was successfully retrieved, and no over exposure was reported.
"The Department [Colorado Department of Public Health and Environment] is preparing for a visit to investigate the event and is expecting a full report from the licensee within 30 days. No reported over exposure from this event."
No additional information on the Radiography Camera or source strength is available at this time.
Event Report ID No.: CO15-I15-26
Agreement State
Event Number: 51390
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: NOT PROVIDED
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NEW YORK STATE
HQ OPS Officer: DANIEL MILLS
Licensee: NOT PROVIDED
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NEW YORK STATE
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/11/2015
Notification Time: 16:41 [ET]
Event Date: 09/10/2015
Event Time: 00:00 [EDT]
Last Update Date: 09/11/2015
Notification Time: 16:41 [ET]
Event Date: 09/10/2015
Event Time: 00:00 [EDT]
Last Update Date: 09/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL TREATMENT DOSE LOWER THAN PRESCRIBED
The following was received from the State of New York via fax:
"A New York State licensee informed the Department [New York State Department of Rad Health] of a patient receiving HDR therapy being delivered a fractionated dose that differed from the prescribed fractionated dose by more than 50 percent. The written directive called for a vaginal treatment consisting of three fractions of 1050 cGy per fraction. The second of the three fractions was scheduled on September 10, 2015. Treatment began as planned with both the AU and the AMP at the console. After successful extension and retraction of the dummy source, it was noticed that treatment countdown time was increasing instead of decreasing. The source extension was in contradiction to the console, which indicated 'treatment terminated' although the source extension warning light was also activated near the console. Two AMPs engaged the Emergency-Stop, terminating the treatment and retracting the source to the shielded position. Surveys of the patient and the HDR unit verified that the source was returned to the shielded position. The HDR console indicated that 41.8 seconds had elapsed with source extended. The Patient received an estimated dose of 105 cGy. The patient was informed of the event and no further patients were treated that day.
"Electa was contacted and a service engineer arrived that same afternoon. He was unable to reproduce the fault condition. Electa is currently investigating the internal performance log of the unit. The physicist performed a complete QC and no aberrations were noted. The HDR unit seems to be performing properly. The last source exchange was on August 14, 2015. Source activity on 9/10/15 was approximately 8 curies."
New York event # NY-15-08
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 State of New York via fax:
"A New York State licensee informed the Department [New York State Department of Rad Health] of a patient receiving HDR therapy being delivered a fractionated dose that differed from the prescribed fractionated dose by more than 50 percent. The written directive called for a vaginal treatment consisting of three fractions of 1050 cGy per fraction. The second of the three fractions was scheduled on September 10, 2015. Treatment began as planned with both the AU and the AMP at the console. After successful extension and retraction of the dummy source, it was noticed that treatment countdown time was increasing instead of decreasing. The source extension was in contradiction to the console, which indicated 'treatment terminated' although the source extension warning light was also activated near the console. Two AMPs engaged the Emergency-Stop, terminating the treatment and retracting the source to the shielded position. Surveys of the patient and the HDR unit verified that the source was returned to the shielded position. The HDR console indicated that 41.8 seconds had elapsed with source extended. The Patient received an estimated dose of 105 cGy. The patient was informed of the event and no further patients were treated that day.
"Electa was contacted and a service engineer arrived that same afternoon. He was unable to reproduce the fault condition. Electa is currently investigating the internal performance log of the unit. The physicist performed a complete QC and no aberrations were noted. The HDR unit seems to be performing properly. The last source exchange was on August 14, 2015. Source activity on 9/10/15 was approximately 8 curies."
New York event # NY-15-08
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: 51385
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM JOHNSON
HQ OPS Officer: JEFF HERRERA
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM JOHNSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/10/2015
Notification Time: 11:35 [ET]
Event Date: 09/10/2015
Event Time: 08:31 [EDT]
Last Update Date: 09/10/2015
Notification Time: 11:35 [ET]
Event Date: 09/10/2015
Event Time: 08:31 [EDT]
Last Update Date: 09/10/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (R2DO)
SCOTT SHAEFFER (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 94 | Power Operation | 94 | Power Operation |
CONTRACT SUPERVISOR TESTED POSITIVE FOR ALCOHOL
"A contract supervisory employee had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
"The licensee has notified the NRC Resident Inspector."
"A contract supervisory employee had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
"The licensee has notified the NRC Resident Inspector."