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Event Notification Report for November 3, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/02/2015 - 11/03/2015

** EVENT NUMBERS **


51493 51499 51510

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Agreement State Event Number: 51493
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: VILLE PLATTE MEDICAL CENTER, LLC
Region: 4
City: VILLE PLATTE State: LA
County:
License #: LA-2956-L01,
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/23/2015
Notification Time: 13:06 [ET]
Event Date: 10/16/2015
Event Time: 12:00 [CDT]
Last Update Date: 10/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT DOSED WITH WRONG ORGAN UPTAKE TAG

The following information was received from the state of Louisiana via email:

"On October 19, 2015, the Radiology/Nuclear Medicine Manager, reported that on October 16, 2015 at 1200 hours, a PRN Licensed Nuclear Medicine Tech inadvertently dosed a patient with 25 mCi of Tc-99-MDP. The error was detected shortly after administration. The patient had physician's orders to have a cardiac scan utilizing 25 mCi of Tc-99-Tetrofosmin. The isotope activity was correct. However, the organ uptake tag was incorrect.

"The error resulted from the Nuclear Medicine Tech not using the patient two identifiers before administering the unit dose. The activity was correct for the unit dose, but the organ uptake tag was different.

"The facility employees were off and a PRN Tech was filling-in on that Friday. This Tech is used at the facility frequently when an essential employee is absent. He is no stranger to the work environment of the Facility/Licensee.

"The source was a 25 mCi Tc-99 unit dose. He performed the receipt procedures, unit dose assay, and utilized procedures to administer the isotope, but did not cross-reference the name on the unit dose with the individual who received the injection.

"This site is a Medical Institution. The unit doses are kept in a locked 'HOT' lab in the Nuclear Medicine Department. KLS Physics Consultants was called in the help with the reporting requirements.

"The Tech was counselled and retrained in the facility's procedures for patient identification and administration of radioactive materials for human in vivo imaging.

"The patient will receive the correct unit dose and scan, 25 mCi Tc-99-Tetrofosmin, for a cardiac scan at a later date."

Event Report ID No.: LA-150018, T166800

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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Agreement State Event Number: 51499
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: QSA GLOBAL, INC.
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-5934-L01 A
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/26/2015
Notification Time: 19:38 [ET]
Event Date: 10/26/2015
Event Time: [CDT]
Last Update Date: 10/26/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

NUCLEAR DENSITY GAUGE POTENTIALLY DAMAGED DURING SHIPMENT

The following report was provided by the Louisiana Department of Environmental Quality via email:

"On 10/26/2015, [The] RSO [Radiation Safety Officer] / Technical Service Manager for QSA Global notified the LDEQ [Louisiana Department of Environmental Quality] about an incident where a [common carrier] delivered a device containing radioactive material to their facility on Langley Dr., Baton Rouge, LA. When the receipt surveys were being performed, they noticed at one point on the surface they had a reading of 2 R/hr at the surface. It appears that one or more of the pull ties used to secure the shutters on the device broke causing a shift in the shielding. Part of the bracing material minimized the shielding shift.

"The device in question is a Texas Nuclear level/density gauge, Model # 5210, SN B1110, loaded with [approximately] 733 mCi of Co-60 sealed source. The origin of the shipment was Puerto Ordaz, EDO Bolivar, Venezuela. It came stateside via [common carrier] to Houston, TX and then to the QSA Global facility in Baton Rouge, LA by [common carrier]. The shipment arrived [at approximately] 1145 [CDT] on 10/26/2015. The activity is below Cat 2 quantities at [approximately] 733 mCi of Co-60.

"The device was surveyed and moved to a bunker on the QSA Global site. Re-enactments and calculations will be conducted on 10/27/2015 AM when [the RSO] is present. The LDEQ personnel will be on site for the measurements, calculations and follow-up information [dissemination].

"This is a preliminary notification of an incident reported to LDEQ [at approximately] 1530 [CDT]. After the source was secure, safe and locked in a bunker at the QSA Global Baton Rouge, LA facility. Possible exposure calculations will be determined from the reconstruction of events.

"The Baton Rouge facility is compliant for the IC [Increased controls] principles and Radiation Safety procedures/aspects for the receipt activities. The Department, LDEQ personnel will be on site for the corrective actions and calculations. The NRC, Region IV, was made aware of this situation on 10/26/2015. Follow-up information will be [disseminated] when available.

"This is being reported as a preventive and protection action under 10 CFR Part 30.50(a).

"Information will be updated when available. LDEQ considers this incident still open."

Event Report ID No.: LA-150019

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Power Reactor Event Number: 51510
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: THOMAS JONES
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/02/2015
Notification Time: 09:20 [ET]
Event Date: 11/02/2015
Event Time: 09:20 [EST]
Last Update Date: 11/02/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)

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 100 Power Operation 100 Power Operation

Event Text

LOSS OF RADIATION MONITORING EQUIPMENT DUE TO PLANNED MAINTENANCE

"A planned modification at Calvert Cliffs Nuclear Power Plant will remove the Spent Fuel Pool Area Radiation Monitoring system from service. The planned out of service window is expected to be 7 weeks, beginning 11/02/15 and ending 12/18/2015. During this time portable radiation monitors will be installed as compensatory measures to monitor and support timely and accurate EAL declarations. Affected Emergency Response Organization personnel have been made aware of the compensatory measures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a planned event that affects Emergency Preparedness Assessment Capability for greater than 72 hours. An update will be provided once the Spent Fuel Pool Area Radiation Monitoring system is restored to normal operation."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, November 03, 2015
Tuesday, November 03, 2015