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Event Notification Report for May 5, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/04/2016 - 05/05/2016

** EVENT NUMBERS **


51883 51884 51888 51907

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Agreement State Event Number: 51883
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: CLINICAL PHARMACY SERVICES, INC.
Region: 1
City: GRAY State: TN
County:
License #: TN-16-059
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/26/2016
Notification Time: 12:16 [ET]
Event Date: 04/25/2016
Event Time: 03:45 [CDT]
Last Update Date: 04/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
ANGELA MCINTOSH (NMSS)

Event Text

AGREEMENT STATE REPORT - RELEASE OF LICENSED MATERIAL AND CONTAMINATION

The following information was obtained from the State of Tennessee via email:

"The Tennessee Division of Radiological Health received a call at 1350 CDT on 4/25/2016 from a consultant for Clinical Pharmacy Services in Gray, Tennessee. He stated that a vial containing 290 milliCuries of stabilized Iodine-131 had been dropped in the pharmacy onto the floor. The vial broke, splattering the liquid onto two pharmacists and objects in the room. Employees were stripped of their clothing. Thyroid count results are zero for both individuals. The Iodine-131 had been stabilized with a buffering agent making it non-volatile. Plastic sheeting and thick pieces of lead were placed over the contaminated areas. All personnel badges were overnighted to Landauer. The corporate compliance officers for Clinical Pharmacy were contacted and will arrive today. The consultant stated that the maximum dose rate at the point where the vial hit the floor was 66 mR/hr. through the lead sheeting. He stated a dose rate at 6 to 7 R/hr. Personnel were placing surface contaminated objects into a large leaded disposal bin."

Tennessee Report No.: TN-16-059

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Agreement State Event Number: 51884
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GEORGIA PACIFIC
Region: 1
City: CEDAR SPRINGS State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: YOSHIKA EASON
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/26/2016
Notification Time: 16:12 [ET]
Event Date: 04/21/2016
Event Time: 00:00 [EDT]
Last Update Date: 04/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN

The following report was received from the State of Georgia via email:

"On Tuesday, April 26, 2016 our department [Georgia Department of Natural Resources, Radioactive Materials Program] received a report from GA Pacific, Cedar Springs, Georgia, that the shutters were stuck in the open position on a Kay Ray fixed gauge with 2000 mCi of Cs-137 and a Berthold fixed gauge with 30 mCi of Cs-137. Georgia Pacific maintenance personnel were doing a 6 month service check and realized that the shutters would not close. The incident occurred on 4/21/16. On 4/22/16, [the licensee RSO] received the report and was trying to determine reporting requirements. On 4/25/16, [the RSO determined] that they needed to do a notification report but our office was closed. Our department was notified on 4/26/16. Tag devices are being used but work cannot be performed around the area near the tank/pipeline. Berthold has been contacted but Kay Ray is out of business. A complaint has been opened in CTS [Complaint Tracking System] and our office has an ongoing investigation."

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Non-Agreement State Event Number: 51888
Rep Org: SPECTRUM HEALTH
Licensee: SPECTRUM HEALTH
Region: 3
City: GRAND RAPIDS State: MI
County:
License #: 21-00243-06
Agreement: N
Docket:
NRC Notified By: EVAN BOOTE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/27/2016
Notification Time: 17:09 [ET]
Event Date: 04/27/2016
Event Time: 14:05 [EDT]
Last Update Date: 04/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - DOSE GIVEN TO INCORRECT SEGMENT OF THE LIVER

During a Y-90 TheraSphere treatment (hepatocellular carcinoma) to the right lobe of the liver segments 5, 6, 7, and 8 (estimated volume of 1290 ml), the catheter moved and the dose was actually given to medial segment 4 (estimated volume of 330 ml). The prescribed dose was 120 Gy (3.3 GBq) and the delivered dose was approximately 118.5 Gy as determined by bremmstrahlung imaging. Segment 4 was previously treated and there was some residual cancer at this location. This dose is not expected to have detrimental effects on the patient.

It is anticipated that segments 5,6,7,8 will be treated at some future time.

The patient has been notified and the prescribing physician will be notified.

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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Part 21 Event Number: 51907
Rep Org: ROTORK CONTROLS, INC.
Licensee: JOHNSON ELECTRIC
Region: 1
City: ROCHESTER State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PATRICK SHAW
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/04/2016
Notification Time: 14:56 [ET]
Event Date: 01/25/2016
Event Time: [EDT]
Last Update Date: 05/04/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
FRED BOWER (R1DO)
MIKE ERNSTES (R2DO)
NICK VALOS (R3DO)
JOHN KRAMER (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - ANOMALY RELATED TO MICRO SWITCHES

The following report was received via email:

"Based on test data, Rotork believes an unsafe condition may exist as defined under 10 CFR 21. The adhesive formulation used for the construction of V12 and K5 safety related micro switches was altered by the switch maker's sub-supplier. K5 switches have no reported failures, but are affected because of construction. The altered adhesive formulation outgases an insulating material at elevated temperatures, which coats the switch contacts as it cools and can prevent the conduction of electricity."

Page Last Reviewed/Updated Thursday, May 05, 2016
Thursday, May 05, 2016