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Event Notification Report for May 2, 2017

U.S. Nuclear Regulatory Commission
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Event Reports For
05/01/2017 - 05/02/2017

** EVENT NUMBERS **


52703 52704

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Agreement State Event Number: 52703
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MEDICAL UNIVERSITY OF SOUTH CAROLINA
Region: 1
City: CHARLESTON State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/21/2017
Notification Time: 14:37 [ET]
Event Date: 04/20/2017
Event Time: [EDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE LESS THAN PRESCRIBED DOSE

The following information was provided by the State of South Carolina via email:

"On April 21, 2017, the licensee provided notification of a medical event that occurred on April 20, 2017. The licensee stated that a patient was administered a dose of Y-90 SIR-Spheres for treatment of a liver tumor. During the treatment process, the tubing used to administer the SIR-Spheres became clogged, and the full dose could not be administered. The prescribed dose for the patient was 120 Gy. The dose delivered to the patient was 90 Gy. The licensee indicated that the required written report detailing the event is being completed, and will be submitted to the Department [South Carolina Department of Health and Environmental Control] within the next few days. Updates to this event will be made through the NMED system."

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: 52704
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP, INC.
Region: 4
City:  State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/21/2017
Notification Time: 17:05 [ET]
Event Date: 04/20/2017
Event Time: 12:30 [CDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNSECURED RADIOGRAPHY CAMERA

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

"Event type: The source/exposure device, a QSA Global 880D s/n # D11837 loaded with 86.7 Ci Ir-192 source s/n #53959G, was left in an unlocked transport buggy and left unattended while the crew took a work break and moved to another work location at the site. Three crew members were in the area, but could not maintain surveillance of the unsecured source. The Bechtel Safety Officer walked up to the transport vehicle and observed the exposure device not secured or locked in the transport vehicle and the Mistras personnel did not have direct surveillance of the transport vehicle. The source incident was reported to the Mistras Group's RSO. Human error, operator distracted.

"Notifications: LDEQ [Louisiana Department of Environmental Control] was notified directly by [the Mistras Group's RSO] to an inspector during office hours approximately 1600 [CDT] on 04/20/2017.

"Event description: On 04/20/2017, approximately 1230 [CDT], the Bechtel Safety Office, BSO, made a site visit to where a Mistras Group crew was working on a liquid natural gas pipeline in Cameron Parish. The BSO observed an exposure device in an unlocked and unattended Mistras vehicle. The Mistras crew was working at this temporary jobsite and moved to help another crew member working at the site. The crew became distracted and left the vehicle unattended and unlocked. The BSO contacted the Mistras RSO about the incident. [The Mistras RSO] investigated and reported the incident to LDEQ. The incident was under control with no possible radiation exposures to the crew members or the general public.

"A LDEQ investigator was contacted to follow-up on the report."

Event Report ID No.: LA-17005.

Page Last Reviewed/Updated Tuesday, May 02, 2017
Tuesday, May 02, 2017