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Event Notification Report for September 29, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/28/2017 - 09/29/2017

** EVENT NUMBERS **


52979 52981 52982 52983

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Agreement State Event Number: 52979
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: ATLANTA State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/19/2017
Notification Time: 10:38 [ET]
Event Date: 08/24/2017
Event Time: [EDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED 20% GREATER THAN PRESCRIBED AND GREATER THAN 50 REM TO THE TARGETED AREA

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

"Emory University had new software installed for their HDR on 2/2/2016. During the time span of 3/2016 through 6/2017 [five] 5 patients received doses that were greater than 20% [percent] and greater than 50 rem to the targeted area. The misadministration was due to a software defect with Elekta's Oncentra Brachy Software version 4.5.2. using the ring applicator. The licensee was only aware of the defect on Aug 22, 2017 when Elekta notified all of their customers of the defect. Emory unofficially notified the State of Georgia on Aug 24, 2017 of a possibility that several of their patients may have been involved in a medical event. The medical event was confirmed on Sept 19, 2017 that [five] 5 patients were involved in a medical event.

"Cause and Corrective Actions: The events were due to a software issue utilizing the Oncentra Brachy Software version 4.5.2. A misadministration occurred due to an inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size.

"Device/Associated Equipment: Oncentra Brachy Software version 4.5.2. in a Elekta Nucleotron MicroSelection v3 HDR using a ring applicator."

The targeted area that received the greater than 50 rem was the tissue of the upper vaginal wall.

The defect in the equipment is identified and described in EN #52922.

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: 52981
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: WELDING TESTING X-RAY, INC.
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-3266-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/20/2017
Notification Time: 16:39 [ET]
Event Date: 09/20/2017
Event Time: [CDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GRETCHEN RIVERA-CAPE (NMSS)

Event Text

AGREEMENT STATE REPORT - POTENTIAL TEDE EXPOSURE IN EXCESS OF 25 REM

Louisiana Department of Environmental Quality called to report a potential overexposure.

Welding Testing X-Ray, Inc., contacted Louisiana Department of Environmental Quality to report an irregular excessive whole body badge exposure for a radiographer. The badge was for August 2017 reporting period of August 1 through 31, 2017. The whole body badge exposure reflected 754 rem.

This individual worked as part of a two man crew at various jobsites. All of the other crew members readings were within the expected range for typical trained radiographers. The individual was advised to contact REAC/TS [Radiological Emergency Assistance Center / Training Site] in Oak Ridge, TN for blood testing and cytogenetic testing. The individual did not exhibit any skin irritations or other signs of radiation sickness.

The licensee is investigating the exposure. Louisiana State advised the licensee to remove the individual from radiation work until the issue is resolved.

Event Report ID No.: LA-2017-0015

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Agreement State Event Number: 52982
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GPD GEOTECHNICAL SERVICE, LLC
Region: 3
City: AKRON State: OH
County:
License #: 31210780024
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: KARL DIEDERICH
Notification Date: 09/20/2017
Notification Time: 16:03 [ET]
Event Date: 09/15/2017
Event Time: [EDT]
Last Update Date: 09/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following information was received via e-mail from the state of Ohio:

"On 9/15/17 at approximately 11:15 AM, the Ohio Department of Health (ODH) was notified by GPD Geotechnical Service, LLC. that a portable gauging device (CPN Model MC-1-DRP which contained a 10 mCi Cesium-137 source and 50 mCi Americium-241:Be source) had been run over and that the device had sustained heavy damage to the casing and the source handle was broken off. The gauging device was run over by a piece of construction equipment at their jobsite located at 225 Elyria Street, Lodi, OH 44254.

"An ODH inspector, responded to the location of the incident and was met by the licensee's RSO. The inspector was lead to the gauging device which had been surveyed and had been determined to have no abnormal radiation readings and that both radioactive sources were intact and properly secured with in the device. The device was secured in its transportation case and placed in the field technician's vehicle. The inspector also conducted a wipe test with no abnormal readings observed.

"In an interview with the field technician the inspector determined that the technician was approximately 10 to 15 feet away from the device but did not have direct line of site to the device as it was partially obstructed due to the construction equipment. It was also observed by the inspector that the equipment operator's view of the gauging device was obstructed due to the configuration of the equipment and the proximity in which the device was placed on the ground in front of the equipment.

"Licensee's leak test showed no removable contamination and the device has been sent to a service provider for repair."

Item Number: OH170005.

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Agreement State Event Number: 52983
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: TERRACON CONSULTANTS, INC.
Region: 1
City: COLUMBIA State: SC
County:
License #: 688
Agreement: Y
Docket:
NRC Notified By: ANDREW M. ROXBURGH
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2017
Notification Time: 12:13 [ET]
Event Date: 09/21/2017
Event Time: 08:59 [EDT]
Last Update Date: 09/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE AT CONSTRUCTION SITE

The following report was received from the South Carolina Department of Health and Environmental Control via email:

"The licensee notified the Department [South Carolina Department of Health and Environmental Control] that a piece of heavy equipment backed over a Instrotek Model 3500 moisture density gauge serial number 2323. The gauge contained 10 mCi of Cs-137 and 40 Ci of Am-241:Be. The gauge operator had contacted his RSO [Radiation Safety Officer] at the time of the incident. The BRH [Bureau of Radiation Health] inspector arrived on scene. The gauge was surveyed and tested for removable contamination. The highest reading found was on the bottom of the gauge at the shutter. The shutter was in the closed position. The reading was 15 mR/hr which is consistent with the radiation profile identified in SSD NC-1241-D-101-S. There was no removable contamination found."

Page Last Reviewed/Updated Friday, September 29, 2017
Friday, September 29, 2017