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Event Notification Report for January 25, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/24/2018 - 01/25/2018

** EVENT NUMBERS **


53168 53169 53171 53172 53177

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Agreement State Event Number: 53168
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/16/2018
Notification Time: 21:14 [ET]
Event Date: 01/05/2018
Event Time: [CST]
Last Update Date: 01/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

The following was received from the State of Wisconsin via email:

"An email the department received on January 5, 2018 was believed to be an update to the previous notification [EN #53148]. Upon further review by the department, it was discovered that the email pertained to a second medical event identified by the licensee on January 5, 2018. This was a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 70 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 48% of the intended dose. The licensee has an additional criterion that the volume of the CTV to which 100% of the prescription dose delivered must be above 80%. The licensee determined only 62% of the volume received the required dose.

"The implant was initially performed on November 10, 2017. A post implant CT scan was performed on December 14, 2017. The physician completed the contour for the dosimetrist to run a Post Seed Plan on January 3, 2018. The dosimetrist notified the physicist of a possible medical event on January 5, 2018.

"DHS is investigating and will be performing a site visit in regards to this event."

Wisconsin Event Report ID: WI180002

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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Non-Agreement State Event Number: 53169
Rep Org: RADIATION SAFETY ASSOCIATES, INC
Licensee: ULBRICH STAINLESS STEELS AND SPECIAL METALS, INC.
Region: 1
City: WALLINGFORD State: CT
County:
License #: 06-12357-01
Agreement: N
Docket:
NRC Notified By: PAUL STEINMEYER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/17/2018
Notification Time: 11:13 [ET]
Event Date: 01/16/2018
Event Time: 14:00 [EST]
Last Update Date: 01/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

NUCLEAR INSTRUMENT WITH RADIOACTIVE SOURCE DISPOSED OF IN LOAD OF SCRAP METAL - RECOVERED

A load of scrap metal was returned by the recycler to the originator (Ulbrich Stainless Steels and Special Metals, Inc.) after their radiation detector alarmed on the load of metal. After arriving back at Ulbrich, the load was checked and a Dickey-John Dewpointer instrument containing a 7 microCurie Radium-226 source was found.

The Dewpointer instrument is believed to have been purchased by Ulbrich more than 20 years ago. The Dewpointer instrument had no stickers or warning labels indicating that it contained a radioactive source. The Dewpointer instrument had been surplused and tossed in the trash.

The Dewpointer instrument is currently in the possession of Radiation Safety Associates, Inc. (license number: 06-30007-01). Ulbrich has taken responsibility for assuring proper disposal of the instrument.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53171
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: KAISER FOUNDATION HOSPITAL
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90464
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: DAVID AIRD
Notification Date: 01/17/2018
Notification Time: 16:45 [ET]
Event Date: 01/15/2018
Event Time: [PST]
Last Update Date: 01/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

On January 15, 2018 a medical event occurred at the licensed facility in which a patient received a prescribed dose less than 80 percent of the target dose to the liver. The dose was delivered via Y-90 microspheres.

The State will investigate this medical event.

* * * UPDATE FROM DARYL LEON TO HOWIE CROUCH VIA EMAIL AT 1616 EST ON 1/19/18 * * *

"On January 15, 2018, a patient was prescribed a dose of 130 Gy (2.789 GBq) for the left lobe of the liver involving two dose vials of Y-90 MDS Nordion TheraSphere microspheres. The first dose vial was administered without issue. The second dose vial was then primed and prepped as normal, however, a train of bubbles was noted in the line between the dose vial and the patient prior to administration. Due to the proximity of gastric artery relative to point of administration and the possibility that the bubbles could cause the flow to reflux into this artery (which could permanently damage the stomach), the AU [Authorized User] determined the best course of action was not to administer the second dose vial. The therapy procedure was then halted and rescheduled to complete on Thursday, January 18th.

"The administered dose was 84.9 Gy (1.760 GBq) to the left lobe of the liver. The dose was therefore 65% of the prescribed dose, a 35% difference. The difference between the prescribed and administered dose to the liver is 45.1 Gy (4510 rem). Therefore, the dose administered exceeds +/- 20% of prescribed dose and differs from the prescribed dose by more than 50 rem to an organ (liver).

"The referring physician has been notified as well as the patient.

"This event was reported to the Oregon Agreement State program on January 16, 2018.

"The licensee has removed all Y-90 therapy tubing sets from the same lot number for return and analysis by the vendor. Tubing sets from a different lot number were provided to interventional radiology for future cases."

Notified R4DO (Proulx) and NMSS Events Resource (email).

State Event Report ID No.: OR-18-0001

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: 53172
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: AS METALS
Region: 4
City: CASTROVILLE State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: DAVID AIRD
Notification Date: 01/17/2018
Notification Time: 19:42 [ET]
Event Date: 01/12/2018
Event Time: [PST]
Last Update Date: 01/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - GAUGE WITH RADIOACTIVE SOURCE DISPOSED OF IN LOAD OF SCRAP METAL - RECOVERED

The following information was received from the State of California via E-mail:

"The California Radiation Control Program (CDPH-RHB) was notified by US CBP [Customs and Border Patrol] on 1/12/18 that a shipping container that had arrived at the Oakland port triggered a radiation detector upon attempting to depart the port. The shipping container contained scrap metal that was later determined to have been rejected at a South Korea port due to radiation detected upon receipt there.

"The Oakland port CBP personnel detected Cs-137, with a maximum dose rate on the outside of the shipping container of 86 microR/hr (gross). The radiation apparently had not been detected when the container was shipped out of the Oakland port to South Korea.

"The shipping container was held at the Oakland port by CBP until Tuesday 1/16/18, when it was released to AS Metals with the provision that CDPH-RHB would be present when the container was opened to determine the source of the radiation and subsequent disposition. CDPH-RHB went to a scrap yard site on 1/16/18 and found the source of the radiation was a gauge that was labeled (in handwriting as the original gauge label was missing) as containing 100 mCi of Cs-137. The gauge shutter was locked in the closed position. Dose rates were measured as approximately 40 mR/hr contact and 3 mR/hr at one foot distance, and the radioactive material was confirmed to be Cs-137.

"The apparent generally licensed gauge, which appeared very old, is being held in secure storage by AS Metals pending an attempt by CDPH-RHB to identify the general licensee who lost control of the gauge. This may be difficult due to the missing original label on the gauge, and because AS Metals has not been able to determine how or where they came into possession of the gauge."

California 5010 Number: 011618

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Part 21 Event Number: 53177
Rep Org: VELAN INC.
Licensee: VELAN INC.
Region:
City: Montreal State:
County: Quebec, Canada
License #:
Agreement: N
Docket:
NRC Notified By: VICTOR APOSTOLESCU
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2018
Notification Time: 16:06 [ET]
Event Date: 11/01/2017
Event Time: [EST]
Last Update Date: 01/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
GLENN DENTEL (R1DO)
GERALD MCCOY (R2DO)
DAVID HILLS (R3DO)
DAVID PROULX (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 NOTIFICATION - CHECK VALVE DISC THICKNESS COULD CAUSE VALVE TO STICK OPEN

The following is a summary of the information received from Velan Inc. via facsimile:

Affected item: Velan Inc. Disc (part number 8205-012) in 4NPS Class 150 through 900 Swing Check Valve

Callaway Nuclear Plant discovered that a Velan check valve installed in 1999 was stuck open. Velan investigated and determined that in 1979, a design change increased the thickness of the disc to allow the check valve to be used in higher pressure applications than the original design. In 1985, the valve body cavity was enlarged which would preclude the disc from sticking. Therefore, the only affected valves are the valves manufactured between 1979 and 1985.

Velan's records only go back to 1982 for purchase orders of this valve. Their records indicate 157 discs of this part number were shipped to U.S. utilities.

The following actions are being taken with respect to the disc:
- Cancel disc part number 8502-012
- Create a new disc part number to fit the body geometry of 1985 and before
-Create another disc part number to fit the current body geometry.

All affected utilities will be notified within a week, for information and to determine a course of action. As a minimum, Velan will recall all discs of the aforementioned part number in inventory at these utilities.

For any additional information on this matter please contact Victor Apostolescu at 514-748-7748 x 2134 or at victor.apostolescu@velan.com.

This disc has been purchased by nuclear plants in all four USNRC regions.

* * * UPDATE ON 1/24/2018 AT 0906 EST FROM VICTOR APOSTOLESCU TO DAVID AIRD * * *

Revised Part 21 report with corrected part number on page 1. Part number for disc revised to 8205-012.

Notified R1DO (Gray), R2DO (Guthrie), R3DO (Cameron), R4DO (Pick), and Part 21 Group via email.

Page Last Reviewed/Updated Thursday, January 25, 2018
Thursday, January 25, 2018