United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > April 30

Event Notification Report for April 30, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2018 - 04/30/2018

** EVENT NUMBERS **


53345 53346 53350 53351 53357

To top of page
Agreement State Event Number: 53345
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: OUR SAVIOR LUTHERAN CHURCH
Region: 4
City: NORFOLK State: NE
County:
License #: GL0595
Agreement: Y
Docket:
NRC Notified By: MALISA MCCOWN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2018
Notification Time: 12:47 [ET]
Event Date: 04/19/2018
Event Time: [CDT]
Last Update Date: 04/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following report was received from the Nebraska Department of Health via email:

"Eagle Distributing of Norfolk, LLC sold their building which contained tritium exit signs to Our Savior Lutheran Church on October 17, 2017. Eagle Distributing did not inform Our Savior Lutheran Church of the General License [GL] responsibility until March of 2018 when the Annual Renewal for GL0595 came overdue. After Our Savior Lutheran Church was informed of the exit signs and their GL responsibility, Our Savior Lutheran Church conducted a search to locate the signs within the building resulting in 3 missing signs. They have no information as to what could have happened or specific dates of their removal."

NE Item Number: NE180003

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

To top of page
Agreement State Event Number: 53346
Rep Org: COLORADO DEPT OF HEALTH
Licensee: A G WASSENAAR INC
Region: 4
City: LITTLETON State: CO
County:
License #: CO 212-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/19/2018
Notification Time: 18:16 [ET]
Event Date: 04/19/2018
Event Time: 15:52 [MDT]
Last Update Date: 04/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

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

"The Department [Colorado Department of Public Health and Environment] was notified via phone on 4/19/18 at approximately 1552 MDT. A G Wassenaar's RSO notified the Department that a portable gauge had been run over by a vehicle and the vehicle did not stop. At the time of the phone call, the gauge was broken into multiple pieces and the RSO was about to go out on-site to assess the damage.

"State inspectors are responding immediately as well."

Colorado Event Report ID No.: CO180008

To top of page
Non-Agreement State Event Number: 53350
Rep Org: RAPID CITY REGIONAL HOSPITAL
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: JAMES MCKEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2018
Notification Time: 12:05 [ET]
Event Date: 03/08/2018
Event Time: [MDT]
Last Update Date: 04/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

PATIENT RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following was received from the licensee via email:

"On March 8, 2018 and March 12, 2018, the patient was treated with the incorrect setup. On March 15, 2018, the patient was treated with the correct setup. Following the third treatment, both physicists were in the HDR [High Dose Rate] vault. The patient's setup was still on the treatment table, the physicist who had delivered the first two treatments noticed the accuform in the setup. At this time the patient had already left the facility. His next treatment was scheduled for March 19, 2018. This was discussed with the physician and the decision was made to perform a CT without the accuform, prior to the next treatment. The plan was recreated, using the same dwell weights and positions as the original plan. At this point we discovered that the patient had been under-dosed by more than 50 percent. Physics notified the NRC and the prescribing physician.

"As a result of the misadministration discovered March 19, 2018, a root cause analysis was performed. The direct cause of the incident was the failure to properly recreate the initial patient setup. The exclusion of the accuform caused the patient's head to be in the wrong position, leaving a gap between the treatment device and the patient's skin.

"Contributing factors include the lack of a specific policy regarding custom immobilization in HDR procedures, this was only the second brachytherapy patient using custom immobilization, the pictures from the simulation did not completely show the accuform, and it is generally a therapist, not a physicist, who reproduces the daily setup using custom immobilization.

"Items identified during root cause analysis: 1. At the time of treatment, there was not a policy specifically written for skin brachytherapy 2. The accuform was not used in the patient setup 3. The pictures from the simulation did not completely show the custom setup. 4. At the time of the incident there was not a verification system in place, to track the items needed for each custom setup.

"Corrective actions: 1. A policy was created and provided to [NRC R4 (Simmons)] on April 4, 2018. 2. Our new policy ensures that a therapist will be present at the first treatment, and any time a physicist is treating the patient for the first time. 3. In the CT simulation, any custom immobilization used in brachytherapy will be photographed with and without the patient. This will ensure that each piece of the custom device can be clearly visualized. Our IT department will be installing a computer monitor, keyboard and mouse in the HDR treatment vault. This will allow the verification of the setup notes and photographs in the treatment room. 4. Physics is working with our IT department and Elekta to implement a bar code scanning system to track custom setup devices."

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.

To top of page
Agreement State Event Number: 53351
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VALERO REFINING COMPANY TEXAS
Region: 4
City: TEXAS CITY State: TX
County:
License #: L02578
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2018
Notification Time: 15:42 [ET]
Event Date: 04/19/2018
Event Time: 17:00 [CDT]
Last Update Date: 04/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGES

The following information was obtained by the State of Texas via email:

"On April 20, 2018, a consultant for the company called to inform the Agency [State of Texas] that a fire had damaged part of the refinery. The fire happened yesterday, April 19, 2018 around 1700 CDT. The radiation safety officer has been informed and the two are preparing an assessment of the damage. There are 19 gauges in the location of the fire. The fire was located in the allocation unit where phrase fractions are allocated into different hydrocarbon groups for refinement. All but two gauges have been assessed for damage. The two remaining gauges are 1 milliCurie or less in activity and cannot be checked at this time due to safety issues. Once the area is released for entry the gauges will be checked for damage. An update will be provided with gauge identification and correct activity. Updates will be provided in accordance with SA-300 guidelines."

Texas Incident No.: I-9562

To top of page
Non-Agreement State Event Number: 53357
Rep Org: STERIS ISOMEDIX PUERTO RICO, INC.
Licensee: STERIS ISOMEDIX PUERTO RICO, INC.
Region: 1
City: VEGA ALTA State: PR
County:
License #: 52-24994-01
Agreement: N
Docket:
NRC Notified By: DAVID JACKSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/22/2018
Notification Time: 11:42 [ET]
Event Date: 04/21/2018
Event Time: 14:37 [AST]
Last Update Date: 04/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
36.83(a)(4) - FAILED CABLE/DRIVE
Person (Organization):
JON LILLIENDAHL (R1DO)
WILLIAM GOTT (IRD)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

FAILURE OF SOURCE RACK DRIVE MECHANISM

The following is a synopsis of information received via E-mail:

On 4/21/2018 at 1437 AST, the irradiator faulted with a 'Source Pass Cylinder Fault.' Source rack No. 1 moved to safe position in the pool but rack No. 2 remained in the raised position. The Maintenance Manager was notified of the situation. After evaluating the problem with the rack, he found that the air from the source rack No. 2 hoist cylinder was not being released through SVP36 and SVP36A. The Operators loosened a pipe fitting and let air slowly bleed from the rack hoist cylinder. This brought rack No. 2 into a fully lowered position at 1446 AST.

The Maintenance Manager contacted the corporate, Radiation Safety Manager and the plant manager and informed them of the situation.

The Maintenance Manager removed SVP36 and SVP36A valves and took them to the maintenance shop. There was no debris or water found in the valves. Both valves were replaced.

The Maintenance Manager contacted the Plant Manager and the corporate RSM to inform them that the rack problem was caused by the valves not releasing and that valves had been replaced.

The Maintenance Manager restarted the irradiator and after one cycle stopped the irradiator to test the valves. The source racks lowered into the pool as designed.

Corrective Actions:
1. The solenoid valve vendor will be contacted Monday morning and backup-replacement valves for SVP35, SVP35A, SVP36 and SVP36A will be ordered.
2. Annual replacement of SVP35, SVP35A, SVP36 and SVP36A will be added as an annual PM task.

Further investigation into the source valve failure will continue and conclusions will be included in the written report to Region 1 within 30 days.

The irradiator is now operating as designed. No personnel were exposed, nor was there the possibility of exposure, to the source.

Page Last Reviewed/Updated Monday, April 30, 2018
Monday, April 30, 2018