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Event Notification Report for June 14, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/13/2018 - 6/14/2018

** EVENT NUMBERS **


53444 53446

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Agreement State Event Number: 53444
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: DIGNITY HEALTH AT ST. JOSEPH'S HOSPITAL AND MEDICAL CENTER
Region: 4
City: PHOENIX   State: AZ
County:
License #: 07-024
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/06/2018
Notification Time: 13:27 [ET]
Event Date: 06/05/2018
Event Time: 00:00 [MST]
Last Update Date: 06/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ARIZONA AGREEMENT STATE REPORT - NUCLETRON HIGH DOSE RATE APPLICATOR MALFUNCTIONED DURING TREATMENT

Below is a summary of multiple emails received from the State:

At 1530 hrs. MST on 6/5/18, the State was notified that a patient was undergoing high dose rate treatment (HDR) when the Nucletron HDR applicator malfunctioned. The treatment plan was to deliver the intended fraction using thirteen dwell points but the HDR applicator failed at dwell point 9 of 13. The vendor, Elekta, was notified and they repaired the applicator. The written directive was modified and the patient will be able to complete the treatment.

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Non-Agreement State Event Number: 53446
Rep Org: CTI AND ASSOCIATES
Licensee: CTI AND ASSOCIATES
Region: 3
City: NOVI   State: MI
County:
License #: 21-17007-01
Agreement: N
Docket:
NRC Notified By: TIM MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/06/2018
Notification Time: 17:35 [ET]
Event Date: 06/05/2018
Event Time: 16:00 [EDT]
Last Update Date: 06/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

The licensee's gauge operator was preparing to sample some work being done by a construction company when the company's road grader began backing into his sample area. The operator attempted to wave off the grader but he was in the grader operator's blind spot. The grader struck the gauge side and damaged the housing. The source rod was retracted so the sources were in their shielded position.

The RSO [Radiation Safety Officer] was contacted and performed an area survey and a survey on the gauge. There were no abnormal readings. The gauge was swipe tested and the licensee has sent the swipe off for analysis. No overexposures were reported.

The gauge was a Troxler model 3440 which contained a 9 mCi Cs-137 source and a 44 mCi Am-241 source.

The gauge is currently in secure storage at the licensee's facility. Once the swipe tests are analyzed, the disposition of the gauge will be determined.

The site of the incident was Ann Arbor, MI.


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Friday, May 03, 2019