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Event Notification Report for June 15, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/14/2018 - 6/15/2018

** EVENT NUMBERS **


53444 53446 53447 53448 53449

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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: 00:00 [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 The source rod was retracted so the sources were in their shielded position.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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Agreement State Event Number: 53447
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: JOHN PETER SMITH HOSPITAL
Region: 4
City: FORT WORTH   State: TX
County:
License #: L02208
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: KENNETH MOTT
Notification Date: 06/07/2018
Notification Time: 12:16 [ET]
Event Date: 01/12/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING CALIBRATION SOURCE

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

"On June 7, 2018, the Agency [Texas Department of State Health Services] received a written report detailing a source had been found leaking in January 2018. The source was a dose calibration reference source. The labeled activity was 198.8 microCuries, Cs137, reference date of 1/1/2012, serial number 1551-38-4, RA number 030880. The leak test was completed twice with results of 9.65 and 12.9 nanoCuries on January 5 and 15, 2018. [Neither] the radiation safety officer nor the medical physicist reported the leak in January. The report was submitted today due to discovery when an inspector found the leak test record during the routine inspection of the facility. The violation was cited in the inspector's report. A second violation was not cited although a record was completed for the leaking source. The source was disposed of at a licensed site on March 20, 2018."

Texas Incident #: 9582

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Agreement State Event Number: 53448
Rep Org: OK DEPT OF ENVIRONMENTAL QUALITY
Licensee: SW REGIONAL MEDICAL CENTER dba CANCER TREATMENT CENTERS
Region: 4
City: TULSA   State: OK
County:
License #: OK-27041-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/07/2018
Notification Time: 16:09 [ET]
Event Date: 06/06/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION

The following was received from the State of Oklahoma by email:

"We [the Oklahoma Department of Environmental Quality] were just informed of a medical event and abnormal occurrence that happened yesterday at Southwestern Regional Medical Center dba Cancer Treatment Centers of America (OK-27041-01) in Tulsa, OK. The incident involved a patient who was supposed to receive a 110.8 Gy dose of Yt-90 SIR Spheres to the right lobe of the liver. A CT [scan] of the patient after the procedure showed that the microspheres had actually been delivered to the left lobe."

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: 53449
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLORIDA INTERNATIONAL UNIVERSITY
Region: 1
City: MIAMI   State: FL
County:
License #: 3669-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: KENNETH MOTT
Notification Date: 06/07/2018
Notification Time: 16:10 [ET]
Event Date: 04/19/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

The following report was received from the State of Florida:

"[The Florida Department of Health / Bureau of Radiation Control] received an email from Florida International University [FIU] reporting a leaking source. On April 19, the RSO [Radiation Safety Officer] opened a cabinet inside CP- 194 and did leak tests on stored sealed sources inside that cabinet. One Ni-63 source (9.4 milliCurie) was contained in a plastic vial with a screw top lid. The RSO removed the plastic vial from the radiation container for one minute to do a swab test, and sent the swab to an approved vendor for analysis. FIU EHS [Environmental Health and Safety] and the RSO were informed that the leak test associated with the Ni-63 source came back with a reading of 0.0119 microCuries (above the max. 0.005 microCurie limit) on May 18th. The RSO removed the radiation container containing the rad source from CP- 194 on May 22nd and moved it to the EHS vault in ACH 4 to await proper disposal. No other contamination was found."

Incident Number: FL18-070


Page Last Reviewed/Updated Thursday, June 28, 2018
Thursday, June 28, 2018