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Event Notification Report for July 13, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/12/2018 - 7/13/2018

** EVENT NUMBERS **


53430 53487 53488

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Agreement State Event Number: 53430
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: STEVEN VITTO
Notification Date: 05/29/2018
Notification Time: 14:48 [ET]
Event Date: 05/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - PATIENT SKIN CONTAMINATION

The following was received from the Commonwealth of Pennsylvania via email:

"On May 29, 2018, the Department's [Bureau of Radiation Protection] staff in Central Office became aware of a medical event (ME) at U PENN hospital in Philadelphia. The ME is reportable as per 10 CFR 35.3045(a)(1)(i) and also meets criteria for an Abnormal Occurrence.

"On May 25, 2018, a 17 year old pediatric patient underwent an 834 millicurie metaiodobenzylguanidine (MIBG) lodine-131 (I-131) treatment for brain cancer. The dose was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medical technician present during the infusion reported seeing a small amount of blood, but other than that, nothing unusual was noted. However, upon completion of the infusion, meter readings noted high activities on the patient's clothing and bed linen. The possible reason given being a faulty connection line on the automatic pump. The contamination is believed to have also been present on the skin all weekend. Due to the large dose of I-131 infused, the licensee's staff were not able to see the contamination on the patient's skin until he developed erythema. The licensee is in the process of doing a dose reconstruction for the skin contamination. Based on the reading from the patient and estimated activity in the various contaminated items, the licensee currently estimates that approximately 50% of the intended dosage was successfully infused. The authorized user has been informed and is currently notifying the patient's parents and the referring physician.

"A reactive inspection is planned by the Department. More information will be provided upon receipt."

PA Event Report ID No: PA 180012

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.


* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD AT 1451 EDT ON 7/12/2018 * * *

"The University of Pennsylvania (U Penn) reported that a patient's skin became contaminated during medical treatment on 5/25/2018. The 17-year-old pediatric patient was scheduled to receive 30.86 GBq (834 mCi) of 1-131 metaiodobenzylguanidine (MIBG) for treatment of brain cancer. The dosage was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medicine technician present during the infusion saw a small amount of blood, but nothing unusual other than that was noted. However, upon completion of the infusion, radiation surveys revealed high activities of 1-131 on the patient's clothing and bed linen.

"U Penn stated that the patient's upper right thigh was cleaned. On 5/27/2018, the patient reported discomfort and reddening (i.e. erythema) on the skin of his upper right thigh, which developed into a lesion and further into desquamation (grade 3) the next day. Radioactive contamination is believed to have been present on the patient's skin for 24 to 48 hours.

"Based on U Penn measurements, nuclear medicine imaging, and the patient's clinical symptoms, the dose to the skin was estimated to be between 50,000 and 120,000 cGy (rad) to a 15 cm2 area. Radiation safety staff consulted with U.S. DOE's REAC/TS in Oak Ridge TN, to verify dose calculations. Calculations of the activity in the waste and the exposure rate from the patient in previous treatments estimated the activity delivered at 15.54 GBq (420 mCi). It was calculated that approximately 7.77 GBq (210 mCi) went to the waste.

"The cause of the incident is believed to be a faulty connection line on the automatic pump. The patient was also disconnected from the infusion pump at the 'Spiros tube' to use the lavatory part way through the procedure. Due to the large dosage of 1-131 infused, U Penn staff were unable to detect the contamination on the patient's skin until he developed erythema.

"The authorized user was informed and notified the patient's parents and referring physician. Pennsylvania DEP, Bureau of Radiation Protection, performed a reactive inspection on 6/7 and 6/13/2018. U Penn is conducting a full root cause analysis to develop and implement corrective actions. Procedures that have already been implemented for 1-131 MIBG patients included placing absorbent chucks between all parts of the infusion line and the patient's body and requiring an authorized user to be contacted for approval if it is necessary to disconnect a patient during the infusion.

"Root Cause(s): possible equipment failure, training, and/or human error in connecting the line to the infusion pump.

"Actions: A reactive inspection has been completed by the Department. More information will be provided upon receipt from U Penn."

Notified R1DO (Bower), NMSS Events Notification E-mail Group, and INES Coordinator (Milligan).

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Agreement State Event Number: 53487
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE   State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 07/04/2018
Notification Time: 23:19 [ET]
Event Date: 07/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT

The following information was received from the State of Texas by email:

"On July 4, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that one of their crews has experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 70 Curie Iridium - 192 source. The licensee did not have a lot of details on the event, but stated the source had been recovered and that no over exposures had occurred. The licensee stated the connector ball on the drive cable was tested after the event and failed the test. The RSO stated they would provide additional information on July 5, 2018. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident- I-9591

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Agreement State Event Number: 53488
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: STANLEY
Region: 4
City: TULSA   State: OK
County:
License #: LOK-32187-0
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/05/2018
Notification Time: 18:02 [ET]
Event Date: 07/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
KEVIN WILLIAMS (NMSS)
GRETCHEN RIVERA-CAPELLA (EMAIL)
PATRICIA MILLIGAN (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE EVENT

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

"On July 5, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's [Stanley out of Tulsa, OK] consultant that an overexposure event may have occurred involving radiographers working in the state of Texas, under reciprocity, at a field site near Midland, Texas, but offered no actionable information. At 1620 hours [CDT], the consultant called back and stated that a crew was performing radiography in a pit using a 99.6 Curie iridium - 192 source. The individual who received the high exposure had been working in the dark room. He completed the task he was working on and exited the dark room and went straight to the pit. He picked up the collimator and started to move it while the source was still in the collimator. The other radiographers yelled at him and he dropped the source and left the pit.

"The consultant stated the calculations for the dose to the individual's hand provided by the licensee is 284 rem. The consultant stated the radiographer held the source for about 3 seconds and the dose calculation was based on no shielding. The consultant stated there is currently no apparent injury to the individual's hand. The consultant stated the licensee is contacting REAC/TS in Oak Ridge, Tennessee, for assistance. The licensee's radiation safety officer is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #9592

* * * UPDATE FROM THE STATE OF OKLAHOMA TO HOWIE CROUCH ON 7/6/18 AT 1032 EDT * * *

The following information is excerpted from an email that was received from the state of Oklahoma:

Oklahoma DEQ [Department of Environmental Quality] Radiation Management was contacted by the radiation safety officer (RSO) of Stanley Inspection, License No.: OK-32187-01, after hours on 7/5/2018. Stanley Inspection, a radiography company, was working in Midland, TX under reciprocity, and one of the radiographers potentially overexposed his hand. Stanley Inspection was instructed by Texas to do medical monitoring for the radiographer, including bloodwork and photographs of his overexposed extremity.

Notified R4DO (Miller) and NMSS Events Notifications (email).

* * * UPDATE FROM IRENE CASARES TO DONG PARK ON 7/19/18 AT 1158 EDT * * *

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

"Stanley Inspection Services reported that a radiation overexposure may have occurred involving radiographers working in Texas, under reciprocity, at a field site on 7/3/2018 near Midland, Texas. Reported to NRC as update on July 19, 2018. After complete investigation and reenactment of the incident the following information was obtained and being provided as an update of the incident.

"On July 3, 2018, a radiographer working a temporary field site project under reciprocity (OK licensee in TX) with another crew had an incident. The radiographer was working in the dark room and was developing film. He completed this task and exited the darkroom. This was the last shot of the day in which this crew was working. It was the last image for this shot in which four images are taken for this weld of a 36 inch pipe at a time of 6.5 minutes each image. They were about to end the workday. It was at dusk and his assistant went to the front of the vehicle to get a flashlight while a member of the other crew showed up. The time of day was between 9 and 10 pm. When this person showed up, the radiographer was exiting the darkroom. These two radiographers both walked down into the pit to retrieve the film, when they were walking to the film, the assistant arrived at the back of the truck, stating that the source was still out and at that time the survey meter being carried by the other crew member (RDS-30, Mirion technologies) was alarming. The person carrying the survey meter was about 2-3 feet behind the first radiographer. The first radiographer had already put his fingers (index and middle) and thumb on the collimator for estimated 3 seconds as he was checking to ensure it had not moved from the mark/film while imaging. He explained that he heard the alarms from the survey and dosimetry meters and they both ran out of the pit. It was reenacted on 16 July to confirm how he placed his fingers on the collimator and estimated the time. The Delta 880, sn D15456, camera was loaded with, QSA, A424-9, 66225G, Ir-192, at an activity of 101.5 curies. The calculated dose to the hand for 3 seconds with a collimator made of tungsten rated at 4 HVL was 25.54 rem for the extremity dose. The initial whole body dose was estimated to be unshielded at 109 mrem. The radiographer had been wearing an electronic dosimeter (Tracerco) which was acting as an alarming rate meter and dosimeter. The film badge was processed with results of 18 mrem. And the dosimetry was reported to have read 24 mrem by the radiographer for that day's work. The dosimeter was sent for verification/accuracy checks. The radiographer had his blood drawn as instructed by REAC/TS and the RSO photographed his fingers/hands for 3 weeks. The radiographer stated he had no abnormal redness, tingling or sensations in the tissue of the hand. The supporting documents and reenactment support an estimated dose of 25.54 rem to the extremity and approximately 20 mrem to the whole body.

"The company is completing its documentation of the incident and will be providing its detailed report with corrective actions, another update will be forthcoming."

Notified R4DO (Young), INES (Milligan) and NMSS Events Notifications via email.


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