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Event Notification Report for July 19, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/18/2018 - 7/19/2018

** EVENT NUMBERS **


53488 53501 53515 53517

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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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Agreement State Event Number: 53501
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CENTRAL TEXAS MEDICAL SPECIALISTS PLLC
Region: 4
City: AUSTIN   State: TX
County:
License #: L 06618
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: STEVEN VITTO
Notification Date: 07/11/2018
Notification Time: 15:58 [ET]
Event Date: 07/10/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On July 11, 2018, a license notified the Agency [Texas Department of State Health Services] that a medical event had occurred. On July 10, 2018, a patient received the first fraction of a treatment plan delivered by a high dose rate afterloader (HDR) utilizing iridium-192. On July 11, 2018, the medical physicist noticed that the dose per fraction entered in the treatment plan of the 1st fraction was incorrect. Instead of a 350 cGy/fraction for 6 fractions, a value of 2100 cGy was entered for one fraction (which was the total dose for the brachytherapy course). The Radiation Oncologist (RO) was notified and he notified the referring physician and patient that day. RO will follow the patient closely and make all possible interventions to minimize potential adverse effects. The Agency is awaiting answers to multiple questions including identification of target area. More information will be provided as it is obtained and in accordance with SA-300.

"Texas Incident #: I-9594"


* * * UPDATE FROM CHRIS MOORE TO DONALD NORWOOD AT 1621 EDT ON 7/13/2018 * * *

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

"The patient was treated for vaginal cancer using HDR (High Dose Rate) brachytherapy using a 6 Curie Iridium-192 source. A written report was received from the licensee indicating several factors contributed to the medical event including a busy work day, mental fatigue, verbal description of the intended dose instead of written direction, and unavailability of another medical physicist (MP) to independently review the dose/fraction entered in the treatment planning system. The overall brachytherapy plan was modified and the volume treated in the first fraction was considered completed and [the patient] will not receive further treatment. The Radiation Oncologist will follow the patient closely and make all possible interventions to minimize potential adverse effects. Immediate changes implemented at the facility include: no HDR treatment will start without a written prescription in the patient electronic medical record and an independent check of the prescription entry and radiation dosimetry will be conducted by an Authorized User, other than the MP who generated the treatment plan. An Agency team will conduct an onsite investigation in early August 2018 when all parties involved are available. Additional information will be provided as it is obtained and in accordance with SA-300."

Notified R4DO (Pick) and NMSS Events Notification E-mail group.

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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Power Reactor Event Number: 53515
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: KARA STACY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/18/2018
Notification Time: 19:27 [ET]
Event Date: 07/18/2018
Event Time: 08:21 [EDT]
Last Update Date: 07/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

CONTRACTOR SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A contractor supervisor tested positive for alcohol during an access upgrade fitness-for-duty test. The employee's access to the facility has been suspended. The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 53517
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: DANIEL MICKINAC
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/19/2018
Notification Time: 12:36 [ET]
Event Date: 07/18/2018
Event Time: 13:00 [EDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

NON-LICENSED CONTRACT SUPERVISOR SUBVERTS FITNESS FOR DUTY TEST

"At 1300 [EDT] on July 18, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD) program by subverting the Fitness for Duty process. The contractor's site access has been terminated. The NRC Resident Inspector was notified."


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019