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Event Notification Report for August 15, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/14/2018 - 8/15/2018

** EVENT NUMBERS **


53450 53518 53550

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53450
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: WESTERN TUMOR MEDICAL GROUP
Region: 4
City: LOS ANGELES   State: CA
County: LOS ANGELES
License #: 7954-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/09/2018
Notification Time: 10:48 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/14/2018
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 report was received from the State of California by email:

"[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.

"The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.

"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification."

* * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *

The following information was received from the State of California via email:

"Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose)."

California ID # 060818

Notified the R4DO (Deese) and NMSS Events Notifications via email.

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: 53518
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: INTERTEK ASSET INTEGRITY MANAGEMENT INC
Region: 4
City: LONGVIEW   State: TX
County:
License #: L06801
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/20/2018
Notification Time: 12:32 [ET]
Event Date: 07/20/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
PATRICIA MILLIGAN (INES)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

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

"On July 20, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that he had been contacted by their dosimetry processor and informed that one of his radiographer's dosimeter had read 37.5 rem for the previous month (June, 2018). The RSO stated the report indicated the dose was irregular. The RSO stated the individual had stated they had not lost their badge, but had left it in the radiography truck a few times on their day off. The RSO stated the individual has been removed from all duties that would give them any additional exposure to ionizing radiation. The individual's current dosimeter has been sent to the processor for reading. The RSO stated the exposure to the radiographer this individual had been working with was normal. The RSO stated they would contact Radiation Emergency Assistance Center/Training Site (REAC/TS) and seek assistance. The RSO does not believe the dose is real and is a badge only exposure. The RSO stated the radiographer has not displayed any signs of a high exposure. Additional information will be provided as it is received in accordance with SA-300."

* * * UPDATE FROM ARTHUR TUCKER TO VINCE KLCO ON 8/14/18 AT 1727 EDT * * *

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

"On August 14, 2018, the licensee reported they had received sample results for the blood samples sent to Radiation Emergency Assistance Center/Training Site (REAC/TS). The sample indicated a dose of 0.44 gray. The licensee stated the individual exposed has not complained of any unusual feelings in the hands. The licensee's Assistant Corporate Radiation Safety Officer is going to the location where the individual works to interview. The investigation into this event is on going. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #9597

Notified the R4DO (Deese). INES Coordinator (Milligan) and NMSS Events notified via email.

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Power Reactor Event Number: 53550
Facility: COMANCHE PEAK
Region: 4     State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN MITCHELL
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 08/14/2018
Notification Time: 02:18 [ET]
Event Date: 08/13/2018
Event Time: 22:58 [CDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RICK DEESE (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO GENERATOR LOCKOUT

"At 23:58 (Central Daylight Time) Unit 2 Reactor Tripped [automatic reactor trip] due to a Turbine Trip/ Generator Lock Out. All Auxiliary Feedwater Pumps started due to steam generator Lo Lo levels.

"Unit 2 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IP0-007B. The Emergency Response Guideline Procedure Network has been exited. Decay heat is being rejected to the Main Condenser via Steam Dump Valves.

"The cause of the Generator Lockout is currently under investigation."

All control rods fully inserted in response to the automatic reactor trip.

The licensee notified the NRC resident.


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Friday, May 03, 2019