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Event Notification Report for August 21, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/20/2018 - 8/21/2018

** EVENT NUMBERS **


53506 53543 53544 53545 53547 53549 53554

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53506
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: SE GEORGIA HEALTH SYSTEMS
Region: 1
City: BRUNSWICK   State: GA
County:
License #: 45-309857-01
Agreement: Y
Docket:
NRC Notified By: KATHARINE ARZATE
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 07/13/2018
Notification Time: 16:21 [ET]
Event Date: 07/13/2018
Event Time: 11:25 [EDT]
Last Update Date: 08/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
30.50(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
STEVE ROSE (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG PICK (R4DO)
FRED BOWER (R1DO)

Event Text

MEDICAL EVENT

The following information is a synopsis of information received via E-mail:

A HDR [high dose rate] brachytherapy incident occurred in Brunswick, Georgia, on July 13, 2018. No one, including the patient, was exposed to excessive radiation. SE Georgia Health Systems treated a Gyn [gynecology] patient using the GammaMed Plus HDR unit and a Tandem and Ring applicator set, both supplied by Varian. Upon completion of the treatment, the source wire retracts back into the shielded HDR unit for safe storage. At that time the room was checked with a survey meter and no exposure readings above background were measured. The HDR unit was surveyed to ensure that the source wire had retracted. The exposure reading on the surface demonstrated that the wire had retracted, and the room was safe. Upon scanning the patient's surface, however, a reading of approximately 2.5mR/hr was measured, which was higher than the expected background reading. The applicator was removed from the patient and scanned, the increased exposure reading was in the applicator. The applicator was placed into a large shielded container provided by Varian and immediately placed in safe storage. The patient, the bedding, and all other materials associated with the implant were re-scanned with no readings above background. The patient was removed from the room, deemed safe and released. The time was recorded to be approximately 5 to 6 minutes and will be used for dose estimates.

The HDR unit was re-scanned along with the Linac vault. All were deemed clear and safe. The HDR unit was locked and secured. Patient treatments in the Linac continued.

The applicator device was then scanned one piece at a time and it was determined that the Ring portion of the Tandem and Ring set was contaminated. It was assumed that the contamination was secure inside the ring which is a rounded hollow metal tube. Exposure readings at the surface of the ring were 96 mR/hr at the surface and approximately 30 mR/hr at 6 inches.

SE Georgia Health Systems notified the Georgia Radiation Protection Programs, and Varian Medical Systems of this incident.

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.

* * * RETRACTION FROM KATHY ARZATE TO HOWIE CROUCH AT 1050 EDT ON 8/7/18 * * *

"After investigation and arrival on site to determine the cause of the contamination, it was found there was no contamination on the patient's body. It was not a failure of the device. We [Varian] inspected the device. We attempted to remove the contamination from the applicator, but were unable to. Therefore, the manufacturer of the source took the applicator back to their facility and were able to remove the contamination there. Ultimately, there was no equipment failure per 10 CFR 30.50(b)(2) or (b)(3)."

Notified R1DO (Cahill), R2DO (Sykes), R4DO (Vasquez), and NMSS Events (by email).

* * * UPDATE FROM KATHY ARZATE TO OSSY FONT AT 1127 EDT ON 8/20/18 * * *

The following was received via email from Varian and is part of their retraction on 8/7/18:

"The Varian Radiation Safety Officer (VRSO), the Varian Field Service Engineer (VFSE), and the AOS Radiation Safety Officer (ARSO) arrived on the site on July 15, 2018 at 0830 EDT. They were met by the site Radiation Safety Officer and medical physicist.

"Utilizing a RADEYE B20-ER Geiger meter, an initial contamination wipe was performed on the afterloader turret. No results above background were found. The VFSE began the process of transferring the potentially contaminated wire from the afterloader to the transport safe. The VRSO then began decontamination steps to remove the particle from the applicator.

"The decontamination effort involved running a dummy cable completely through the applicator to the closed end. Once the cable reached the end of the applicator, the wire was moved back-and-forth in the location of the contamination while rotating the applicator. Once the site was agitated for an appropriate amount of time, the cable was slowly pulled from the applicator while holding a wipe on the wire. This action was performed for approximately 45 minutes without success.

"Once the old source wire was removed from the afterloader, the afterloader was scanned to determine if any contamination was present in the source wire tubing. No results above background were found. The new wire was installed into the afterloader. The plastic transfer catheter was wiped. No results above background were found. All gloves, wipes, and dummy cable were scanned for potential contamination prior to placement in the biohazard waste stream. No results above background were found.

"The ARSO took the contaminated applicator back to the AOS facility. Further efforts at that facility allowed the applicator to be cleaned and returned to the customer site.

"The results of all testing indicate that the afterloader was clear of possible radiological contamination. A new source wire was installed and the customer was able to resume treatments as scheduled. There was no indication that the contamination was from a leaking sealed source, but rather external contamination on the wire. There is no indication of patient contamination or equipment failure. Therefore, the NRC Event Report 53506 has been retracted."

Notified R1DO (Young) and R2DO (Sandal), R4DO (Taylor) and NMSS Events by email.

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Agreement State Event Number: 53543
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: INTERNATIONAL PAPER
Region: 1
City: RIEGELWOOD   State: NC
County:
License #: 024-0013-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: OSSY FONT
Notification Date: 08/10/2018
Notification Time: 14:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILED GAUGE SHUTTER

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

"NC RMB (North Carolina Radioactive Materials Branch) was notified by an authorized service provider, Systems Service Corporation (License Number: 090-1071-1), that they had repaired a failed shutter on a fixed nuclear gauge located at International Paper located in Riegelwood, NC on 8/9/18. The shutter detent spring was corroded and dissolved due to its corrosive environment. The service provider removed the gauge and rebuilt it on site with another source housing.

"No known overexposures occurred during this event and it is unknown at this time whether the shutter was in an open or closed position. However, this investigation is still ongoing at the time of this report.

"No other generic implications at this time. No other notifications made.

"Source & Device Information: TBD. This report will be updated once RMB completes its investigation."

North Carolina Report Number: 180034

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Agreement State Event Number: 53544
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND   State: OR
County:
License #: 90013
Agreement: Y
Docket:
NRC Notified By: HILLARY HASKINS
HQ OPS Officer: OSSY FONT
Notification Date: 08/10/2018
Notification Time: 17:29 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF Y-90 MICROSPHERES

The following is a summary from a report received via email from the State of Oregon:

On 08/09/18, the Oregon Health & Science University (OHSU) Radiation Safety Officer (RSO) reported a misadministered of Y-90 treatment. The activity was 294 Gy, more than twice what was in the written directive (WD), 136 Gy. The prescribed range was 109-163 Gy.

The normal pre-procedure process, while still in Nuclear Medicine, includes a dose calibrator reading, which was done, and a decay calculation done based on the manufacturer's calibration data sheet. The two were within 10%. The decayed activity result (or calibrator reading) is supposed to be compared with the WD required activity before taking the dose up to Interventional Radiology (IR) for the preadministration measurements.

For this case, the RSO was responsible for the calculation and verification, and should have noticed the incorrect dose before taking it to IR, but the comparison with the WD dose was not done.

Another Y-90 dose had been delivered to Nuclear Medicine that morning to decay prior to a case the next week. This was the dose the Nuclear Medicine tech opened and measured, without checking the printed code on the shipping box, which includes the patient's initials.

Additionally, another check is done by the nurse manager for these cases, who goes down the day before to verify what was received. The packing slip showed a 5 GBq dose, which was correct and it was the right shipping box.

The interventional radiologist was informed as soon as the post-delivery calculations were confirmed. He spoke with the patient, and sent the patient to Nuclear Medicine to be imaged. The scan showed very good containment within the liver. The physician felt the patient actually should tolerate the dose, as he had considered administering a high ablation type of dose (>200 Gy), and because of where the dose was delivered.

Corrective actions included a procedure modification; specifically, a dose verification step will be added when the dose is up in IR during the preliminary set-up with the nurse manager. Other steps will be put in place after further discussion. The event is being entered into the hospital notification system, and likely will receive further review at that level.

The RSO will submit the full report within the required 20 days.

Oregon Item Number: OR180002

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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Non-Agreement State Event Number: 53545
Rep Org: US DEPARTMENT OF VETERANS AFFAIRS
Licensee: US DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: PORTLAND   State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT Jr.
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/10/2018
Notification Time: 19:36 [ET]
Event Date: 08/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MISADMINISTRATION OF Y-90 MICROSPHERES

"This event occurred on August 9, 2018, at the VA Portland Health Care System, Portland, Oregon.

"The patient was to receive a prescribed dose of 134 gray to a segment of the liver as a treatment for liver cancer, with Y-90 microspheres. After the procedure, the [actual] dose to the intended segment was estimated as approximately 103 gray, 77 percent of the prescribed dose.

"The patient has been notified. No harm to the patient is anticipated."

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: 53547
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GENERAL LICENSE
Region: 3
City: WARREN   State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: OSSY FONT
Notification Date: 08/11/2018
Notification Time: 17:34 [ET]
Event Date: 06/29/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"A process was set up to remove all tritium exit signs (over 100) from [General Motors LLC -] Lordstown Complex, all with replacement dates of 8/1/2014. After reviewing records during an annual self-evaluation audit of self-luminous exit signs located at the Lordstown Complex, 2300 Hallock Young Road, Lordstown, Ohio 44481, it has been determined that up to 34 tritium exit signs are potentially missing. An investigation was launched to try to determine the location of these signs. The Lordstown Complex will continue to periodically search for these exit signs, and employees will be instructed to notify the Environmental Engineering department if any exit signs are discovered. There are no self-luminous tritium exit signs left in operation at the Lordstown Complex. Other than the 34 misplaced exit signs, all others have been transported off site to the recycling facility, Isolite Corporation."

Ohio NMED Report: OH180007

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL



THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53549
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE   State: TX
County:
License #: L 06462
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: VINCE KLCO
Notification Date: 08/13/2018
Notification Time: 12:05 [ET]
Event Date: 08/11/2018
Event Time: 12:00 [CDT]
Last Update Date: 08/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE

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

"On August 12, 2018 at approximately 1135 [CDT]., the licensee notified the Agency [Texas Department of State Health Services] that one of its radiography crews had experienced a source disconnect. The event occurred on August 11, 2018, at approximately 1200 [CDT] at a temporary job site near Whitsett, TX. The device involved was an INC IR-100 (SN: 6792) containing a 91 curie iridium-192 source (SN: ZH0109). The crew had set up the device and performed a procedure shot and everything functioned properly. They performed the first shot of the job and the source would not retract into the device--it felt as though it had stuck on something. After a second unsuccessful attempt, the source was cranked back out into the collimator, boundaries set, and an authorized person came to the site and performed the retrieval. The drive cable and source were both new. There was no observable cause for the failure. The device and associated equipment will be sent to the manufacturer for evaluation. Per readings from all three individuals' self-reading pocket dosimeters, there were no overexposures. The source retriever's dosimetry badge is being sent for processing. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

* * * UPDATE FROM KAREN BLANCHARD TO VINCE KLCO ON 8/13/18 AT 1559 EDT * * *

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

"Clarification: The source assembly [never disconnected] from the drive cable. [The licensee was] unable to retract it back into the exposure device."

Notified R4DO (Deese) and NMSS Events Notification Group via email.

Texas Incident: I-9606

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Power Reactor Event Number: 53554
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: PAUL ANGOVE
HQ OPS Officer: OSSY FONT
Notification Date: 08/21/2018
Notification Time: 12:25 [ET]
Event Date: 08/20/2018
Event Time: 18:56 [EDT]
Last Update Date: 08/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
HIRONORI PETERSON (R3DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

FAILED FITNESS FOR DUTY TEST

"At 08/20/2018 at 1856 [EDT], it was determined that a contract supervisor failed a test specified by the FFD [fitness for duty] testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."


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