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Current Event Notification Report for July 05, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/4/2018 - 7/5/2018

** EVENT NUMBERS **


53473 53474 53475

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Agreement State Event Number: 53473
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Region: 1
City: NEW YORK CITY   State: NY
County:
License #: 75-2909-04
Agreement: Y
Docket:
NRC Notified By: HAILU TEDLA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/26/2018
Notification Time: 08:16 [ET]
Event Date: 06/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERES

The following information was obtained from New York City Department of Health and Mental Hygiene, Office of Radiological Health via email:

"On June 25, 2018, a 65-year old male patient was treated with Y90 TheraSphere to the right side of the liver. The intended dose of administration was 64.8 mCi (2.4 GBq). Upon conclusion of the procedure, when the waste materials (delivery line, vial, gauze, etc.) was counted, it was found that 41.87 mCi (1.55 GBq) of Y90 TheraSphere was actually administered to the patient. In other words patient received 64.6% of intended dose. The Radiation Safety Office of Mount Sinai Hospital reported the incident to the New York City Department of Health and Mental Hygiene [NYCDOH] on 6/25/2018 at 1340 hrs. These findings were communicated to the patient and the referring physician within 24 hours. The licensee stated that no serious adverse events occurred and the patient will be followed up with Interventional Radiology as per protocol. The licensee indicated that the root cause analysis of the event is currently being performed and a detailed report of the event with corrective action will be sent to the NYCDOH within 15 days."

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: 53474
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EXXON MOBIL CORPORATION
Region: 4
City: BAYTOWN   State: TX
County:
License #: L01135
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 06/26/2018
Notification Time: 17:30 [ET]
Event Date: 11/29/2017
Event Time: 00:00 [CDT]
Last Update Date: 06/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was received from the State of Texas:

"During the review of an event, the Agency [Texas Department of State Health Services] found a letter from a licensee reporting the shutter on a Ohmart model SHD-45 containing a 50 millicurie cesium - 137 source had failed in the closed position. The report was dated November 29, 2017. The shutter did not pose an exposure risk to any individual. The licensee has worked with the manufacturer and the gauge was scheduled to be replaced on June 21, 2018. The Agency has not been able to confirm if the gauge was repaired/replaced. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9588

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Agreement State Event Number: 53475
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GE HITACHI NUCLEAR ENERGY AMERICA, LLC DBA VNC
Region: 4
City: SUNOL   State: CA
County:
License #: 0017-01
Agreement: Y
Docket:
NRC Notified By: K. A. HEWADIKARAM
HQ OPS Officer: ANDREW WAUGH
Notification Date: 06/26/2018
Notification Time: 18:28 [ET]
Event Date: 03/24/2017
Event Time: 00:00 [PDT]
Last Update Date: 06/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILURE TO PROPERLY LABEL A SHIPMENT

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

"On 03/16/18, the Site Manager at Vallecitos Nuclear Center (VNC) contacted RHB [California Radiologic Health Branch] licensing unit to notify of an incident related to a shipment from their facility. The incident occurred a year ago on 03/24/17, where a shipment of Cf-252 sources with a TI [Transportation Index] of 19 was inadvertently not flagged as exclusive use. This was identified by CHP [California Highway Patrol] at a weigh station approximately 10 miles from VNC [in Livermore, CA] and the shipment was returned to the facility. VNC corrected the paperwork, calling the shipment out as exclusive use. VNC was cited by CHP. VNC has recently received a letter from Alameda County District Attorney's Office referencing a Vehicle Code and a Professional Code. RHB will be following up on this investigation regarding failure to immediately notify RHB and for failure to label the shipment as exclusive use.

"Note: Inspection unit at RHB was notified of this incident on 06/18/18."

California Report No: 5010-031618


Page Last Reviewed/Updated Friday, July 06, 2018
Friday, July 06, 2018