Event Notification Report for February 05, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/4/2019 - 2/5/2019

** EVENT NUMBERS **

Agreement State	Event Number: 53847
Rep Org: NJ RAD PROT AND REL PREVENTION PGM Licensee: INSPIRA MEDICAL CENTERS, INC. Region: 1 City: VINELAND State: NJ County: License #: 450632 Agreement: Y Docket: NRC Notified By: RICHARD PEROS HQ OPS Officer: THOMAS KENDZIA	Notification Date: 01/25/2019 Notification Time: 10:37 [ET] Event Date: 01/24/2019 Event Time: 00:00 [EST] Last Update Date: 01/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MEL GRAY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSED BY GREATER THAN 20 PERCENT

The following was received from the State of New Jersey via email:

"While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. The licensee will follow-up with a full report."

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.

Agreement State	Event Number: 53848
Rep Org: OK DEQ RAD MANAGEMENT Licensee: SAGEBRUSH PIPELINE AND EQUIPMENT COMPANY, INC. Region: 4 City: TULSA State: OK County: License #: OK-32109-01 Agreement: Y Docket: NRC Notified By: JENNIFER MCALLISTER HQ OPS Officer: ANDREW WAUGH	Notification Date: 01/25/2019 Notification Time: 16:27 [ET] Event Date: 01/25/2019 Event Time: 14:30 [CST] Last Update Date: 01/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

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

"On January 25, 2019, at approximately 1430 CST, [Oklahoma Department of Environmental Quality (DEQ)] received a call from Sagebrush Pipeline Equipment Company, Inc., Oklahoma License No. OK-32109-01. [The licensee] experienced a guide tube disconnect, while the source was cranked out. They were using a SPEC 150 with 48 Ci of Ir-192. The carded radiographer explained that when cranking out the source, there was a small catch, so he attempted to crank the source back into the camera. That was when they realized the guide tube was disconnected from the camera, and the source while still connected to the guidewire, was still in the guide tube. They were able to return the source back to its shielded position. [Oklahoma DEQ] will provide updates when they receive the licensee's report."

Power Reactor	Event Number: 53860
Facility: COLUMBIA GENERATING STATION Region: 4 State: WA Unit: [2] [] [] RX Type: [2] GE-5 NRC Notified By: GREG KNUDSON HQ OPS Officer: BETHANY CECERE	Notification Date: 02/04/2019 Notification Time: 18:40 [ET] Event Date: 02/04/2019 Event Time: 14:03 [PST] Last Update Date: 02/04/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): RAY AZUA (R4DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

FITNESS FOR DUTY - LICENSED OPERATOR CONFIRMED POSITIVE FOR DRUG TEST

A licensed reactor operator had a confirmed positive random fitness-for-duty drug test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Wednesday, March 24, 2021