Event Notification Report for February 12, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/11/2019 - 02/12/2019
Agreement State
Event Number: 53874
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: COOPER HEALTH SYSTEMS
Region: 1
City: CAMDEN State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: JEFFREY WHITED
Licensee: COOPER HEALTH SYSTEMS
Region: 1
City: CAMDEN State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 02/13/2019
Notification Time: 13:29 [ET]
Event Date: 02/12/2019
Event Time: 00:00 [EST]
Last Update Date: 02/13/2019
Notification Time: 13:29 [ET]
Event Date: 02/12/2019
Event Time: 00:00 [EST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - POTENTIAL GAMMA KNIFE TREATMENT UNDERDOSE RECEIVED
The following was received from the state of New Jersey via e-mail:
"While receiving treatment with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, the patient's head may have slipped forward in the stereotactic frame by two millimeters. This was not noticed until after the treatment was completed. The licensee is not sure when the slippage occurred. If the movement occurred during treatment, the dose received would have been 50 percent of the prescribed dose. The authorized user and authorized medical physicist are in discussions with the Radiation Safety Officer concerning the matter. 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.
The following was received from the state of New Jersey via e-mail:
"While receiving treatment with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, the patient's head may have slipped forward in the stereotactic frame by two millimeters. This was not noticed until after the treatment was completed. The licensee is not sure when the slippage occurred. If the movement occurred during treatment, the dose received would have been 50 percent of the prescribed dose. The authorized user and authorized medical physicist are in discussions with the Radiation Safety Officer concerning the matter. 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: 53875
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: DESERT NDT, LLC DBA SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: 42-35224-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: RODNEY CLAGG
Licensee: DESERT NDT, LLC DBA SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: 42-35224-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: RODNEY CLAGG
Notification Date: 02/13/2019
Notification Time: 14:35 [ET]
Event Date: 02/12/2019
Event Time: 16:45 [CST]
Last Update Date: 02/13/2019
Notification Time: 14:35 [ET]
Event Date: 02/12/2019
Event Time: 16:45 [CST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION
The following information was received via email from the state of North Dakota:
"Desert NDT, LLC dba Shawcor reported a 3.256 TBq (88 Ci) Iridium-192 sealed source (Industrial Nuclear Model 32, serial #022E) had disconnected from a drive cable connected to an Industrial Nuclear Model IR-100 radiography exposure device (serial #4321) at a temporary job site in Williston, ND on 2/12/2019. The event occurred at 1645 [MST] while the radiography crew, consisting of a radiographer and assistant radiographer, was performing industrial radiography under extreme cold weather conditions on a pipe section. Upon retracting the source after the third exposure, the crew noticed the radiography device's safety latch did not pop up indicating the source in the safe/locked position. Upon performing a radiation survey while approaching the device, the crew noticed an increased exposure rate indicating a source disconnect. The crew immediately retreated from the device and reset an actual 2 mR/hr public dose boundary and contacted their radiation safety officer who made arrangements for authorized retrieval personnel to dispatch to the site. The crew maintained constant surveillance of the site while awaiting the source retrieval personnel. The source was successfully retrieved at 2020 [MST]. At the time of the event, the radiographer had received 50 mR and the assistant radiographer 55 mR on their direct reading dosimeters. The retrieval individual received a total of 357 mR to the direct reading dosimeter located on his arm and 243 mR to the direct reading dosimeter located on his chest. Shawcor will provide a detailed report to the North Dakota Department of Health upon establishing the root cause and corrective actions."
NMED Item #ND190001
The following information was received via email from the state of North Dakota:
"Desert NDT, LLC dba Shawcor reported a 3.256 TBq (88 Ci) Iridium-192 sealed source (Industrial Nuclear Model 32, serial #022E) had disconnected from a drive cable connected to an Industrial Nuclear Model IR-100 radiography exposure device (serial #4321) at a temporary job site in Williston, ND on 2/12/2019. The event occurred at 1645 [MST] while the radiography crew, consisting of a radiographer and assistant radiographer, was performing industrial radiography under extreme cold weather conditions on a pipe section. Upon retracting the source after the third exposure, the crew noticed the radiography device's safety latch did not pop up indicating the source in the safe/locked position. Upon performing a radiation survey while approaching the device, the crew noticed an increased exposure rate indicating a source disconnect. The crew immediately retreated from the device and reset an actual 2 mR/hr public dose boundary and contacted their radiation safety officer who made arrangements for authorized retrieval personnel to dispatch to the site. The crew maintained constant surveillance of the site while awaiting the source retrieval personnel. The source was successfully retrieved at 2020 [MST]. At the time of the event, the radiographer had received 50 mR and the assistant radiographer 55 mR on their direct reading dosimeters. The retrieval individual received a total of 357 mR to the direct reading dosimeter located on his arm and 243 mR to the direct reading dosimeter located on his chest. Shawcor will provide a detailed report to the North Dakota Department of Health upon establishing the root cause and corrective actions."
NMED Item #ND190001
Power Reactor
Event Number: 53870
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: BILLY NEWMAN
HQ OPS Officer: JEFF HERRERA
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: BILLY NEWMAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/13/2019
Notification Time: 09:42 [ET]
Event Date: 02/12/2019
Event Time: 09:00 [CST]
Last Update Date: 02/13/2019
Notification Time: 09:42 [ET]
Event Date: 02/12/2019
Event Time: 09:00 [CST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
VINCENT GADDY (R4DO)
FFD GROUP (EMAIL)
VINCENT GADDY (R4DO)
FFD GROUP (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY - ENTERGY NON LICENSED SUPERVISOR FAILED TO REPORT FOR FITNESS FOR DUTY TEST
On 1/17/2019 at 0619 CST, a non-licensed employee supervisor failed to report to perform a fitness for duty test. The individual's access to the site was terminated.
The NRC Resident Inspector will be notified.
On 1/17/2019 at 0619 CST, a non-licensed employee supervisor failed to report to perform a fitness for duty test. The individual's access to the site was terminated.
The NRC Resident Inspector will be notified.