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Event Notification Report for February 22, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/21/2019 - 2/22/2019

** EVENT NUMBERS **


53836 53871 53872 53873 53874 53875

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53836
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: DALLAS   State: TX
County:
License #: L04878
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JEFFREY WHITED
Notification Date: 01/18/2019
Notification Time: 16:49 [ET]
Event Date: 01/18/2019
Event Time: 00:00 [CST]
Last Update Date: 02/21/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 2/22/2019

EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION OF RADIUM-223 TO PATIENT

The following was received via e-mail:

"On January 18, 2019, the Texas Department of State Health Services was contacted by the licensee's radiation safety officer (RSO) and notified that they had a treatment error occur at their facility. The error occurred to a patient who was to be treated with multiple fractions of radium-223. The treatment was to relieve bone pain in the patient. The dose from each fraction was based on the weight of the patient. The fraction activity was determined to be 75 microCuries based on the weight in pounds of the patient involved. The technician involved with administering the dose mistook the weight units and ordered the fraction dose based on the patients weight measured in kilograms. As a result the patient was administered 165 microCuries of radium-223 instead of the 75 microCuries. The error was discovered as they were preparing to administer the second dose (The date of the first dose was not provided). The RSO stated the patient and prescribing physician have been contacted and notified of the error. The RSO stated the patient would not experience any adverse effects from the dose received. The RSO stated the patient's treatment going forward is being reviewed. The RSO stated they would provide a written report next week.

"At 1530 hours the Agency contacted the RSO and confirmed the dose to the patient. The RSO stated the dose to the bones from the activity given would be 693 rad instead of 315 rad.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Department of State Health Services Incident Number 9651

* * * RETRACTION AT 1558 EST ON 2/21/2019 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"This event was determined not to be a reportable event. It does not meet the reportability criteria. Dosage on the written directive, signed by the prescribing physician/authorized user, was the dosage administered to the patient."

Notified the R4DO (Deese) and NMSS (via e-mail).

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: 53871
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTH AMERICAN STAINLESS
Region: 1
City: GHENT   State: KY
County:
License #: 201-499-57
Agreement: Y
Docket:
NRC Notified By: ANJAN (AJ) BHATTACHARYYA
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 02/13/2019
Notification Time: 12:00 [ET]
Event Date: 02/10/2019
Event Time: 00:00 [EST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE DEVICE DAMAGED BY MOLTEN STEEL

The following report was received from the Commonwealth of Kentucky via fax:

"KY RHB [Kentucky Radiation Health Branch] was notified by telephone on 2/12/2019 at 1315 EST by a representative from a specifically licensed facility, North American Stainless, that on Sunday, 2/10/2019, North American Stainless encountered a 'breakout' when molten steel escaped and poured onto billet caster molds located below a 'tundish' filled with molten steel. One of the molds attached to a Berthold Model No. LB300ML Mold Level Control fixed gauging device, serial number 9415, containing 1 mCi (37 MBq) Co-60 (source serial number 1819-11-15) was covered with the liquid steel encapsulating the source holder. After the steel and mold had cooled, it was freed on 2/12/2019 and segregated. The encapsulating steel rendered the device on-off mechanism (shutter) inoperable. Initial readings taken with a Ludlum 2241-3 survey instrument measured 6.25 mR/hr measured 12 inches directly in front of the window, and 1.25 mR/hr measured 90 degrees from the line of the window measured at a distance of 12 inches. Readings at the back of the source holder were 132 microR/hr measured at a distance of 12 inches. No overexposures have been reported. On 2/12/2019, Radiametric Technologies, a service provider located in Lorain, Ohio, requested reciprocal approval and was granted reciprocity on 2/13/2019 in order to assess and remediate the situation.

"The fixed gauging device involved in the incident was recently leak tested (test conducted on 7/31/2018) by Suntrac Services, League City TX. Radiametric Technologies, Lorain OH, recently tested the source holder on-off mechanism (1/31/2019) and it was found to be in good working order. North American Stainless is reviewing the incident to avoid future incidents involving 'tundish' failures. A full report will be provided once the remediation is complete.

"Reporting criteria in 10 CFR 30.50(b)(2)."

KY Report #KY190001

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Non-Agreement State Event Number: 53872
Rep Org: US ARMY AVIATION MISSILE COMMAND
Licensee: US ARMY
Region: 1
City: REDSTONE ARSENAL   State: AL
County:
License #: 01-00126-21
Agreement: Y
Docket:
NRC Notified By: HAROLD DEASON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 02/13/2019
Notification Time: 12:12 [ET]
Event Date: 01/31/2019
Event Time: 00:00 [CST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

REPORT OF LOSS OF AM-241 SOURCES CONTAINED IN HELICOPTER LASERS

The following is a summary of a call with the US Army Aviation Missile Command.

While taking inventory of sources located in decommissioned helicopter lasers, the US Army Aviation Missile Command identified that they were missing 88 Am-241 sources located in 44 helicopter lasers. It can not be determined exactly where the sources were lost, though the licensee is going to provide possible options, including that the lasers could have been lost during combat. It is assumed that the sources are not in public areas. It can not be determined when the sources were lost.

The licensee noted that it is unlikely anyone would receive a dose as a result of this loss of material because it is difficult to retrieve the sources.

The US Army continues to attempt to find the sources during routine house keeping activities. They have a similar license for a new aircraft and will perform inventory checks more frequently to ensure that any losses are more promptly reported.

The licensee has notified the NRC Regional Office.

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: 53873
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: BARD BRACHYTHERAPY
Region: 3
City: CAROL STREAM   State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 02/13/2019
Notification Time: 13:20 [ET]
Event Date: 02/13/2019
Event Time: 00:00 [CST]
Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - REPORT OF LOSS OF BRACHYTHERAPY SEEDS

The following was received from the State of Illinois via e-mail:

"The agency [Illinois Emergency Management Agency] was notified the morning of 2/13/19 by Bard Brachytherapy, IL-02062-01, in Carol Stream to advise that a package of (34) I-125 brachytherapy seeds arrived with no obvious damage, but (5) of the (34) seeds were unaccounted for. Facility staff were immediately alerted of the issue when [the common carrier] opened the dock door and meters alerted to elevated radiation readings. (2) seeds were identified by the licensee staff outside of the package on the floor. Package wipes were taken and there is no indication of removable contamination. Each of the seeds has a current activity of 0.346 mCi and would have an exposure rate of approximately 0.6 mR/h at one foot. There is currently no reason to suspect any malicious intent or deliberate diversion of package contents. The five unaccounted for seeds contain an aggregate activity of 1.73 microCuries as of 2/13/19.

"The [common carrier] driver's vehicle was surveyed by licensee staff. Additionally, it was determined that the driver picked the package up at O'Hare airport, went to the [common carrier's] hub and then directly to Bard. Licensee staff are coordinating with [the common carrier] and are currently en route to the hub to perform surveys. Additional details will be provided as they become available. This matter remains open."

Illinois Item Number: IL190008

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: 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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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.

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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


Page Last Reviewed/Updated Friday, February 22, 2019
Friday, February 22, 2019