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Event Notification Report for March 28, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/27/2019 - 3/28/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State	Event Number: 53902
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: KAISER PERMANENTE Region: 4 City: LOS ANGELES State: CA County: License #: 0372 Agreement: Y Docket: NRC Notified By: ROBERT GREGER HQ OPS Officer: JEFF HERRERA	Notification Date: 02/28/2019 Notification Time: 20:51 [ET] Event Date: 02/25/2019 Event Time: 00:00 [PST] Last Update Date: 03/27/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RICK DEESE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 3/28/2019

EN Revision Text: AGREEMENT STATE REPORT - UNINTENDED DOSE TO NON-TARGET TISSUE

The following was received from the state of California:

"The licensee reported an unintended dose to non-target tissue of a patient from an HDR [High Dose Rate] treatment, apparently due to mispositioning of the uterus-ovary applicator. The unintended dose occurred on the final of four fractions. The target tissue received the intended dose in each of the four fractions, but non-target tissue of the bowel received in excess of 50 rem and 150 percent of the expected dose to the non-target bowel tissue from the four fractions combined, with the excess non-target bowel dose occurring in the final fraction due to the mispositioned applicator.

"The licensee will submit a 15-day written report to the California Department of Public Health-Radiologic Health Branch (CDPH-RHB) in accordance with 10 CFR 35.3045(d), and will include the calculated dose to the non-target tissue of concern. That report will be forwarded to NRC by CDPH-RHB.

"The referring physician was informed of the unintended dose to the non-target bowel tissue."

CA 5010 Number: 022719

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 AT 1644 EDT ON 03/27/2019 FROM ROBERT GREGER TO JOANNA BRIDGE * * *

The following was received via e-mail:

"The licensee determined that a dose volume of 5 cc was appropriate for the unintended tissue exposure (instead of 2 cc). Based on the 5 cc tissue volume, the dose was less than the Medical Event reporting criteria contained in 10 CFR 35.3045(a)(3). Please note that the original event submittal by California erroneously referenced the applicable regulatory reporting requirement as 10 CFR 35.3045(a)(1)(iii)."

Notified R4DO (Kozal) and NMSS Events.

Agreement State	Event Number: 53945
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: IPSCO KOPPEL TUBULARS, LLC Region: 1 City: BEAVER FALLS State: PA County: License #: PA-1049 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: THOMAS KENDZIA	Notification Date: 03/19/2019 Notification Time: 10:54 [ET] Event Date: 03/18/2019 Event Time: 00:00 [EDT] Last Update Date: 03/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - EQUIPMENT DISABLED AND FAILED TO FUNCTION AS DESIGNED

The following was received from the Commonwealth of Pennsylvania via fax:

"On March 19, 2019, the licensee informed the Department [PA Department, Bureau of Radiation Protection] of a fixed gauge becoming disabled during routine source movement. It is reportable per 10 CFR 30.50(b)(2). Event location is Koppel, PA.

"During the process of installing a Co-60 source rod and moving it from a transfer shield to a gauge and industrial process mold, the licensee observed difficulty in getting the source rod to insert into the mold. It is suspected that the rod is slightly bent. The rod was retracted into the fully shielded position in a spare transfer shield. The transfer shield containing the Co-60 rod was then taken to a designated storage area where it is secured from unauthorized access. A service provider has been contacted for possible repair or replacement. No exposures over regulatory limits occurred.

"Radionuclide: Co-60
Manufacturer: Berthold Technologies
Source Model: P 2608-100
Gauge Model: LB 300 ML
Source Serial Number: unknown at this time
Activity: approximately 12 milliCuries

"The rod has been securely stored and placed out of service until repairs or return can be accomplished by a licensed service provider. The Department has scheduled a reactive inspection. More information will be provided when available.

"PA Event Report ID No: PA190009"

Agreement State	Event Number: 53946
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: CROSSBRIDGE COMPLIANCE LLC Region: 4 City: LONGVIEW State: TX County: License #: Licen-RAM-L06904 Agreement: Y Docket: NRC Notified By: MATTHEW KENNINGTON HQ OPS Officer: BETHANY CECERE	Notification Date: 03/19/2019 Notification Time: 12:13 [ET] Event Date: 02/24/2019 Event Time: 00:00 [CST] Last Update Date: 03/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SOURCE NOT CONTROLLED WHILE VEHICLE IMPOUNDED

The following was received from the state of Texas by email:

"On February 25th, 2019, the Agency [Texas Department of State Health Services] was notified by a licensee that control was lost of a Spec 150 (SN: 2472) radiography camera containing a 49 Curie iridium-192 source (Source SN: ZL1103, model G-60 manufactured by SPEC) as the result of an employee arrested for driving while intoxicated [in Odessa, TX]. The vehicle containing the source was impounded. The keys to the vehicle were left with the impound yard. The vehicle was locked, alarm armed, in a fenced lot, behind a locked gate, and under video surveillance. Keys to the darkroom, where the source was stored, were located in the center console of the vehicle. No individuals accessed the vehicle while in the impound lot. The vehicle was retrieved by the licensee shortly after being notified of the arrest and impounding. The source was out of the licensee's control for approximately eleven hours. No exposures occurred as a result of this event."

TX Incident #: 9657

Agreement State	Event Number: 53948
Rep Org: OK DEQ RAD MANAGEMENT Licensee: OKLAHOMA STATE UNIVERSITY Region: 4 City: STILLWATER State: OK County: License #: OK-00237-03 Agreement: Y Docket: NRC Notified By: KEVIN SAMPSON HQ OPS Officer: OSSY FONT	Notification Date: 03/20/2019 Notification Time: 14:14 [ET] Event Date: 03/20/2019 Event Time: 00:00 [CDT] Last Update Date: 03/20/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED RADIATION WORKER

The following was received from the Oklahoma Department of Environmental Quality via email:

"A person administering a dose of I-131 to a cat at Oklahoma State University (OK-00237-03) was found to have contamination on the palm of one hand after the injection. According to the licensee, the contaminated individual is a radiation worker. The amount of material on the individual is estimated at 0.17 microCuries and it is believed to have been on the person for 15 to 30 minutes. After the discovery, the person was decontaminated, which reduced the radiation level to background. The [contaminated individual] will be bio-assayed tomorrow."

Inspection number 19-01

Page Last Reviewed/Updated Wednesday, March 24, 2021