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Event Notification Report for May 03, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/2/2019 - 5/3/2019

** EVENT NUMBERS **


54025540265402854029


Agreement State Event Number: 54025
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: PALL HAUPPAUGE
Region: 1
City: HAUPPAUGE   State: NY
County:
License #: C1935
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: HOWIE CROUCH 		Notification Date: 04/24/2019
Notification Time: 13:55 [ET]
Event Date: 04/23/2019
Event Time: 09:00 [EDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NEW YORK AGREEMENT STATE REPORT - PANORAMIC IRRADIATOR SOURCE FAILED TO RETRACT

The following information was received from the state of New York via facsimile:

"The New York State Department of Health (NYSDOH) was notified by [the radiation safety officer] (RSO) of Pall Hauppauge (C1935) that they had an incident where the source did not retract completely leaving the source partially exposed for a period of time.

"According to the RSO, he was notified on April 23, 2019, at approx. [0900 hrs. EDT] of a fault at Vault 4, and arrived approximately 15 minutes later and found that the source had gotten stuck very slightly above the down (safe) position when the cycle ended. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action.

"The RSO contacted Nordion to discuss the situation and he was able to free the source and get it into the safe position without any issue. The RSO then checked the radiation levels in the irradiator and found that they were normal. There was no risk of personnel or public exposure at any time during this incident, nor was there any risk of contamination.

"The root cause for the source getting stuck has not been yet determined. The RSO will be working with Nordion to assess the equipment and decide the course of action.

"DOH will continue to monitor this incident.

"Pall Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."

NY Event Report ID No.: NY-19-06


Agreement State Event Number: 54026
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: WEEKS MARINE, INC.
Region: 4
City: HOUMA   State: LA
County:
License #: LA-2770-L01, AI # 2380
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 04/25/2019
Notification Time: 11:04 [ET]
Event Date: 04/24/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE STUCK SHUTTER

The following was received via email from the State of Louisiana:

"On 04/24/2019, Weeks Marine, Inc. was performing their routine operations with their licensed device. During their dredging operations, work ceased and the gauge shutter would not close when not in operation. The gauge shutter would not close due to dirt and grime residue in the shutter mechanism. Weeks Marine, Inc. called a service contractor, Applied Health Physics, to evaluate the situation and determine the best course of action to correct the problem (clean and lubricate).

"The sources and device with the stuck open shutter will remain installed on the process until the repairs are made. This is not a radiation exposure hazard and does not pose a health and safety situation for the Weeks Marine, Inc. employees or the general public.

"The density/level gauge is a Berthold Model 7400D series device/source holder, loaded with an approximately 1500 mCi Cs-137 source, s/n 372-1-85. Initial activity was 3000 mCi in 1985 [manufacture] date.

"This event is being reported to the NRC Operations Center as required by Regulatory Requirement 10 CFR Part 30.50(b)(2) and LAC 33:XV 340.B."

Louisiana Event Report ID No.: LA-190006

* * * UPDATE AT 0933 EDT ON 4/26/2019 FROM JOSEPH NOBLE TO JEFF HERRERA * * *

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

"[On] 04/25/2019, at [1440 CDT] Weeks Marine reported that Applied Technical Services had completed the maintenance on this fixed density gauge and that Hopper Dredge # 456 is back in operation. This event is considered completed and closed."

Notified the R4DO (Young) and NMSS (via email).


Agreement State Event Number: 54028
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: CAPE COD HOSPITAL
Region: 1
City: HYANNIS   State: MA
County:
License #: 44-0164
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: BETHANY CECERE 		Notification Date: 04/25/2019
Notification Time: 12:09 [ET]
Event Date: 04/23/2019
Event Time: 16:11 [EDT]
Last Update Date: 04/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE GREATER THAN PRESCRIBED DOSE

The following was sent by email from the Commonwealth of Massachusetts:

"The licensee reported on April 24, 2019 that it discovered on April 23, 2019 two High Dose-rate Remote Afterloader (HDR) medical events where tissue other than the treatment site received a dose exceeding the reporting requirements 105 CMR 120.594(A)(1)(c). One of the medical events occurred in March of 2019 and the other occurred in October of 2018.

"The licensee reported that a 5 cm offset from the target location resulted in dose to unintended tissue during each treatment.

"The licensee used a Varian Medical Systems, Inc. Model VariSource iX HDR containing iridium-192 to deliver the doses for both treatments. Each prescribed dose to each patient was 10 gray (1,000 rad) to the vaginal cavity across two fractions.

"Both events occurred as a result of an unintended area of each patient's vaginal cavity receiving a portion of the prescribed dose. The licensee reported that the cause of the events is a combination of a change in applicator size and incorrect parameters input into the device console. Some two years ago, the size of the vaginal applicator changed from 120 cm in length to 125 cm in length, but there were no issues until the two aforementioned events. From the administration documentation, the licensee determined that the technician erroneously entered 120 cm into the device console rather than 125 cm, effectively causing a 5 cm offset. As a result the lower 5 cm of each patient's vaginal cavity received more dose than intended. The exact number is yet unknown. The licensee will provide additional information in a written report.

"The licensee reported that the referring physician, who is the same for each patient, has been notified and that the referring physician intends to notify each patient.

"The Agency [Massachusetts Radiation Control Program] plans to perform a special inspection and considers this event to be open."

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: 54029
Rep Org: AZ DEPARTMENT OF HEALTH SERVIC
Licensee: ABRAZO SCOTTSDALE CAMPUS
Region: 4
City: PHOENIX   State: AR
County:
License #: 07-246
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JOANNA BRIDGE 		Notification Date: 04/25/2019
Notification Time: 17:42 [ET]
Event Date: 04/25/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANDREA KOCK (NMSS)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE

The following was received from the state of Arizona via e-mail:

"The [Arizona Department of Health Services] received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event.

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

"Arizona incident Number 19-008."

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.

* * * UPDATE ON 4/26/19 AT 1134 EDT, FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following was received from the state of Arizona via e-mail:

"This correspondence is a follow-up to the notification sent [on 4/25/19] regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead [certified radiation technologist] in an [operating room] department of a hospital performing 6-7 fluoroscopic procedures per day."

It is believed that the actual exposure was just to the badge and not to the person.

Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).

Page Last Reviewed/Updated Wednesday, March 24, 2021