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Event Notification Report for July 05, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/4/2019 - 7/5/2019

** EVENT NUMBERS **


54132 54133 54134 54135 54136 54148

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Agreement State Event Number: 54132
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CONE HEALTH WESLEY LONG HOSPITAL
Region: 1
City: GREENSBORO   State: NC
County:
License #: 041-0153-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: CATY NOLAN
Notification Date: 06/26/2019
Notification Time: 15:45 [ET]
Event Date: 06/24/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE DIFFERENT THAN PRESCRIBED

The following was received from the North Carolina Radioactive Materials Branch via email:

"On 6/24/19, a patient underwent a Xofigo therapy treatment and did not receive the full dose as prescribed but had to return the following day to receive the full dose on 6/25/19. Due to the size of the patient and the fact that Xofigo doses typically arrive to the licensee in 10cc syringes, [in order] to accommodate the patient with the correct dose, the dose prescribed to the patient was split between two doses/syringes. On 6/24/19, licensee personnel delivered the first dose of 119.19 microCuries (Ra-223) which was approximately 50 percent of the prescribed dose. It was discovered after the patient was discharged that the remaining dose was still in the hot lab. The prescribing physician was immediately notified and the patient returned the following day, 6/25/19, and received the second dose of 114.5 microCuries (Ra-223). NC Radiation protection is currently investigation this incident and will follow up to close and complete this report."

NC tracking number: 190021

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: 54133
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: FIBER INDUSTRIES
Region: 1
City: DARLINGTON   State: SC
County:
License #: SC-360
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: OSSY FONT
Notification Date: 06/27/2019
Notification Time: 09:21 [ET]
Event Date: 03/01/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE TO MEMBERS OF THE PUBLIC

The following was received from the South Carolina Department of Health and Environmental Control (the Department) via phone:

On June 26, 2019, the Department was officially notified that 22 workers (members of the public) received doses while performing vat cleaning at Fiber Industries, a polymer manufacture. Seven of those individuals received a dose exceeding the annual limit of 100 mrem, as stated in 10 CFR 20.1301. The exposures occurred in March and April 2019, after which the Department was notified of the potential overexposures. The cleaning occurred in two vessels that had the Cs-137 gauge sources in the open position but no tag out. The gauges are a level density gauge (300 mCi, 1974) and a filling dip tube (20 mCi, 1974). The doses were calculated by Chase Environmental Group based on the individuals' time in the vessels and distance from the sources. The midpoint dose estimate for the seven individuals range from 112 to 205 mrem.

The Department conducted a site visit on June 14, 2019, and is currently evaluating the incident. Based on the 30-day notification provided to the Department on June 26, it is unknown if the individuals have been notified and no names were provided.

Additional information will be sent to the NRC once the review is complete.

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Non-Agreement State Event Number: 54134
Rep Org: U.S. NAVAL RESEARCH LABORATORY
Licensee: U.S. NAVAL RESEARCH LABORATORY
Region: 1
City: WASHINGTON   State: DC
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: JERETTE SPANN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/27/2019
Notification Time: 09:30 [ET]
Event Date: 05/09/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

LEAKING NI-63 SOURCES

The following is a summary of the phone conversation with the licensee:

Two Ni-63 sources (Agilent Technologies S/Ns PRO30 and U11381) used in an electron capture detector were found to be leaking. Both sources contained 15 mCi Ni-63. Leakages were 0.048 and 0.039 microCuries. Both sources will be transferred to Agilent Technologies for disposal. Leak tests are performed every 6-months. The last leak tests were performed on 01/08/2019.

The licensee contacted NRC Region I regarding this event.

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Agreement State Event Number: 54135
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ISOMEDIX OPS INC DBA STERIS APPL STERIL TECH
Region: 1
City: WHIPPANY   State: NJ
County:
License #: 507147
Agreement: Y
Docket:
NRC Notified By: CATHERINE BIEL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/27/2019
Notification Time: 09:45 [ET]
Event Date: 06/25/2019
Event Time: 18:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POOL WATER CONDUCTIVITY EXCEEDS LIMIT

The following was received via e-mail:

"At approximately 1800 EDT on 6/25/2019, the conductivity of the underwater pool irradiator water rose to 308 microSiemens/cm and remained in this range throughout the night. This was in conjunction with low flow through the water circulation pump. The pump was repaired the morning of 6/26/2019 and subsequent conductivity readings have ranged from 24.3 microSiemens/cm to 13.9 microSiemens/cm. The licensee is currently on a plan of changing the deionization tanks every two days to continue cleaning the water. In addition they are working with a supplier on additional methods to clean the pool water."

New Jersey Event Report Identification No.: INV190001-507147

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Agreement State Event Number: 54136
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: THE CLEVELAND CLINIC FOUNDATION
Region: 3
City: SANDUSKY   State: OH
County:
License #: 02230220000
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 06/27/2019
Notification Time: 13:32 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE DUE TO DISLODGING OF DEVICE

The following was received via e-mail:

"A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder.

"The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery.

"The patient and referring physician have been notified."

Ohio Item Number: OH190009

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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Power Reactor Event Number: 54148
Facility: SUSQUEHANNA
Region: 1     State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: SCOTT MYRTHEL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/04/2019
Notification Time: 12:36 [ET]
Event Date: 07/04/2019
Event Time: 08:44 [EDT]
Last Update Date: 07/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
CHRISTOPHER LALLY (R1DO)
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY REPORT - LICENSED SUPERVISOR FAILED A RANDOM SCREENING

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

The licensee notified the NRC Senior Resident Inspector.


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019