Event Notification Report for July 05, 2019
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U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 54132 | 54133 | 54134 | 54135 | 54136 | 54148 |
| 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. |
| 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. |
| 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. |
| 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 |
| 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. |
| 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 Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021