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Event Notification Report for August 02, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/1/2019 - 8/2/2019

** EVENT NUMBERS **


54128 54180 54181 54182

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 54128
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ACUREN INSPECTION
Region: 4
City: LA PORTE   State: TX
County:
License #: LL01774
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: CATY NOLAN
Notification Date: 06/24/2019
Notification Time: 15:19 [ET]
Event Date: 06/21/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE DURING RADIOGRAPHY

The following report was received from the Texas Department of State Health Services (the Agency) via email:

"The licensee called [the Agency] to report an event involving a radiographer and trainee. They were conducting [non-destructive testing] NDT on pipe, shooting 8 second shots with a 76.3 Curie Ir-192 source and a QSA Global D888 camera. The radiographer went to the darkroom to complete some paperwork. The trainee took down film and moved the collimator to the next shot location. It was about then [the trainee] realized [the trainee] had not retracted the source. [The trainee] reported the mistake to the radiographer trainer. The trainee did not have dosimetry and did not conduct a camera survey prior to moving the camera. Both the trainer and trainee were issued RadEye G's so they did not have direct reading dosimeters. [The trainer and trainee] took the trainee's dosimeter that was left in the truck and decided to expose it to the source for a few seconds. Then they reported that [the trainee] received 145 mrem on his dosimeter. When the RSO questioned them, they told [the RSO] what had happened and [the RSO] then conducted a time dose study. Based on reenactment, the RSO determined the trainee was exposed to the source about 6 seconds. The calculations indicated the trainee may have received 1456 rem to the hand. [The RSO] didn't take credit for the collimator shielding and used 5.9 R/hr/Curie at 1 foot as the basis for the calculation. The radiographer and trainee have been placed on administrative leave pending a decision from the company's review board. [The Agency] told [the licensee] that it would be investigating this event and that it will want to interview the radiographer and trainee."

The Agency believes the calculated dose may be high but will follow-up during the investigation.

Texas Incident #: 9691


* * * UPDATE ON 06/27/2019 AT 1531 EDT FROM KAREN BLANCHARD TO JEFFREY WHITED * * *

The following report was received from the Texas Department of State Health Services (the Agency) via email:

"During an investigation, the Agency learned there had been a miscommunication in the dose the licensee reported for the radiographer trainee's hand. The dose was not 1456 rem. The licensee is working with a consultant to make both a hand and whole body dose calculation. With the information provided, it appears the calculated dose to the radiographer trainee's hand should be less than 10 rem, which is below the regulatory reporting limit. The licensee will continue to monitor the radiographer trainee's hand. More information will be provided as it is obtained in accordance with SA-300."

Notified R4DO (Groom) NMSS (Rivera-Capella) and NMSS Events and INES (Milligan) via e-mail.

* * * RETRACTION ON 8/1/19 AT 1725 EDT FROM KAREN BLANCHARD TO MICHAEL BLOODGOOD * * *

The following retraction information was obtained from the state of Texas via email:

"Miscommunication during initial incident reporting. Exposure was well below reporting requirement/no overexposure."

Notified R4DO (Groom) and NMSS Event Notifications via email.

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Agreement State Event Number: 54180
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UPA TECHNOLOGY, INC.
Region: 3
City: WEST CHESTER   State: OH
County:
License #: 03214090000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/24/2019
Notification Time: 09:34 [ET]
Event Date: 07/12/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHARLES NORTON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING RADIOACTIVE SOURCE

The following information was obtained from the state of Ohio via email:

"[Manufacturing and Distribution] licensee received beta back-scatter on a device from customer for repair. Upon receipt, licensee conducted leak test and results indicated >185 Bq (0.005 microCi). Device contained 100 microCi Pm-147 source and is distributed under a general license.

"Upon investigation, licensee determined customer had used probe on wet surface, which clogged aperture, and customer attempted to clear aperture with sharp, pointed object which damaged source. At customer's request, licensee went to customer's location to survey area of use for contamination. No contamination was found."

Ohio report no.: OH190012

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Agreement State Event Number: 54181
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GENESIS HOSPITAL
Region: 3
City: ZANESVILLE   State: OH
County:
License #: 02120610006
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/24/2019
Notification Time: 10:37 [ET]
Event Date: 06/27/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHARLES NORTON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO THE LIVER

The following information is summarized from an email received from the state of Ohio:

A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment.

The patient and prescribing physician were notified.

The State will be performing an investigation.

Ohio report no.: OH190013

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: 54182
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: APPLUS RTD USA
Region: 1
City: SOUTH PORTLAND   State: ME
County:
License #: ME 05139 #19
Agreement: Y
Docket:
NRC Notified By: JAY HYLAND
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/24/2019
Notification Time: 12:58 [ET]
Event Date: 02/08/2017
Event Time: 17:30 [EST]
Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY EXPOSURE DEVICE

The following is a synopsis of information received via email from the state of Maine:

At approximately 1730 EST on 2/8/2017, Applus RTD had a source disconnect on a radiography exposure device at Casco Bay Steel in South Portland, Maine. The radiography exposure device was an Amersham Model 880 with an Ir-192 source. The Radiation Safety Officer (RSO) was contacted about the incident, went to the site, and helped secure the area with the help of a radiographer. The RSO replaced the drive cable and retrieved the source back into the radiography camera.

The drive cable and exposure device have been taken to the manufacturer to determine the cause of the problem.

The original notification for this event was made through the Nuclear Materials Event Database (NMED) under the 30-day reporting requirement due to the fact that the State felt it was not an equipment failure. During the State's review it was determined that a notification to NRC was required within 24 hours due to the equipment being disabled during the recovery operations.

Maine Event Report ID No.: ME 17-001


Page Last Reviewed/Updated Friday, August 02, 2019
Friday, August 02, 2019