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Event Notification Report for November 14, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/13/2019 - 11/14/2019

** EVENT NUMBERS **


54370543725437354374


Agreement State Event Number: 54370
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE DOW CHEMICAL COMPANY TEXAS INNOVATION CENTER - APB
Region: 4
City: LAKE JACKSON   State: TX
County:
License #: L00451
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: OSSY FONT 		Notification Date: 11/05/2019
Notification Time: 19:00 [ET]
Event Date: 11/05/2019
Event Time: 00:00 [CST]
Last Update Date: 11/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

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

"On November 5, 2019, the licensee notified the Agency that during routine, 6-month leak tests and shutter operation checks [at their Freeport, TX location], it found the shutter on one of its Vega, model SHF-2B, fixed nuclear gauges was stuck in the open position. The gauge contains a 1,000 milliCurie cesium-137 source (SN 0325CR). The gauge normally operates with the shutter in the open position. The gauge is mounted on the side of a vessel and there is no risk of exposure to any individual. The licensee has contacted a service company to schedule repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident # I-9722


Agreement State Event Number: 54372
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER HOLY SPIRIT CANCER CENTER
Region: 1
City: MECHANICSBURG   State: PA
County:
License #: PA-0249A
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: ERIC SIMPSON 		Notification Date: 11/06/2019
Notification Time: 09:12 [ET]
Event Date: 11/04/2019
Event Time: 00:00 [EST]
Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CHERUBINI (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE FAILS TO FUNCTION AS DESIGNED

The following information was received via fax:

"On November 4, 2019 the licensee was performing a mask treatment with the Elekta Gamma Knife Icon containing Cobalt 60. The treatment was interrupted when the High Definition Motion Management tracking system lost communication with 1 minute and 29 seconds remaining from shot B6, (planned for 2 minutes 13 seconds) and 2 minutes 36 seconds remaining for B3 (No treatment was delivered from this shot). The sources safely retracted into their home position and the software message prompted the user to reinitiate the Gamma Knife system; however, an error message occurred on each attempt to reinitiate. The system was then rebooted; however, the same error occurred again. The patient was removed from the treatment vault and a service call was made to Elekta. The onsite service engineer arrived that same day to troubleshoot and new parts were ordered and arrived on November 5, 2019. The intent is to complete the remaining treatment on November 5, 2019 once the Gamma knife repair and subsequent QA is completed. The doctor and patient were informed immediately. No overdose to anyone has occurred and no harm is expected to the patient. The [PA Bureau of Radiation Protection] will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190025

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: 54373
Rep Org: COLORADO DEPT OF HEALTH
Licensee: CHILDREN'S HOSPITAL COLORADO
Region: 4
City: AURORA   State: CO
County:
License #: CO 075-02
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: OSSY FONT 		Notification Date: 11/06/2019
Notification Time: 16:34 [ET]
Event Date: 11/01/2019
Event Time: 00:00 [MST]
Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION DUE TO DISLODGED CATHETER

The following was received from the Colorado Radioactive Materials Unit via email:

"On 11/6/19, the Colorado Department of Public Health and Environment was notified of a potential reportable contamination event. On 11/1/19, approximately 12 hours after an I-131 MIBG [meta-iodobenzylguanidine] administration (293.6 mCi) on 10/31/19, the patient's catheter was dislodged [while asleep]. I-131 contaminated urine spilled out of the catheter and contaminated the patient, bed, bedding, and floor under the bed. Most of the spill was located under the bed. The patient was decontaminated after the spill was identified and has since been released from the facility. After the patient was released, the extent of the spill was identified by the licensee. The treatment room has not been released for unrestricted use as of 11/6/19. Dose rates taken by the licensee indicate the potential for greater than 5 times the ALI [annual limit on intake] prior to decontamination efforts."

Colorado Event Report No: CO190018

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: 54374
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: APEX ENVIRONMENTAL
Region: 4
City: LENEXA   State: KS
County:
License #: 22-B791
Agreement: Y
Docket:
NRC Notified By: DAVID LAWRENZ
HQ OPS Officer: OSSY FONT 		Notification Date: 11/06/2019
Notification Time: 17:04 [ET]
Event Date: 11/06/2019
Event Time: 00:00 [CST]
Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - POTENTIAL LOST SOURCE

The following is a summary of an email received from the Kansas Department of Health and Environment's Radioactive Materials Team:

Apex Environmental reported that they sent their X-ray fluorescence to Massachusetts via a common carrier to be resourced. They have a delivery receipt, but have been unsuccessful in contacting the company. Perhaps the device is being held for payment. The State has requested additional information from Apex and will follow up with Massachusetts' Radiation Control Program and the vendor to determine the status of the device.

Kansas Event Report ID No: KS190010

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Page Last Reviewed/Updated Thursday, March 25, 2021