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Event Notification Report for August 13, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/12/2020 - 8/13/2020

** EVENT NUMBERS **


54813 54814 54815 54817 54818 54832

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Agreement State Event Number: 54813
Rep Org: ALABAMA RADIATION CONTROL
Licensee: Applied Technical Services, Inc.
Region: 1
City: Mobile   State: AL
County:
License #: 1454
Agreement: Y
Docket:
NRC Notified By: Neil Maryland
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 13:29 [ET]
Event Date: 08/03/2020
Event Time: 17:00 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following is a summary of information received from the Alabama Department of Public Health via telephone:

On August 3, 2020 at approximately 1700 CDT, the licensee was working at an asphalt plant in Mulga, AL, when one of its radiography cameras was damaged. The source of the radiography camera was being exposed when a magnetic stand, which was attached to the source, fell and crushed part of the guide tube. Multiple efforts to retrieve the source were unsuccessful. The licensee's radiation safety officer (RSO) responded to the scene. The RSO was able to retract the source after cutting part of the guide tube.

No un-badged personnel received any dose as part of the event and applicable dosimetry badges have been sent for emergency processing. The camera is being sent to the manufacturer for investigation.

Alabama Incident Report No.: 20-16

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Agreement State Event Number: 54814
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS Group, Inc.
Region: 4
City: Geismar   State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 15:38 [ET]
Event Date: 08/04/2020
Event Time: 11:20 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following is a summary of information that was received from the Louisiana Department of Environmental Quality via email:

On August 4, 2020, at 1120 CDT, at a job site in New Iberia, LA, the drive cable on one of the licensee's industrial radiography cameras broke six inches from the drive cable to source cable connector. The radiographers set up a 2mR boundary after being unable to retract the source into a shielded position. One of the licensee's radiation safety officers (RSO) was called to the scene and was able to retrieve the source. During this event the RSO received a dose of 313 mR and the crew received 16 and 11 mR according to their insta-dose badges.

The radiography camera is a SPEC 150 (s/n: 2131) with a 56 Ci Ir-192 source (s/n: BF2401).

Event Report ID No.: LA20200007

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Agreement State Event Number: 54815
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Methodist Hospitals of Dallas
Region: 4
City: Dallas   State: TX
County:
License #: L 00659
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 21:21 [ET]
Event Date: 08/03/2020
Event Time: 00:00 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"On August 4, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that an event occurred during the administration of Y-90 TheraSpheres on August 3, 2020. The RSO stated the written directive prescribed dosage was 22.3 mCi. During the administration of the TheraSpheres, the pressure observed by the Authorized User (AU) became significantly less than expected, and activity leaving the dose administration vial into the catheter decreased significantly before the entire dose could be delivered. The RSO stated a TheraSpheres (Boston Scientific) representative was present during the procedure and assisted the authorized user through troubleshooting, and remote consultation with TheraSpheres medical specialists. However, flow from the dose administration vial could not be re-initiated. The AU chose to end the procedure.

"Following survey of the dose administration vial in the hot lab, it was determined that approximately 7.1 mCi (31.8 percent) was delivered to the patient. The RSO stated that their initial assessment is that this was the result of a device malfunction. There were no adverse effects to the patient. It is likely that a second procedure will be scheduled to complete the procedure. The RSO stated that the patient and referring physician were notified.

"This is the first event involving TheraSpheres reported to the Agency by this licensee.

"The RSO stated additional information on the event will be provided within the next 10 days. Additional information will be provided as it is received by the Agency in accordance with SA-300."

Texas Incident Number: 9782

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: 54817
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: International Paper Savannah Mill
Region: 1
City: Savannah   State: GA
County:
License #: 143-1
Agreement: Y
Docket:
NRC Notified By: Shatavia Walker
HQ OPS Officer: Andrew Waugh
Notification Date: 08/05/2020
Notification Time: 13:19 [ET]
Event Date: 07/21/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/06/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 8/7/2020

EN Revision Text: AGREEMENT STATE REPORT - BROKEN SHUTTER

The following is a summary of information received via email:

On July 21, 2020, the licensee was conducting a semi-annual leak test and inventory when they discovered a shutter was not working on an in service source device. The source has been barricaded and appropriate warnings have been posted. An offsite technician is being contacted to replace the device.

The device is an Ohmart Model A-2102 density gauge with a 100 mCi Cs-137 source.

* * * UPDATE ON 8/6/20 AT 1757 EDT FROM SHATAVIA WALKER TO ANDREW WAUGH * * *

The following is a summary of information received via email:

The broken shutter concerned in this event was stuck in the open position.

Notified R1DO (Arner) and NMSS Event Notifications via email.

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Agreement State Event Number: 54818
Rep Org: VT OFFICE OF RADIOLOGICAL HEALTH
Licensee: Tam Recycling
Region: 1
City: Pownal   State: VT
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Francis O'Neill
HQ OPS Officer: Andrew Waugh
Notification Date: 08/05/2020
Notification Time: 17:17 [ET]
Event Date: 02/27/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/05/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT RADIOACTIVE MATERIAL REJECTED AT WASTE FACILITY

The following is a summary of information received via email:

On 2/27/20, the Vermont Department of Health (VDH) was notified that a waste transport truck was rejected at a waste facility in Hudson Falls, NY. The truck was rejected because radioactive material was detected measuring 1.4 mrem/hr while background radiation was 0.01 mrem/hr. The truck was redirected to Tam Recycling in Pownal, VT, and instructed to isolate the waste.

On 3/2/20, the Vermont Hazardous Materials Response Team (VHMRT) and a member of VDH Radiation Control responded to the recycling center. The radioactive waste was identified as human bladder control products which contained an estimated 4.6 microCi of I-131. The contents were double bagged and isolated in a remote storage area at the recycling center for to decay.

On 4/3/20, VDH issued Vermont Information Notice IN 20-001 (Release of humans and animals receiving I-131 therapy) to all Vermont radioactive materials licensees who are authorized to use I-131. This Information Notice recommends all affected licensees review their I-131 administration procedures, patient release criteria, and pet owner release instructions.

On 6/26/20, a VDH inspector returned to survey the material, and found that the radiation levels of the material were indistinguishable from background.

With the decay of the I-131 waste this incident has been closed out by VDH on 8/5/20.

Vermont Incident No.: VT-20-001

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Power Reactor Event Number: 54832
Facility: Palo Verde
Region: 4     State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Sean Dornseif
HQ OPS Officer: Brian Lin
Notification Date: 08/12/2020
Notification Time: 11:24 [ET]
Event Date: 08/11/2020
Event Time: 14:32 [MST]
Last Update Date: 08/12/2020
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
DAVID PROULX (R4DO)
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
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY - LICENSED OPERATOR VIOLATED THE FFD POLICY

On August 11, 2020, at approximately 1432 MST, a licensed operator's test results were confirmed positive for use of a controlled substance following a random Fitness For Duty screening test. The individual's unescorted access has been terminated in accordance with station procedures.

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Thursday, August 13, 2020
Thursday, August 13, 2020