Event Notification Report for October 02, 2020
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U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 54878 | 54906 | 54909 | 54910 |
| !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | |
| Agreement State | Event Number: 54878 |
| Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: Home Depot #3210 Region: 4 City: Scottsbluff State: NE County: License #: GL0644 Agreement: Y Docket: NRC Notified By: Deb Wilson HQ OPS Officer: Thomas Herrity |
Notification Date: 09/03/2020 Notification Time: 16:17 [ET] Event Date: 05/31/2012 Event Time: 00:00 [CDT] Last Update Date: 10/01/2020 |
| Emergency Class: Non Emergency 10 CFR Section: Agreement State |
Person (Organization): RICK DEESE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
EN Revision Imported Date : 10/2/2020 EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS This is information received from the state of Nebraska via email: "In conducting a search for records for NRC Event #54500, it was determined that Home Depot #3210 was remodeled at the same time as Home Depot #3208 in Grand Island, NE and all (16) tritium exit signs were exchanged for LED in May 2012. Disposal records are unavailable due to Staybright Electric, the contractor in charge of replacement and disposal, going out of business. Home Depot was unable to produce disposal records but it is their belief that the signs were disposed of properly as Staybright conducted tritium exit sign removals for other Home Depots in the region prior to their closing for which records of disposal were obtained, demonstrating knowledge of proper procedure. "The State of Nebraska also checked with Tritiumdisposal.com and SRBT in attempt to locate records as the outlets of disposal for Staybright, but no records were found. "Home Depot currently has a plan in place that was submitted to the NRC in July of 2009 for facility management to reiterate tritium exit sign management requirements to existing vendors to ensure signs are managed within NRC requirements. As part of ongoing tritium exit sign servicing it is very reasonable to believe that Staybright transferred and disposed of tritium exit sign inventory properly. Home Depot continues to proactively address and replace (as appropriate) its remaining tritium exit sign inventories through the use of professional, third party vendors and continues to responsibly manage its existing inventories at current stores throughout the United States. "A Home Depot corporate representative will track all purchases and returned signs to ensure accurate inventory and disposal. "All Tritium Exit Signs have been replaced with LED. "Home Depot will no longer install tritium exit signs within newly constructed locations." Nebraska Item Number: NE200006 * * * RETRACTION ON 10/1/2020 AT 1020 EDT FROM DEB WILSON TO ANDREW WAUGH * * * This is information received from the state of Nebraska via email: "While the Home Depots were remodeled at similar times, it was found that the tritium exit signs at Store 3210 in Scottsbluff were kept in service until the end of their useful life. Records were recovered showing all signs being disposed of by Curie Environmental Services in Albuquerque, NM on 9/20/2019." Notified R4DO (Silva), NMSS Events (email), and ILTAB (email). 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 |
| Agreement State | Event Number: 54906 |
| Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: Western Illinois Cancer Treatment Center Region: 3 City: Galesburg State: IL County: License #: IL-01902-01 Agreement: Y Docket: NRC Notified By: Gary Forsee HQ OPS Officer: Brian Lin |
Notification Date: 09/23/2020 Notification Time: 14:58 [ET] Event Date: 09/22/2020 Event Time: 00:00 [CDT] Last Update Date: 09/23/2020 |
| Emergency Class: Non Emergency 10 CFR Section: Agreement State |
Person (Organization): JAMNES CAMERON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL) |
Event Text
| AGREEMENT STATE REPORT - MEDICAL EVENT The following information was received via email from the Illinois Emergency Management Agency (The Agency): "The Agency was notified on 9/23/20 that a high dose rate afterloader (HDR) administration resulted in a medical event on 9/22/20 at the Western Illinois Cancer Treatment Center in Galesburg, IL. The licensee states no untoward effects are expected of the patient. Agency staff will respond and evaluate on 9/24/20. The Agency was contacted by an authorized medical physicist and radiation safety officer for Western Illinois Cancer Treatment Center in Galesburg (RML IL-01902-01), to report a medical event that occurred the previous day on September 22, 2020. Reportedly, a patient was prescribed a 30 Gy therapeutic dose to the vaginal cuff, to be delivered over a series of (5) fractionated 6 Gy administrations. Two of the 6 Gy administrations had already been performed on 9/15/20 and 9/18/20 without issue. The patient arrived for the third fractionated dose of 6 Gy on 9/22/20. An unnamed nurse was present as well. It is unclear if an authorized medical physicist was physically present at time of administration. Rather than delivering the dose through the vaginal cavity, the HDR applicator was inserted into the rectal cavity. This was not noticed until after the treatment was delivered. Based on the information currently available, the written directive specified a 6 Gy fraction to be delivered to the vaginal treatment area. The dose delivered was 1.46 Gy. This meets the reportable criteria in 32 Ill. Adm. Code 335.1080(a)(1) for an underdose. Additionally, had the administration gone as prescribed; the rectum would have only received (for 50% of the volume) 1.53 Gy per fraction. In this administration, the dose to the rectum (50% of volume) was 3.94 Gy. This also meets the reportable criteria for an overexposure. The format of this report provides data in the context of an overexposure. The language in the written directive will be reviewed, as well as procedures, personnel present, treatment plan and post-plan calculations on September 24, 2020. Reporting timeliness appears appropriate at this time. A written report will be required to the Agency by October 7, 2020. The referring physician has been notified. The patient is being advised today, which at this time appears to be in accordance with applicable regulations. This report will be updated as additional information becomes available." Illinois Item Number: IL200017. 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: 54909 |
| Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: Terracon Consultants Region: 1 City: Sarasota State: FL County: License #: 3817-13 Agreement: Y Docket: NRC Notified By: Mark Seidensticker HQ OPS Officer: Thomas Herrity |
Notification Date: 09/24/2020 Notification Time: 12:41 [ET] Event Date: 09/24/2020 Event Time: 09:30 [EDT] Last Update Date: 09/24/2020 |
| Emergency Class: Non Emergency 10 CFR Section: Agreement State |
Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) |
| This material event contains a "Less than Cat 3" level of radioactive material. |
Event Text
| AGREEMENT STATE REPORT - LOST/STOLEN TROXLER GAUGE The following is a summary of information reported by the Florida Department of Health via email: Terracon Consultants reported a Troxler 2440 gauge was stolen from a truck while the truck was parked at a residence in Brandenton, Florida. The gauge was stolen around 0930 EDT on 9/24/2020. The gauge was secured with two chains and two locks by the driver of the truck. The local police department has been notified. The gauge contained a 8 mCi Cs-137 source (S/N: 75-1841) and a 40 mCi Am241:Be source (S/N: 47-15958). Florida Incident Number: FL20-109 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 Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021