Event Notification Report for October 04, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/03/2023 - 10/04/2023
Agreement State
Event Number: 56782
Rep Org: NH Dept of Health & Human Services
Licensee: Mary Hitchcock Memorial Hospital
Region: 1
City: Lebanon State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Lawrence Criscione
Licensee: Mary Hitchcock Memorial Hospital
Region: 1
City: Lebanon State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: David Scalise
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/09/2023
Notification Time: 14:32 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/09/2023
Notification Time: 14:32 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kevin Williams (NMSS)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kevin Williams (NMSS)
AGREEMENT STATE - GREATER THAN ANTICIPATED DOSE TO NON-TARGET ORGAN
The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:
"Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR).
"During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive.
"The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive.
"The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days.
"Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated."
NMED Report Number: NH-23-0002
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.
The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:
"Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR).
"During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive.
"The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive.
"The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days.
"Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated."
NMED Report Number: NH-23-0002
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: 56793
Rep Org: Colorado Dept of Health
Licensee: Williams Corporation Hays Gulch Pt
Region: 4
City: Parachute State: CO
County:
License #: GL001884
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Licensee: Williams Corporation Hays Gulch Pt
Region: 4
City: Parachute State: CO
County:
License #: GL001884
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/13/2023
Notification Time: 16:04 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Notification Time: 16:04 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Hays Gulch Plant and several walkdowns of the facility, six exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number: SLX60 (7.5 Ci of H-3 each).
Event Report ID No.: CO230037
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
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Hays Gulch Plant and several walkdowns of the facility, six exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number: SLX60 (7.5 Ci of H-3 each).
Event Report ID No.: CO230037
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: 56794
Rep Org: Colorado Dept of Health
Licensee: Williams Corporation Crawford Trail
Region: 4
City: Parachute State: CO
County:
License #: GL001652
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Licensee: Williams Corporation Crawford Trail
Region: 4
City: Parachute State: CO
County:
License #: GL001652
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/13/2023
Notification Time: 14:58 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Notification Time: 14:58 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT- LOST EXIT SIGN
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Crawford Trail and several walkdowns of the facility, one exit sign was reported as lost. The sign was manufactured by Isolite Corporation, model number 2000 (11.5 Ci of H-3).
Event Report ID No.: CO230036
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
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Crawford Trail and several walkdowns of the facility, one exit sign was reported as lost. The sign was manufactured by Isolite Corporation, model number 2000 (11.5 Ci of H-3).
Event Report ID No.: CO230036
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: 56795
Rep Org: Colorado Dept of Health
Licensee: Williams Corporation - Parachute Creek Gas Plant
Region: 4
City: Parachute State: CO
County:
License #: GL002037
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Licensee: Williams Corporation - Parachute Creek Gas Plant
Region: 4
City: Parachute State: CO
County:
License #: GL002037
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/13/2023
Notification Time: 14:53 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Notification Time: 14:53 [ET]
Event Date: 10/05/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/13/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Parachute Creek Gas Plant and several walkdowns of the facility, eight exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number SLX60 (8.1 Ci of H-3 each).
Event Report ID No.: CO230038
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
The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:
On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Parachute Creek Gas Plant and several walkdowns of the facility, eight exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number SLX60 (8.1 Ci of H-3 each).
Event Report ID No.: CO230038
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: 56776
Rep Org: Florida Bureau of Radiation Control
Licensee: James Hardie Building Products, Inc
Region: 1
City: Plant City State: FL
County:
License #: GO663
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Karen Cotton-Gross
Licensee: James Hardie Building Products, Inc
Region: 1
City: Plant City State: FL
County:
License #: GO663
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/04/2023
Notification Time: 14:37 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Notification Time: 14:37 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOSS OF CONTROL
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau."
Florida Incident number - FL23-152
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
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau."
Florida Incident number - FL23-152
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: 56777
Rep Org: Colorado Dept of Health
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Ian Howard
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Ian Howard
Notification Date: 10/05/2023
Notification Time: 10:14 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2023
Notification Time: 10:14 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Colorado Department of Public Health and Environment (the Agency) via email:
"On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation."
Event Report ID No.: CO2300034
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.
The following information was provided by the Colorado Department of Public Health and Environment (the Agency) via email:
"On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation."
Event Report ID No.: CO2300034
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.