Event Notification Report for October 30, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/27/2023 - 10/30/2023
Agreement State
Event Number: 56805
Rep Org: Florida Bureau of Radiation Control
Licensee: Florida Cancer Spec. & Res. Inst.
Region: 1
City: Orlando State: FL
County:
License #: 3897-2
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/20/2023
Notification Time: 12:44 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted."
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: 56806
Rep Org: Maryland Dept of the Environment
Licensee: ECS Mid-Atlantic
Region: 1
City: Clarksburg State: MD
County:
License #: MD-21-037-01
Agreement: Y
Docket:
NRC Notified By: Paul Kovach
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/20/2023
Notification Time: 12:49 [ET]
Event Date: 08/31/2023
Event Time: 15:20 [EDT]
Last Update Date: 10/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the Maryland Department of the Environment (MDE) via email:
"At 1520 EDT on August 31, 2023 a troxler gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241 source was struck by a dump truck at a construction site in Clarksburg, Maryland. The gauge was licensed to, and being operated by, ECS Mid-Atlantic, LLC (MD-21-037-01). The display and source guide handle was damaged but the part of the gauge containing the sources was not. The sources' shielding was not damaged. The source rod was successfully retracted by the Radiation Safety Officer (RSO) and several surveys of the area were performed by the RSO confirming only background radiation levels. At the time, the gauge was returned to the licensee's storage facility and tested for source leakage. MDE was notified and requested that the gauge be tested for leakage and the RSO's dosimetry be read. Leak tests later showed no leakage of radioactive material and the RSO's dosimetry read a minimal dose. At this time, the gauge has been repaired by the manufacturer and returned to service.
Agreement State
Event Number: 56807
Rep Org: Texas Dept of State Health Services
Licensee: The Methodist Hospital (Houston)
Region: 4
City: Houston State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/20/2023
Notification Time: 16:52 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNSHIELDED SOURCE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event."
Texas Incident Number: 10060
Texas NMED Number: TX230048
Part 21
Event Number: 56821
Rep Org: Curtiss Wright Flow Control Co.
Licensee:
Region: 4
City: Brea State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Loretta Anaya
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/27/2023
Notification Time: 20:57 [ET]
Event Date: 08/30/2023
Event Time: 00:00 [PDT]
Last Update Date: 10/27/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Deese, Rick (R4DO)
Event Text
PART 21 - INCONSISTENT POTENTIOMETER RESISTANCE VALUES
The following is a synopsis of information that was provided by Curtiss-Wright via fax:
On August 30, 2023, Enertech (a division of Curtiss-Wright) determined a potential defect for Potentiometer part number D2060S based on the inspection of a returned items from Korea Hydro and Electro Power in Korea. A number of returned potentiometers exhibited inconsistent resistance values at certain stroke positions. The potentiometers are used in modulating actuators.
A shorter wiper was used in the manufacture of the potentiometers that introduced the possibility of intermittent separation between the wiper (sliding contact) and the coil at certain stroke positions, resulting in momentary signal interruptions.
The evaluation at Enertech is also ongoing regarding the potential effects of wiper separation on the functionality of the modulating actuator and will not be completed within 60 days. The expected date of completion is December 20, 2023.
South Texas Project Electric Generating Station (Operator: STP Nuclear Operating Company) purchased defective modulating actuators on four occasions.
Questions should be directed to Loretta Anaya, Quality Assurance Manager, Enertech, at 714-982-1856.
Known potentially affected plant(s): South Texas Project