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Event Notification Report for December 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/25/2019 - 12/26/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54448
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: MOUNT NITTANY MEDICAL CENTER Region: 1 City: STATE COLLEGE State: PA County: License #: PA-0126 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: CATY NOLAN	Notification Date: 12/17/2019 Notification Time: 10:44 [ET] Event Date: 12/13/2019 Event Time: 00:00 [EST] Last Update Date: 12/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - HIGH DOSE RATE APPLICATOR DISLODGED

The following was received from the PA Department Bureau of Radiation Protection (DEP) via fax:

"On December 16, 2019, the medical physicist for the licensee verbally reported that during an HDR [high dose rate] treatment using a Varian Model VariSource IX with a Tandem & Ovoid applicator, the applicator was found dislodged at the end of the treatment period. This was fraction 4 of 5 planned fractions. It is unknown at this time how long the applicator was not in the planned position or what caused it to move. The prescribed dose was 600 cGy from a 5.126 Ci Iridium-192 source. No further information is available at this time. The DEP will update this event as soon as more information is provided."

Event Report ID No: PA190029

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: 54450
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: ECS-FLORIDA, L.L.C. Region: 1 City: SOUTH DAYTONA State: FL County: License #: 3440-4 Agreement: Y Docket: NRC Notified By: PAUL NORMAN HQ OPS Officer: OSSY FONT	Notification Date: 12/17/2019 Notification Time: 22:42 [ET] Event Date: 12/17/2019 Event Time: 14:50 [EST] Last Update Date: 12/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the Florida Department of Health via email:

"[The Radiation Safety Officer (RSO)] reported an incident involving a damaged Troxler Soil Moisture Density Gauge. The 2 sources [Cs-137 (8 mCi); Am-Be (40 mCi)] were not damaged or dislodged. The only damage was to the operator handle. At approximately [1450 EST], the gauge was bumped by a bulldozer [at a temporary work site in Ocala, FL], damaging the handle. The gauge is repairable. [The RSO] will follow-up his initial report with a written report on Wednesday, December 18, 2019. No further action is required."

Event Incident Number: FL19-151

* * * UPDATE ON 12/18/2019 AT 1110 EST FROM MATTHEW SENISON TO ANDREW WAUGH * * *

The following was received from the Florida Department of Health via email:

The sources are currently in the licensee's possession. The State will dispatch an inspector for this incident and pictures of the gauge, a leak test, and a report including corrective actions taken to prevent re-occurrence will be required.

Notified R1DO (Werkheiser) and NMSS Events (email).

Agreement State	Event Number: 54451
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: EMAGIN CORPORATION Region: 1 City: HOPEWELL JUNCTION State: NY County: License #: G5795 Agreement: Y Docket: NRC Notified By: DANIEL SAMSON HQ OPS Officer: OSSY FONT	Notification Date: 12/18/2019 Notification Time: 12:20 [ET] Event Date: 12/05/2016 Event Time: 00:00 [EST] Last Update Date: 12/20/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) - CNSC (CANADA) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - TWO LOST Po-210 IONIZERS

The following was received from the New York State Department of Health (NYSDOH) via fax:

"NYSDOH was notified in writing by an administrator for Emagin Corporation on December 18, 2019 (letter dated December 5, 2019), that two Nuclecel In-Line Ionizers had been lost and unable to be located at the licensee's facility in Hopewell Junction, New York.

"These two devices are NRD, LLC P-2021 ionizers. Both devices contain sealed Po-210 sources with 10 mCi per device (assayed at the time of production). The device serial numbers are A2JY966 with source s/n 057171, and A2HM243 with source s/n 047955. Both sources are believed to be decayed down to greater than 14 half-lives to date.

"According to the licensee, these sources were identified as lost during periodic housecleaning of their facility clean room approximately three years ago. The licensee attempted to locate the devices at that time and continues to attempt to locate the devices. The licensee also states that NRD, LLC verified that the devices in question were not returned to their facility.

"NYSDOH will continue to monitor this incident under NYSDOH Incident No. 1312. The licensee will be providing additional information on the event, corrective actions, and steps to prevent recurrence in the future."

EVENT REPORT ID NO.: NY-19-11

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

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