Event Notification Report for November 30, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/29/2022 - 11/30/2022

EVENT NUMBERS
56235 56237 56238 56241 56243
Agreement State
Event Number: 56235
Rep Org: NE Div of Radioactive Materials
Licensee: BryanLGH Medical Center
Region: 4
City: Lincoln   State: NE
County:
License #: 02-06-03
Agreement: Y
Docket:
NRC Notified By: Becki Harisis
HQ OPS Officer: Ian Howard
Notification Date: 11/22/2022
Notification Time: 15:16 [ET]
Event Date: 10/24/2022
Event Time: 00:00 [CDT]
Last Update Date: 11/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED

The following information was provided by the Nebraska Department of Health and Human Services via email:

"A Radioactive Seed Localization (RSL) contained 247 microcuries of I-125 on 10/24/2022. After the tissue sample containing the seed was surgically removed from the patient, it was placed on a flat plastic pathology grid. It was then placed in a cabinet x-ray unit. The x-ray showed the seed was in the tissue sample and was in fact removed from the patient. The sample was transferred from the plastic grid to a specimen container and then secured with a lid. The container was placed in a bag for transport to the lab. The lab removed the cup from the bag and placed it on the processing bench. The cup was surveyed with a gamma probe to locate the seed. The pathologist was unable to locate the seed using the gamma probe. The pathologist began to slice the sample to locate the seed. All tissue, except the tissue being sent for analysis, was returned to the specimen cup. Pathology then notified the nuclear medicine technologists (NMTs). The NMTs told pathology to control access to the room and not remove any trash or equipment. The NMTs also notified the operating room about the missing seed and had them control access to the room, to include not removing any linens, equipment, or trash. The NMTs then notified the Radiation Safety Officer (RSO) of the missing seed. A NMT surveyed the operating room, the patient, and the operating room staff. Additionally, the x-ray unit, floor, linens, equipment carts, pathology grid, and trash in the operating room were surveyed multiple times. All operating room staff were surveyed, including their shoes, before being allowed out of the room. All surveys were performed with both a GM survey meter and a gamma probe. During this time, another NMT went to the pathology room where the sample was taken and surveyed the room and the staff. The processing bench and hood, floor, and trash of the pathology room were surveyed multiple times. All pathology staff in the room were surveyed multiple times, including their shoes, before being allowed to leave the room. Surveys in the pathology room were also completed with both a GM survey meter and a gamma probe. The RSO viewed the tissue sample x-ray, confirmed that the seed had been removed from the patient and determined the patient was able to go. The RSO performed a survey with the gamma probe of the specimen container, tissue sample, room, processing bench, and trash of the pathology room. The RSO also performed a survey of the operating room, x-ray unit, equipment carts, pathology grid, and trash. The seed was lost sometime after imaging the tissue sample and before the sample was processed by the pathologist in the pathology room. The RSO thinks either the source came loose when being transferred either from the plastic grid into the specimen cup or from the specimen cup onto the processing bench. The RSO thinks it is possible that the seed fell into a seam or opening inside the x-ray cabinet or processing bench and is being shielded by the metal structures. With no shielding the dose rate of the seed is about 0.04 mR/hr at one meter. The RSO stated that since even the most sensitive survey could not find any radiation above background, it is unlikely that any staff or member of the public would, or will, receive any unintended radiation exposure from the missing source. The licensee has revised their procedure to eliminate one of the tissue transfer steps. The tissue sample is now being place directly into the specimen container after removal from the patient. The sample will be x-rayed in the container instead of transferring it to the flat plastic grid."

Source/Radioactive Material: Sealed Source Ionizing
Radionuclide: I-125, 0.000247 Ci

Nebraska Item Number: NE220005

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: 56237
Rep Org: Texas Dept of State Health Services
Licensee: CHI ST LUKES HEALTH BAYLOR
Region: 4
City: Houston   State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 11/23/2022
Notification Time: 11:30 [ET]
Event Date: 11/21/2022
Event Time: 00:00 [CST]
Last Update Date: 11/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 SIR-SPHERES

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing."

Texas Incident Number: 9965

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: 56238
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Siemens Industry Inc.
Region: 1
City:   State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Joesph Power
HQ OPS Officer: Kerby Scales
Notification Date: 11/23/2022
Notification Time: 14:46 [ET]
Event Date: 10/20/2022
Event Time: 00:00 [EST]
Last Update Date: 11/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - CONTAMINATED WASTE STORAGE ROOM

The following was received from the state of New Jersey via email:

"Siemens has operated a take-back program for smoke detectors containing radiation sources since the 1990s. Most smoke detectors contained Am-241, but Ra-226 sources were also handled. This program has been discontinued and the licensee is now undergoing decommissioning. On October 20, 2022, as part of the license termination process, a consulting Health Physicist was contracted to perform characterization surveys of a waste storage room on site. The storage room was the only room where licensed materials were handled. Here, the licensee would disassemble smoke detectors for ultimate disposal via a licensed radioactive waste broker. The results of the survey indicated that fixed alpha contamination existed across the entire floor surface and on the walls in smaller concentrations. The highest reading observed on the floor was 4,387 cpm [counts per minute]. This equated to 13,282 dpm [disintegrations per minute]/100 centimeters squared with the health physicist's survey instrument. This was the first indication that contamination existed within this facility. This was an unplanned contamination event and possibly involved a quantity of material greater than five times the lowest annual limit on intake specified in Appendix B of 20.1001-20.2401 of 10 CFR Part 20, for Am-241.

"Licensee corrective actions: No more smoke detectors are being received by the licensee, so no changes to procedures will occur. Current decontamination work is underway by a licensed radiation contractor. The facility will need to be decontaminated to acceptable levels meeting New Jersey's 15 mrem/year release criteria.

"On November 17, 2022, the state performed independent surveys of the room to confirm areas of contamination. The presence of fixed contamination was confirmed and removable contamination was also discovered. The state instructed the licensee to cordon off contaminated areas to prevent entry of personnel. The state will also perform confirmatory surveys after decontamination work is completed."


Power Reactor
Event Number: 56241
Facility: Fermi
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Adam Koziol
Notification Date: 11/28/2022
Notification Time: 08:38 [ET]
Event Date: 11/28/2022
Event Time: 04:00 [EST]
Last Update Date: 11/29/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Stoedter, Karla (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 11/30/2022

EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 0400 EST on November 28, 2022, during the performance of Division 2 Residual Heat Removal (RHR) cooling tower fan operability and RHR Service Water valve lineup verification, it was reported that the Mechanical Draft Cooling Tower (MDCT) Fan 'B' was making a loud metallic noise. The cause of the metallic noise is unknown at this time. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on inoperable cooling water to the HPCI room cooler, per LCO 3.0.6.

"Investigation into the Division 2 MDCT Fan 'B' abnormal noise is in progress.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 56243
Facility: Ginna
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: Jacquelyn Holshouser
HQ OPS Officer: Brian Lin
Notification Date: 11/28/2022
Notification Time: 15:34 [ET]
Event Date: 11/28/2022
Event Time: 09:15 [EST]
Last Update Date: 11/28/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Cahill, Christopher (R1DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
FITNESS FOR DUTY REPORT

A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.