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Event Notification Report for May 28, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/27/2020 - 5/28/2020

** EVENT NUMBERS **
 
54439 54717 54722 54729

Agreement State Event Number: 54439
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SOUTHERN BAPTIST HOSPITAL OF FLORIDA
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: 0155-4
Agreement: Y
Docket:
NRC Notified By: RENO J FABII
HQ OPS Officer: OSSY FONT		 Notification Date: 12/12/2019
Notification Time: 12:26 [ET]
Event Date: 12/11/2019
Event Time: 00:00 [EST]
Last Update Date: 05/28/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week."

Incident Number: FL19-146

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.

* * * UPDATE ON MAY 28, 2020 AT 0820 EDT FROM MATT SENISON TO BRIAN LIN * * *

The following update was received from the Bureau via email:

"[On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. After attempts were unsuccessful at restoring function, the user terminated the procedure before the full implant could be completed. Of the 50 Seeds planned for implantation, 30 were successfully inserted into the patient. No I-125 seeds were lost and no spills or contamination occurred. Radiological review of seed placement determined that an adequate number of seeds were placed and dosing achieved in the target area. No further surgical intervention indicated. The patient will be followed with radiological studies and with PSA [prostate specific antigen] labs as previously planned."

Notified R1DO (DeBoer) and NMSS Events Notification via e-mail.

Agreement State Event Number: 54717
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Lynn Cancer Institute - Boca Raton Regional Hospital
Region: 1
City: Boca Raton   State: FL
County:
License #: 0550-2
Agreement: Y
Docket:
NRC Notified By: Matt Senison
HQ OPS Officer: Brian P. Smith		 Notification Date: 05/19/2020
Notification Time: 07:38 [ET]
Event Date: 05/12/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via report from the Florida Bureau of Radiation:

"On May 15, 2020 at 1530 EDT, the Bureau of Radiation Control (BRC) received a call from the medical physicist at the Lynn Cancer Institute regarding the following narrative which was received this morning, May 18, 2020 at 1000 EDT, from the Chief Medical Physicist. On May 12, 2020, a patient presented for a Vaginal Cylinder treatment utilizing the Elekta Ir-192 high dose rate remote afterloader. The written directive was initially written for 7 Gy [Ir-192] x 3 fractions to a depth of 0.5cm (5mm) and a 20mm diameter cylinder was chosen to treat the patient. Due to the relatively small diameter of the cylinder, the Radiation Oncologist decided to change the written directive to 7 Gy x 3 fractions to the surface of the cylinder. The treatment plan was created and the doses to the normal tissues (bladder, rectum and bowel) were accepted by the Radiation Oncologist and the treatment plan was subsequently approved. The approved treatment plan was then delivered to the patient.

"On May 14, 2020 it was discovered that the prescription isodose line did not appear to fall on the surface of the cylinder and on May 15, 2020, it was discovered that the 7 Gy isodose line was at about 4.2mm from the surface of the cylinder, and the dose to the points on the surface of the cylinder was found to be 158.3 percent of the prescription, on average. In the professional opinion of the Radiation Oncologist, the dose delivered did not negatively affect the patient and the doses to the normal tissues were acceptable dose levels for this type of treatment. It should be reiterated that the initial intent was to deliver the 7 Gy per fraction to a depth of 0.5cm (5mm) which would have fallen close to the 4.2mm at which the prescription dose was actually delivered. Additionally, had the plan been normalized to the surface of the cylinder the Radiation Oncologist would more than likely have increased the dose and he stated that the dose would have been too low for the intended treatment."

Incident Number: FL20-060

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: 54722
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PerkinElmer, Inc.
Region: 1
City: Atlanta   State: GA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Brian P. Smith		 Notification Date: 05/20/2020
Notification Time: 21:34 [ET]
Event Date: 05/20/2020
Event Time: 15:52 [EDT]
Last Update Date: 05/20/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
FRED BOWER (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 PACKAGE IN TRANSIT

The following is taken from the Massachusetts Radiation Control Report abstract:

"PerkinElmer reported on May 20, 2020, that one UN2910 package, Transport Index 0.0, shipped from the licensee's Billerica, Massachusetts facility via a common carrier, containing 5.73 mCi I-125, was reported missing by the carrier on May 20, 2020. The last known location of the package was at the Atlanta, Georgia, airport on May 15, 2020 (when the carrier reported to the licensee that the package was still being held in place awaiting transfer). The package, measuring 10x6x6 inches and weighing approximately 2 kg, was one of a 22-package shipment destined for a customer in the Netherlands. The package was left behind in Atlanta on May 6, 2020, due to external package damage and the other twenty-one packages continued to the customer. There was no reported external package radioactive contamination or loss of radioactive material. The licensee continues to work with the carrier to locate package. No significant public health and safety concern exists based on the package radiation measured at background levels.

"This situation is an immediately reportable event per regulation. The Agency (Massachusetts Radiation Control Program) currently considers this docket to still be OPEN."

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

Power Reactor Event Number: 54729
Facility: Cook
Region: 3     State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Jim Havlik
HQ OPS Officer: Brian Lin		 Notification Date: 05/27/2020
Notification Time: 11:35 [ET]
Event Date: 05/27/2020
Event Time: 09:12 [EDT]
Last Update Date: 05/27/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification		 Person (Organization):
LAURA KOZAK (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT ACTUATION OF SIRENS

"On 5/27/20 at approximately 0912 EDT, the Operations Shift Manager was made aware that the Berrien County Sheriff's Department (BCSD) inadvertently actuated the emergency sirens during a planned weekly test. BCSD notified Cook Nuclear Plant that an audible test was initiated instead of a silent test. All Emergency Notification sirens remain in service. No press release is planned by the licensee at this time.

"This notification is being made under 10 CFR 50.72(b)(2)(xi), Offsite Notification, as a four (4) hour report.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, March 24, 2021