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Event Notification Report for September 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/23/2020 - 9/24/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54899
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: Memorial Hermann Health System Region: 4 City: Houston State: TX County: License #: L06439 Agreement: Y Docket: NRC Notified By: Art Tucker HQ OPS Officer: Brian P. Smith	Notification Date: 09/15/2020 Notification Time: 12:08 [ET] Event Date: 09/01/2020 Event Time: 00:00 [CDT] Last Update Date: 09/15/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING MEDICAL TREATMENT

The following information was received via e-mail from the Texas Department of State Health Services (the Agency):

"On September 14, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that they had discovered a medical event [occurred September 1, 2020] involving a Varian high dose rate remote afterloader (HDR) unit had occurred. The RSO reported that a patient was to receive two boost treatments using the HDR unit. While setting up for the second treatment, the licensee noted the length of source catheter tube used in the first treatment was incorrect, therefore only part of the intended target was treated. The RSO stated the patient and physician were both notified of the event and that the current plan is to perform an additional treatment to the area that was under exposed in the first treatment. The RSO stated they did not expect any adverse effects to the patient. The Agency has requested additional information on the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9796

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: 54900
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: Pavetex Engineering LLC Region: 4 City: Pottsboro State: TX County: License #: L 06407 Agreement: Y Docket: NRC Notified By: Art Tucker HQ OPS Officer: Brian Lin	Notification Date: 09/16/2020 Notification Time: 07:40 [ET] Event Date: 09/14/2020 Event Time: 00:00 [CDT] Last Update Date: 09/16/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOST AND FOUND DEVICE

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

"On September 15, 2020, at 1700 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that one of their technicians had left a Troxler model 4640B density gauges at a job site overnight. The technician had completed their work on September 14, 2020, and left the job site after completing their paperwork, but failed to store the device into their truck. The RSO stated the gauge handle was locked and did not believe any individual would receive an exposure. The RSO stated the device contains two cesium-137 sources, but did not know the activities. The manufacturer's website states the activity to be 8 (+ or - 1) milliCuries. The licensee's license states a device source cannot exceed 9 milliCuries. The RSO stated they had technicians out searching for the gauge. At 1736 CDT, on September 15, 2020, the RSO contacted the Agency and reported the gauge had been recovered. He could not provide any additional information. Additional information has been requested. If during the investigation of this event it is determined that an individual could have been exposed, the Agency will submit an update to this report. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 9797

Agreement State	Event Number: 54902
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: Roswell Park Cancer Institute Corp. Region: 1 City: Buffalo State: NY County: License #: 2923 Agreement: Y Docket: NRC Notified By: Daniel J. Samson HQ OPS Officer: Howie Crouch	Notification Date: 09/16/2020 Notification Time: 17:16 [ET] Event Date: 08/11/2020 Event Time: 00:00 [EDT] Last Update Date: 09/16/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) - CNSC (CANADA) (FAX) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was obtained from the state of New York via facsimile:

"On September 9, 2020, the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO [radiation safety officer] when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered.

"In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered.

"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."

New York Event Report ID No.: NYDOH-20-04

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: 54903
Rep Org: UTAH DIVISION OF RADIATION CONTROL Licensee: St. Mark's Hospital Region: 4 City: Salt Lake City State: UT County: License #: UT 1800253 Agreement: Y Docket: NRC Notified By: Phil Goble HQ OPS Officer: Thomas Herrity	Notification Date: 09/16/2020 Notification Time: 18:00 [ET] Event Date: 09/16/2020 Event Time: 13:00 [MDT] Last Update Date: 09/16/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT RADIONUCLIDE ADMINISTERED TO A PATIENT

The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email:

"At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient."

State Event Report No.: Will be provided in a follow up report.

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: 54904
Rep Org: ARIZONA DEPT OF HEALTH SERVICES Licensee: Geotek Operations Limited Region: 4 City: Phoenix State: AZ County: License #: 07-495 Agreement: Y Docket: NRC Notified By: Brian Goretzki HQ OPS Officer: Thomas Herrity	Notification Date: 09/16/2020 Notification Time: 18:48 [ET] Event Date: 09/16/2020 Event Time: 00:00 [MST] Last Update Date: 09/16/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CONSTRUCTION GAUGE RUN OVER BY CONSTRUCTION VAN

The following was received from the Arizona Department of Health Services (The Department) via email:

"The Department received notification from the licensee that a construction vehicle ran over a portable gauge. The gauge is a Troxler 3430, Serial Number 21871, containing approximately 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241:Beryllium. The Department has requested additional information and continues to investigate the event."

Arizona Event No. 20-018.

Power Reactor	Event Number: 54907
Facility: Fort Calhoun Region: 4 State: NE Unit: [1] [] [] RX Type: (1) CE NRC Notified By: Brock Lindau HQ OPS Officer: Thomas Herrity	Notification Date: 09/23/2020 Notification Time: 18:56 [ET] Event Date: 09/23/2020 Event Time: 15:28 [CDT] Last Update Date: 09/23/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(xi) - Offsite Notification	Person (Organization): RICK DEESE (R4DO) JEFFERY GRANT (IRD) CHRIS MILLER (NRR EO) ANDREA KOCK (NMSS) NMSS_EVENTS_NOTIFICATION (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Defueled

Event Text

OFFSITE NOTIFICATION - PRESS RELEASE FOR A FIRE IN CONTAINMENT

"At 1528 CDT, a fire was reported in containment. Fire was extinguished using a portable fire extinguisher by dedicated fire watch. Offsite fire departments responded at 1541 CDT and the fire was confirmed extinguished at 1601 CDT. There were no injuries reported. The state Fire Marshal of Nebraska has been notified. There was no release of radioactivity or hazardous materials.

"The following statement is planned to be released to the media:

"A small industrial fire broke out this afternoon at OPPD's Fort Calhoun Station, the decommissioning nuclear plant just south of Blair, Nebraska. It had been put out by fire extinguishers before firefighters arrived. No release of radioactivity occurred. All employees and contractors are accounted for and safe.

"Based on our preliminary investigation, the fire appears to have been caused by a torch used for cutting. Firefighters are using a thermal gun to identify any potential remaining hot spots.

"The plant is undergoing decommissioning and all spent nuclear fuel is fully secured in industry-standard dry cask storage, located away from the site of today's fire. The public remains safe and the facility remains secure. All work at the site is on a temporary hold. Safety remains our highest priority.

"OPPD will provide additional information as it becomes available."

Page Last Reviewed/Updated Wednesday, March 24, 2021