Event Notification Report for December 13, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/12/2019 - 12/13/2019
EVENT NUMBERS
54443544445444554448
Non-Agreement State
Event Number: 54443
Rep Org: BASF CORPORATION
Licensee: BASF CORPORATION
Region: 3
City: WYANDOTTE State: MI
County:
License #: 21-00627-02
Agreement: N
Docket:
NRC Notified By: DEREK HETES
HQ OPS Officer: BETHANY CECERE
Licensee: BASF CORPORATION
Region: 3
City: WYANDOTTE State: MI
County:
License #: 21-00627-02
Agreement: N
Docket:
NRC Notified By: DEREK HETES
HQ OPS Officer: BETHANY CECERE
Notification Date: 12/13/2019
Notification Time: 14:46 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Notification Time: 14:46 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
KENNETH RIEMER (R3DO)
LAURA PEARSON (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
KENNETH RIEMER (R3DO)
LAURA PEARSON (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
LOST TRITIUM EXIT SIGNS
The following is a synopsis of a telephonic report:
An electrical contractor did not follow disposal instructions and disposed of eight (8) tritium exit signs (approximately 9.5 Ci each) in a dumpster on 12/2/19. The dumpster was removed on 12/4/19. The licensee discovered the error on 12/13/19 when they could locate two of the ten signs planned for removal.
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
The following is a synopsis of a telephonic report:
An electrical contractor did not follow disposal instructions and disposed of eight (8) tritium exit signs (approximately 9.5 Ci each) in a dumpster on 12/2/19. The dumpster was removed on 12/4/19. The licensee discovered the error on 12/13/19 when they could locate two of the ten signs planned for removal.
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: 54444
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON REGIONAL HOSPITAL
Region: 1
City: BOCA RATON State: FL
County:
License #: 550-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Licensee: BOCA RATON REGIONAL HOSPITAL
Region: 1
City: BOCA RATON State: FL
County:
License #: 550-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 12/13/2019
Notification Time: 14:50 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Notification Time: 14:50 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - I-125 SEED MISTAKENLY INCINERATED
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
"I-125 therapy seed (243 microCi) was mistakenly incinerated with medical waste. Pathologist mistook metal clip for seed and included it in the material to be incinerated. This information is from a preliminary phone report [to the Bureau]; a full written report with radioactive source info will be submitted via email."
Incident Number: FL19-148
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
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
"I-125 therapy seed (243 microCi) was mistakenly incinerated with medical waste. Pathologist mistook metal clip for seed and included it in the material to be incinerated. This information is from a preliminary phone report [to the Bureau]; a full written report with radioactive source info will be submitted via email."
Incident Number: FL19-148
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
Non-Agreement State
Event Number: 54445
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: BETHANY CECERE
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: BETHANY CECERE
Notification Date: 12/13/2019
Notification Time: 20:37 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [CST]
Last Update Date: 12/13/2019
Notification Time: 20:37 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [CST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICROSPHERES DEPOSITED TO DIFFERENT SEGMENT OF LIVER
The following is a synopsis of a telephonic report:
On 12/6/19, a patient was administered Y-90 microspheres, intended for segment 4 of the liver.
On 12/13/19, the post-administration imaging was interpreted and examined. It was determined that, despite taking precautions of blood vessel embolization to limit the microspheres from other segments, some of the microspheres deposited in segment 2 as well as segment 4. The patient was notified. No adverse effects are expected as the microspheres all went to the same lobe of the liver, and within about 95 percent of the prescribed dose.
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.
The following is a synopsis of a telephonic report:
On 12/6/19, a patient was administered Y-90 microspheres, intended for segment 4 of the liver.
On 12/13/19, the post-administration imaging was interpreted and examined. It was determined that, despite taking precautions of blood vessel embolization to limit the microspheres from other segments, some of the microspheres deposited in segment 2 as well as segment 4. The patient was notified. No adverse effects are expected as the microspheres all went to the same lobe of the liver, and within about 95 percent of the prescribed dose.
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: 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
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: 01/09/2020
Notification Time: 10:44 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 01/09/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
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.
* * * UPDATE ON 1/9/20 AT 1:17 PM FROM JOHN CHIPPO TO KARL DIEDERICH * * *
The following information was received from the Agreement State via fax:
"The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event."
Notified R1DO (Schroeder) and NMSS group (via e-mail).
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.
* * * UPDATE ON 1/9/20 AT 1:17 PM FROM JOHN CHIPPO TO KARL DIEDERICH * * *
The following information was received from the Agreement State via fax:
"The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event."
Notified R1DO (Schroeder) and NMSS group (via e-mail).