United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > April 13

Event Notification Report for April 13, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/12/2018 - 04/13/2018

** EVENT NUMBERS **


53313 53314 53315 53316 53327 53328

To top of page
Agreement State Event Number: 53313
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MEDICAL UNIVERSITY OF SC
Region: 1
City: CHARLESTON State: SC
County:
License #: SC 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/04/2018
Notification Time: 10:10 [ET]
Event Date: 03/06/2018
Event Time: [EDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG TREATMENT SITE

A patient was prescribed treatment by High Dose Rate (HDR) brachytherapy to a breast keloid in two fractions on 3/6/18 and 3/7/18 of 600 cGy per fraction. The patient contacted the oncologist when a skin/tissue reaction was discovered on 4/2/18. The reaction was not an anticipated response to the treatment plan.

The fractions were likely directed to the wrong treatment site due to an improper length HDR catheter.

The patient will be evaluated by the oncologist this week.

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.

To top of page
Agreement State Event Number: 53314
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA SAN DIEGO
Region: 4
City: LA JOLLA State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/04/2018
Notification Time: 14:20 [ET]
Event Date: 04/02/2018
Event Time: 16:00 [PDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following was received via email from the state of California:

"A medical event per 10 CFR 35.3045 was determined to have occurred on April 2, 2018 during a University of California San Diego (UCSD) Y-90 liver therapy procedure. The total delivered dosage was greater than 20 percent less than the prescribed dosage.

"The authorized user prescribed MDS Nordion Theraspheres Y-90 activity of 22.7 mCi to be delivered to the left lobe of the patient's liver. During the medical procedure, blockage occurred in the delivery apparatus, and the authorized user was unable to complete the administration of the Y-90 Therasphere dosage. Post-procedural dosage vial chamber measurements were performed that indicated only 32.5 percent (7.4 mCi) of the prescribed Y-90 dosage was delivered.

"An MDS Nordion representative was observing the procedure.

"The UCSD campus Radiation Safety office was notified that the administration resulted in a medical event and the California Radiation Health Branch was notified. The patient and their referring physician were notified on April 2, 2018. The patient will be scheduled for another Therasphere administration in the near future to complete the treatment plan."

California 5010 Number: 040218


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.

To top of page
Agreement State Event Number: 53315
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: SIEMENS MEDICAL SOULTIONS
Region: 3
City: HOFFMAN ESTATES State: IL
County:
License #: IL-01130-02
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/05/2018
Notification Time: 15:31 [ET]
Event Date: 04/05/2018
Event Time: 09:04 [CDT]
Last Update Date: 04/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GREGORY AHERN (ILTA)

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

Event Text

AGREEMENT STATE REPORT - ABANDONED SOURCE

The following was received from the State of Illinois via email:

"At approximately 0904 [CDT] on 4/5/18, the Agency [Illinois Emergency Management Agency (IEMA)] received a call reporting a radioactive source abandoned near a dumpster in residential Carpentersville, IL. Carpentersville Fire and Hazmat was managing the scene. A patrol with the Carpentersville police department reported finding the source at approximately 0806 [CDT] this morning and utilized the manufacturer label and emergency contact information on the package to notify Siemens Medical Solutions. Police had secured the scene until the fire department had arrived. Siemens' RSO [Radiation Safety Officer] had arrived on scene by 0930 [CDT] and contacted the IEMA radioactive materials section. The RSO confirmed the source to be an improperly abandoned Ge-68 phantom source (model CS-20-1, S/N 11054). Review of the Siemens license confirmed they were authorized for possession of the material and qualified to perform an assessment/transport. After discussion with Fire/Hazmat and IEMA, the RSO took possession of the phantom and the scene was cleared. At 1026 [CDT], the Agency received confirmation of the source being safely placed in Siemens' licensed storage area. Additional leak tests confirmed no contamination and Siemens is tracking down the owner of the source. Preliminary checks show the source was originally shipped to California. Additional details will be provided as they become available.

"The radioactive material recovered was a Ge/Ga-68 epoxy-based reference source utilized in the calibration of PET/CT scanners. The Ge-68 source was contained within its storage packaging and exhibited exposure rates of 0.8 mR/h at one foot and 0.090 mR/h at one meter. Although it originally contained 1.39 mCi of Ge/Ga-68 (assay date of March 31, 2016), the source had decayed to approximately 212 microCuries. However, unshielded contact exposure rate could still be as high as 1100 mR/h on contact. The police officer and fire department personnel established a fifty foot perimeter and never got closer than seven feet to the package. There are no exposure concerns resulting from this incident. The package markings were clearly displayed and no effort was apparent to cover or deface."

Illinois Report Number: IL180026


* * * UPDATE ON 04/10/18 AT 1347 EDT FROM GARY FORSEE TO ANDREW WAUGH * * *

The following update was received from the State of Illinois via email regarding two additional missing sources:

"At approximately 0904 [CDT] on 4/5/18, the Agency received a call reporting a radioactive source abandoned near a dumpster in residential Carpentersville, IL. A patrol with the Carpentersville police department reported finding the source at approximately 0806 [CDT] that morning and utilized the manufacturer label and emergency contact information on the package to notify Siemens Medical Solutions. Police had secured the scene until the fire department had arrived. Siemens' RSO had arrived on scene by 0930 [CDT] and contacted the IEMA radioactive materials section. The RSO confirmed the source to be an improperly abandoned Ge-68 phantom source (model CS-20-1, S/N 11054). Review of the Siemens license confirmed they were authorized for possession of the material and qualified to perform an assessment/transport. After discussion with Fire/Hazmat and IEMA, the RSO took possession of the phantom and the scene was cleared. At 1026 [CDT], the Agency received confirmation of the source being safely placed in Siemens' licensed storage area. Additional leak tests confirmed no contamination and the phantom source is pending proper disposal at the manufacturer's Knoxville, TN location. In coordination with Siemens and State of California officials, it was determined the source was originally supplied to Huntington Memorial Hospital in Pasadena, CA. On the evening of 4/5/18, officials with the State of California confirmed Huntington Memorial Hospital's PET/CT unit was serviced and (3) sources shipped for disposal by Zetta Medical (a non-licensed company based out of Lake Zurich, IL). This 11/27/17 servicing by Zetta Medical resulted in the removal and replacement of the following sources: Ge-68 1.14 mCi rod source (S/N 19626), Ge-68 1.14 mCi rod source (S/N 19625), and a Ge-68 1.39 mCi phantom source (S/N 11054). IEMA staff contacted Eckert and Ziegler and confirmed that neither package was received at their company. At this point, IEMA notified first responders and other state and federal partners of the two additional missing sources. IEMA staff dispatched two responders to conduct gamma scintillator surveys of the area where the phantom was found. Extensive searches of the area on the afternoon of 4/6/18, did not result in locating the two missing Ge-68 rod sources.

"IEMA performed an investigation at Zetta Medical on 4/9/18. According to provided FedEx manifests and shipping receipts, Zetta Medical's on site technician, packaged the three sources and transported them to a local FedEx drop off location on 12/7/17. The location of the sources from the time of removal on 11/27/17 until 12/7/17 remains under investigation as well. The shipping manifest was obtained that identifies Zetta Medical as the shipper. The intended recipient was Eckert and Ziegler in California. The shipper/recipient information was inadvertently reversed; resulting in the sources being shipped to Zetta Medical in Lake Zurich. The two packages arrived in Lake Zurich, IL on 12/12/17. On 12/13/17, Zetta Medical attempted to ship the sources back to Eckert and Zeigler in Burbank, CA via Pilot Freight Services. The two packages were consigned as UN2915 for return via air out of O'Hare airport to LAX. The two packages were returned to Zetta Medical on 12/19/17. At this point, the sources were stored in Zetta Medical's warehouse for several months.

"The Zetta Medical employee claims to have packaged and shipped the two packages (containing three Ge-68 sources total) back to Eckert and Zeigler via FedEx on or around 3/12/18. Although electronic shipping records are retained for outgoing shipments, Zetta Medical representatives said this shipment did not have an electronic record. Video surveillance is present in the company. However, the equipment was not recording for the time period of concern. After speaking with FedEx's corporate Radiation Safety Officer and their review of dispatch records over the last four months, FedEx has determined they have no records of a hazmat (radioactive) package being picked up from Zetta Medical. Police found the abandoned phantom source at the dumpster adjacent to the home of the Zetta Medical employee who claims to have shipped the packages.

"It was identified that Zetta Medical has performed unauthorized work with licensed radioactive material. It was also confirmed that representatives of Zetta Medical took possession of at least three Ge-68 sources before losing control of the same. This investigation remains open pending enforcement proceedings and pending paperwork from those entities involved.

"The radioactive material recovered was a Ge/Ga-68 epoxy-based reference source utilized in the calibration of PET/CT scanners. Ge-68 has a 271 day half-life, with gamma exposure from the Ga-68 daughter in equilibrium. The recovered Ge-68 source exhibited exposure rates of 0.8 mR/h at one foot and 0.090 mR/h at one meter. Although it originally contained 1.39 mCi of Ge/Ga-68 (assay date of 3/31/16), the source had decayed to approximately 212 microCi. Leak tests were taken on scene and confirmed to not have removable contamination. The police officer and fire department personnel established a fifty foot perimeter and never got closer than seven feet to the package. There are no exposure concerns resulting from this portion of the incident. The package markings were clearly displayed and no effort was apparent to cover or deface.

"The two remaining, missing Ge-68 rod sources were originally assayed with 1.14 mCi of activity each. They now each contain approximately 0.2 mCi of Ge-68 and are sealed in a 0.25" x 11" steel rod. There should be no airborne hazard due to the internal matrix unless immersed in fire. Data made available from the manufacturer states if the sources are removed from their shielding, the exposure rate would be approximately 1 mR/h at one foot and 100 microR/h at one meter. There are no exposure concerns reported from this incident; however, efforts to recover the remaining two sources are still ongoing."

Notified R3DO (Stone), ILTAB DO (Ahern), and NMSS Events Notification (email).

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

To top of page
Agreement State Event Number: 53316
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: AMERICAN CRYSTAL SUGAR COMPANY
Region: 4
City: HILLSBORO State: ND
County:
License #: ND33-05208-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/05/2018
Notification Time: 17:40 [ET]
Event Date: 04/05/2018
Event Time: [MDT]
Last Update Date: 04/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SOURCE

The following was received from the State of North Dakota via email:

"American Crystal Sugar Company experienced a stuck sealed source (Berthold Technologies U.S.A., LLC Model SSC-100, 60 milliCuries [Co-60] at calibration) in a source tube located inside a vessel during a routine shutter check at their Hillsboro, ND location. The sealed source is fixed to a cable which allows the source to be lowered through a source tube which is located inside a vessel. Upon attempting to retract the source into the shielded gauge housing (Berthold Technologies U.S.A., LLC Model LB 8120-01) to perform the shutter check, the source did not budge. The licensee contacted Berthold Technologies U.S.A., LLC (manufacturer) regarding the stuck source. Berthold personnel instructed the licensee to apply a penetrating oil to the source tube in an attempt to break it loose. As of the notification time, the source remained lodged in the source tube in its normal operating position. The five detectors associated with this source continue to read radiation levels as expected. The licensee will continue to apply the penetrating oil and attempt to pull it back into the shielded gauge housing and provide an update in the morning. More information will be provided as received."

ND Incident Report # ND180001

To top of page
Power Reactor Event Number: 53327
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETE WILLIAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/12/2018
Notification Time: 12:14 [ET]
Event Date: 04/12/2018
Event Time: 09:20 [EDT]
Last Update Date: 04/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARVIN SYKES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP

"At 0920 EDT on April 12, 2018, the Watts Bar Unit 2 reactor automatically tripped while operating at 100 percent power. All control and shutdown bank rods inserted properly in response to the automatic reactor trip. All safety systems including Auxiliary Feedwater actuated as designed. The plant is stable with decay heat removal through Auxiliary Feedwater and Steam Dump Systems.

"The cause of the automatic reactor trip is being investigated.

"The automatic actuation of the Reactor Protection System (RPS) is being reported as a four-hour report under 10 CFR 50.72 (b)(2)(iv)(B).

"The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72 (b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been notified for this event."

The plant is currently stable at normal operating temperature and pressure. The grid is stable and the plant is in its normal shutdown electrical lineup. Unit 1 was unaffected by the Unit 2 trip.

To top of page
Power Reactor Event Number: 53328
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOSHUA SPALTER
HQ OPS Officer: DAVID AIRD
Notification Date: 04/12/2018
Notification Time: 17:36 [ET]
Event Date: 04/12/2018
Event Time: 11:18 [EDT]
Last Update Date: 04/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DON JACKSON (R1DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY REPORT INVOLVING DISCOVERY OF KOMBUCHA TEA INSIDE THE PROTECTED AREA

"At 1148 EDT on April 12, 2018, a 16.2 ounce bottle of Kombucha tea was found in a small refrigerator in the Administration Building inside the Protected Area. The bottle was found to have a small amount missing from the contents. Kombucha tea is a fermented tea containing trace amounts of alcohol, and is legally sold without restrictions. Dominion Energy Nuclear Connecticut had previously notified its workforce that Kombucha tea was prohibited from being consumed or carried onsite. The owner has not yet been determined. This is considered an alcoholic beverage and is being reported pursuant to the requirements of 10 CFR 26.719 as a 24 hour report."

The NRC Resident Inspector, the State of Connecticut, and local authorities have been notified.

Page Last Reviewed/Updated Friday, April 13, 2018
Friday, April 13, 2018