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Event Notification Report for January 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/31/2018 - 1/1/2019

** EVENT NUMBERS **


53802 53803 53804 53811

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Agreement State Event Number: 53802
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: REGIONAL WEST MEDICAL CENTER
Region: 4
City: SCOTTSBLUFF   State: NE
County:
License #: 21-01-03
Agreement: Y
Docket:
NRC Notified By: LARRY HARISIS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 12/21/2018
Notification Time: 10:05 [ET]
Event Date: 12/13/2018
Event Time: 00:00 [CST]
Last Update Date: 02/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - REPORT OF LOST I-125 SEED DURING MEDICAL PROCEDURE

"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on December 21, 2018 at 8:50 am CST by the Radiation Safety Officer (RSO) from Regional West Medical Center (Nebraska license 21-01-03) that one I-125 seed is lost and still missing at this time. The I-125 seed was part of a manual brachytherapy procedure that involved one hundred permanently implanted I-125 seeds in the patient's prostate. The procedure occurred in a surgery suite at approximately 9 am MST, the patient was then transported to a recovery room and then to a CT suite to confirm the placement of the seeds at approximately 12:19 pm MST. During the review of the CT, the licensee observed that only ninety nine seeds were implanted. The licensee then conducted a search for the missing I-125 seed.

"During the search of the missing I-125 seed on December 13, 2018, licensee staff surveyed the surgical suite and recovery room of the patient. The licensee staff were not able to find the missing seed. During the survey, licensee staff also questioned the nursing staff and it was noted that a nurse emptied a catheter bag into a toilet shortly following the completion of surgery. Licensee staff believe that the missing I-125 seed may have been flushed and disposed in the sanitary sewage system.

"The missing I-125 seed was a Bard Medical product, serial number 7815544SO, containing 283 uCi and was one of many seeds preloaded into a needle to be injected into the patient. On December 13, 2018 at 9:30 am CST, the RSO was contacted to report the search results in the adjacent hallways, the CT suite, and if possible, any sewage holding areas. The RSO has dispatched staff to conduct a new search of all areas and transport beds that the patient was in and in contact areas. The RSO expects this to be completed later in the day of 12/21/2018.

"The State is awaiting the results of this new survey and will be following up with the licensee and US NRC."

Nebraska Report: NE-18-0009

* * * UPDATE AT 1721 EST ON 02/07/2019 FROM LARRY HARISIS TO JEFF HERRERA * * *

The following update was received from the Nebraska Department of Health and Human Services (DHHS) via email:

"On 01/16/2019, Nebraska DHHS Office of Radiological Health staff arrived at the licensee's facility. Discussions, reenactments, radiological surveys, and presentations were performed and given to assess if the I-125 seed was disposed of in the sanitary system. A review of the licensee's training of oncology staff and nursing personnel, policies and procedures for specific seed implantation for oncology and nursing staff, and interviews of all involved personnel were completed.

"It was determined that all 100 I-125 seeds were implanted into the patient as ordered and the bladder was verified as emptied by a cystoscope after removing an inflated balloon to prevent seeds from entering the bladder. After the inflatable balloon device was removed from the patient, a seed near the urethra was dislodged and entered the urethra then into a urinary catheter bag. When the oncology personnel arrived at the patient's recovery room, they noticed that the urinary catheter bag was abnormally low. Oncology personnel found that a nurse in the recovery room emptied the urinary catheter bag without approval from Oncology personnel, inadvertently disposing of the seed in a sink in the recovery room. Oncology personnel surveyed the surgical suite, recovery room, and sink with no results above background. A review of the policies and procedures of radioactive seed implantation with the nursing staff was also completed.

"The licensee's implementation of corrective measures to prevent a reoccurrence will be reviewed on the next inspection."

Notified the R4DO (Werner) and NMSS Events (via email).

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.

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

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Non-Agreement State Event Number: 53803
Rep Org: IRIS NDT
Licensee: IRIS NDT
Region: 3
City: WHITING   State: IN
County:
License #: 13-32791-01
Agreement: N
Docket:
NRC Notified By: KYLE LEDBETTER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/21/2018
Notification Time: 14:46 [ET]
Event Date: 02/24/2018
Event Time: 00:00 [EST]
Last Update Date: 12/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ANN MARIE STONE (R3DO)
ROBERT GATONE (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

RADIOGRAPHY CAMERA GUIDE TUBE DISCONNECTED DURING USE

The following is a synopsis of the report received via email:

The quick connect fitting on the guide tube came apart when the source was being cranked out. When the source was cranked out beyond where the end of the guide tube was supposed to be the technicians stopped and tried to crank the source back into the camera. The source rod became stuck because the control cable had become entangled. The RSO (Radiation Safety Officer) was later able to disconnect the source's pigtail, unkink the control cable, reconnect the guide tube, and reconnect the control cable to retrieve the source. The maximum doses received were 114 mRem whole body and 260 mRem to the right hand.

Camera: model SPEC-300 with model G-70 source assembly
Source: 88 Ci Co-60

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Agreement State Event Number: 53804
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE   State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/21/2018
Notification Time: 15:55 [ET]
Event Date: 12/19/2018
Event Time: 00:00 [PST]
Last Update Date: 01/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE SOURCE FAILS LEAK TEST

The following report was received via e-mail:

"A routine leak test at the Swedish Cancer Institute found a leaking Cs-137 e-vial source in the Physics Lab. The initial leak test was taken 12/19/2018 and analyzed on 12/20/2018. It revealed an activity of approximately 10 nanoCuries, and additional confirmation tests found contamination above the regulatory threshold for a leaking source.

"The source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a larger pig while it is being held for disposal. Surveys of the original storage pig and the hot lab where the source was utilized found no removable contamination and there was no personnel contamination detected.

"The RSO [Radiation Safety Officer] was notified of the positive results the morning of 12/21/2018 and provided notification to DOH [Washington State Department of Health] at 1114 PST on 12/21/2018."


* * * UPDATE ON 01/17/2019 AT 1201 EST FROM ANDREW HALLORAN TO JEFFREY WHITED * * *

The following report was received via e-mail:

"A leaking sealed source was discovered at The Swedish Cancer Institute during periodic leak tests performed by the health physics staff. The source (MED3550 Gamma Reference Standard, SN 11345, Cs-137, initial activity 209.6 micro-Ci, reference date 8/1/2001) was used in the A Level Physics Lab as part of routine radiation oncology operations. The source was initially received by Swedish 12/6/2007.

"The sample was collected on 12/19/2018 using an alcohol wipe, and analyzed on 12/20/2018 using a Ludlum 261 single channel analyzer coupled with a NaI well detector. The system was set to detect the 662 keV photon energy for Cs-137, with a calculated efficiency of 11.71 percent. The result of the wipe test analysis was a removable activity of 9.92 Nano-Ci, above the 5 Nano-Ci threshold for a leaking source.

"After the RSO was notified of the positive result on 12/21/2018, the source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a lead pig. The pig is currently being stored in the Radiation Safety Office Lab awaiting disposal. Wipes of the A Level Physics Lab source storage cabinet and all surfaces of the pig used to house the source when it was in service yielded no detectable removable contamination.

"After reviewing the final report of the licensee, this event is now closed as of 1/3/2018. DOH will verify that the source has been disposed of during the next routine inspection of the licensee."

Washington Event Report ID: WA-18-031

Notified R4DO (Drake) and NMSS Event Notification (e-mail).

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Power Reactor Event Number: 53811
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: ETHAN HAUSSER
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 01/01/2019
Notification Time: 11:02 [ET]
Event Date: 01/01/2019
Event Time: 04:54 [EST]
Last Update Date: 01/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ERIC DUNCAN (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 5 Startup 5 Startup

Event Text

GLAND SEAL EXHAUSTER - AUTOMATIC TRIP FUNCTION INOPERABLE

"On January 1, 2019 at approximately 0454 EST, while performing planned maintenance activities on the Feedwater Distributed Control System (FW DCS), it was discovered that the automatic trip instrumentation of the Gland Seal Exhauster (GSE) was inoperable. The automatic GSE trip is assumed in the safety analysis for the Control Rod Drop Accident (CRDA) and is required when Thermal Power is less than or equal to 10%.

"The automatic trip function of the GSE was inoperable for 1 minute, 19 seconds. No Control Rod movement occurred while the automatic trip of the GSE was inoperable. There was no adverse impact to public health and safety or to plant employees and there was no radiological release.

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(C) and 10CFR50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019