Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for April 08, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/5/2019 - 4/8/2019

** EVENT NUMBERS **

Agreement State	Event Number: 53963
Rep Org: NC DIV OF RADIATION PROTECTION Licensee: NOVANT HEALTH PRESBYTERIAN MEDICAL CENTER Region: 1 City: CHARLOTTE State: NC County: License #: 060-0019-1 Agreement: Y Docket: NRC Notified By: TRAVIS CARTOSKI HQ OPS Officer: JEFF HERRERA	Notification Date: 03/29/2019 Notification Time: 11:01 [ET] Event Date: 03/05/2019 Event Time: 00:00 [EDT] Last Update Date: 03/29/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT SOURCE STRENGTH ENTERED RESULTING IN OVERDOSE OF 20 PERCENT

The following report was received from the North Carolina Division of Health Service Regulation via email:

"A prostate patient returned for a 30 day post treatment review and CT scan. Licensee Physics Group reviewed the Post Op Plan with the Intended Plan. It was found that when the Intended Plan was entered into the planning software, a dosimetrist entered an incorrect source strength into the planning system, causing the planning system to appear to be implanting weaker seeds than were being implanted resulting in an over dose of 20 percent.

"Event Date: 3/5/19
Discovered Date: 3/28/1
Prescribed dose: 164.85 mCi
Administered dose: 213.15 mCi
Isotope: PD-103.
Target organ: Prostate
Referring Physician notified on: 3/28/19
Patient notified on: 3/28/19
Effects/Outcome to the Patient: None anticipated. Physician will monitor patient for side effects.
Notifications & Generic Implications: None.
Corrective Action: Procedure revision.

"A reactive inspection was conducted today [by the North Carolina Division of Health Service Regulation]. Following this entry into NMED we [the North Carolina Division of Health Service Regulation] would like to request the event be closed and complete. We [the North Carolina Division of Health Service Regulation] have concluded our investigation.

"NC Tracking Number: 190011"

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: 53964
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: MESKEL & ASSOCIATES ENGINEERING, PLLC Region: 1 City: JACKSONVILLE State: FL County: DUVAL License #: 4344-1 Agreement: Y Docket: NRC Notified By: MATTHEW G SENISON HQ OPS Officer: THOMAS KENDZIA	Notification Date: 03/29/2019 Notification Time: 15:44 [ET] Event Date: 03/29/2019 Event Time: 11:00 [EDT] Last Update Date: 03/29/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (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 TROXLER DENSITY GAUGE

"At around 1:50 p.m. EDT, [the radiation safety officer] of Meskel Associates called to notify the BRC [Bureau of Radiation Control] of the loss of a Troxler Soil Moisture Density Gauge Model 3440 S/N 17405, source numbers 507-6784 & 47-12827. The gauge fell off of the back of a pickup truck because the tailgate was down and the gauge was not secured. No injuries were reported, the licensee checked with FHP for collision reports. Five people from the licensee looked for it, none found it."

Florida Incident Number FL19-046

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: 53965
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: ADVENTIST HEALTH SYSTEM Region: 1 City: DAYTONA State: FL County: License #: 2897-1 Agreement: Y Docket: NRC Notified By: TIM DUNN HQ OPS Officer: ANDREW WAUGH	Notification Date: 03/29/2019 Notification Time: 16:23 [ET] Event Date: 03/29/2019 Event Time: 00:00 [EDT] Last Update Date: 04/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (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 - LOSS OF AN I-125 SEED

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

"Received a call from Adventist Health to report the loss of an I-129 seed that was removed from a patient. According to [Adventist Health], the seed was removed on 2/19/2019 and discovered missing on 2/20/2019, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator. A preliminary report will be sent to [the Florida Bureau of Radiation Control] as soon as possible, and followed up with the official report from the hospital when their investigation is complete."

Florida Incident Number: FL19-047

* * * UPDATE ON 4/5/2019 AT 1602 EDT FROM TIM DUNN TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"Adventist Health reported the loss of an I-125 seed that was removed from a patient. The seed was removed [from the patient] on Feb. 19th and discovered missing on Feb. 20th, all attempts to locate the seed have been unsuccessful. It is believed that the seed was discarded with the medical waste and sent to the incinerator.

"There was no adverse outcome in patient care from this incident. The seed was either disposed of in biohazard or normal trash. In either case, the portal monitors would not have measured the radiation emitted from the seed due to the low activity. No personnel or general public exposure would have been significant based upon the low exposure rate and the nature of controlled biohazard waste. The waste was incinerated. No environmental impact is expected.

"Corrective actions taken as a result of the loss of this source:
1) Surgery will survey the specimen when placed in the bag before sending to imaging. Education on this process has occurred to ensure compliance.
2) X-ray will scan the specimen placed in the bag with a survey meter when obtaining the specimen x-ray, prior to going to pathology. Education on this process has occurred to ensure compliance.
3) Pathology will survey the specimen upon receipt to confirm the seed is present. Reeducation on this process has occurred to ensure compliance."

This event was previously reported as a loss of an I-129 seed, which was incorrect.

Seed activity: 241 microCuries

Notified R1DO (Young) and NMSS Events and ILTAB (via e-mail).

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: 53982
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: ETHAN HAUSER HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 04/05/2019 Notification Time: 12:19 [ET] Event Date: 04/05/2019 Event Time: 11:25 [EDT] Last Update Date: 04/05/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): JOHN HANNA (R3DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

FITNESS-FOR-DUTY: FALSIFIED PRE-EMPLOYMENT INFORMATION

A non-licensed employee falsified pre-employment information. The employee's access to the plant has been terminated.

Non-Power Reactor	Event Number: 53983
Facility: GENERAL ELECTRIC OF PLEASANTON RX Type: 100 KW NTR (TANK) Comments: Region: 0 City: PLEASANTON State: CA County: ALAMEDA License #: R-33 Agreement: Y Docket: 05000073 NRC Notified By: SCOTT MURRAY HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 04/05/2019 Notification Time: 14:00 [ET] Event Date: 04/04/2019 Event Time: 12:50 [PDT] Last Update Date: 04/05/2019
Emergency Class: NON EMERGENCY 10 CFR Section: NON-POWER REACTOR EVENT	Person (Organization): DUANE HARDESTY (NRR) BETH REED (NRR)

Event Text

NON POWER REACTOR - REACTOR NOT PROPERLY SECURED

"On 4/4/19 at approximately 1250 PDT, it was discovered that the Nuclear Test Reactor (NTR) facility control room console had not been properly secured at the Vallecitos Nuclear Center (VNC) in accordance with license technical specifications and internal procedures. The console key remained in the console and no licensed operator was present. The reactor is considered secured when the console key lock switch is off and the console key is in proper custody.

"The reactor was shut down at the time and the key lock was in the off position. The licensed operator exited and locked the control room at 1250 PDT but left the console key at the console failing to secure it in the designated storage safe as required.

"No personnel entered the control room until 1345 PDT when an authorized Radiation Monitoring Technician entered, discovered the key and immediately notified a licensed operator. Additional actions are being evaluated as a part of the corrective action program.

"No unsafe condition existed, however, the event is being reported pursuant to an inadequacy of an administrative or procedural control in NTR Technical Specification 6.2.2(a)(2) because it could have caused the existence or development of an unsafe condition with regard to reactor operations."

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