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Event Notification Report for May 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/30/2019 - 5/1/2019

** EVENT NUMBERS **


54004 54018 54019 54022 54023 54037 54038

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Agreement State Event Number: 54004
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER UNIVERSITY MEDICAL CENTER - TUCSON
Region: 4
City: TUCSON   State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 04/16/2019
Notification Time: 23:34 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [MST]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNABLE TO INJECT FULL PRESCRIBED DOSE DURING MEDICAL TREATMENT

The following was received via e-mail:

"On April 16, 2019, the Department [Arizona Department of Radiation Control] received notification from the licensee [Banner University Medical Center - Tucson] of a possible medical event involving yttrium-90 radiolabeled glass microspheres (Therasphere). The pre-treatment calibration measured an activity of 2.91 GBq and the post-treatment calibration measured 2.65 GBq. The patient was being treated for a hepatocellular carcinoma in the left hepatic lobe, segment II. The Department has requested additional information and continues to investigate the event."

Additional information from call to licensee Radiation Safety Officer:

During injection of the prescribed dose to the patient, backpressure during the injection prevented injecting the full dose, with 2.65 GBq of a prescribed dose of 2.91 GBq not delivered (24 percent was delivered).

Arizona Incident 19-006

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.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 54018
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: LINDSEY GRISSOM
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/22/2019
Notification Time: 16:16 [ET]
Event Date: 04/22/2019
Event Time: 11:30 [EDT]
Last Update Date: 04/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
FRANK EHRHARDT (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text



EN Revision Imported Date : 5/1/2019

EN Revision Text: CONTRACT SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST

A contract supervisor tested positive for drugs on a random fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a follow-up test administered the previous day (see EN #54017).

* * * RETRACTION ON 4/30/2019 AT 1642 EDT FROM KELLI ROBERTS TO BRIAN LIN * * *

"On April 16, 2019, an individual was selected for a follow-up drug test. The same individual was selected again on April 17, 2019 for a random drug test. The results for both tests were ruled by the Medical Review Officer (MRO) on the same day and ruled positive for the same drug on April 22, 2019. These FFD violations were reported to the NRC on April 22, 2019, as EN #54017 and EN #54018, respectively. As allowed by 10 CFR 26.185(o), the MRO further reviewed the quantitation of the drug in both tests and determined that no further drug use had occurred since the first positive test. Therefore, the MRO concluded that this should be considered one FFD violation, and EN #54018 is being retracted. No changes are needed to EN #54017."

The NRC Resident Inspector has been notified of this retraction.

Notified R2DO (Heisserer) and FFD Group (email).

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Agreement State Event Number: 54019
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO   State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: MARY BURKHART
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/22/2019
Notification Time: 17:38 [ET]
Event Date: 04/19/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED I-125 SOURCE

The following information was obtained from the state of Illinois via email:

"The RSO [radiation safety officer] at the University of Chicago [Hospital], called to report that the University received one lsoAid, Model IAl-125A, I-125 source for a seed localization procedure. It had an activity of 271 microCuries when implanted in the patient on Thursday, April 18, 2019. On Friday, the patient's tissue [containing the I-125 seed was excised] and sent to pathology for evaluation. During all steps, the individuals involved reported that they measured appropriate dose rates from the seed. The Pathology technician was using scissors on the patient's tissue and the seed popped out of the specimen and fell into the sink. The seed was recovered before it went down the drain. Surveys of the sink show no contamination or dose rate measurements. The radiation safety staff measured the recovered source with both a survey instrument and a gamma counter, and the source has no measureable dose rate. The patient was surveyed and it was determined that the source [was] not in the patient.

"A review of the SSDR [sealed source and device registry] sheet has determined that this source contains I-125 adsorbed on a silver rod which is further encased in the outer capsule. The outer capsule measures 3.0 mm x 0.5 mm and there are no visible signs that the source was cut. They plan to take the seed for an x-ray today to determine if the inner rod is missing and to see if there are obvious signs that the outer capsule was breached.

"UPDATE: The I-125 seed was found intact in the sink trap. The source that was initially believed to be the subject seed was from another patient and was a three-year-old prostate seed that had decayed to background."

NMED Item Number: IL190012

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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Agreement State Event Number: 54022
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE   State: WA
County:
License #: M008
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/23/2019
Notification Time: 19:33 [ET]
Event Date: 04/23/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

WASHINGTON AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE MATERIAL

The following information was received from the state of Washington via email:

"Swedish Medical Center notified the state of Washington that a lead pig, containing 50 mCi (1.86 GBq) of Y-90 Sir-Spheres, was picked up for lead recycling. When the recycling company (Stericycle) came to collect all the lead pigs, a tech let the company into the waste room to collect the pigs not knowing that one of the pigs contained the Y-90 material left over from a treatment on Friday the 19th of April 2019. On April 23rd, the RSO [radiation safety officer] was reviewing the lead disposal paperwork and realized the material was sent out with the other lead pigs and notified the State. The RSO called the recycling company and was told the pigs were still in a drum and had not been processed. They will be returning the drum to the medical center on April 24th, 2019 and the RSO will notify the State when it arrives."

WA Event Report ID No.: WA-19-014

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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Agreement State Event Number: 54023
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF SOUTHERN CALIFORNIA MEDICAL CENTER
Region: 4
City: LOS ANGELES   State: CA
County: LOS ANGELES
License #: 0134-19
Agreement: Y
Docket:
NRC Notified By: GEZA MIKO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/23/2019
Notification Time: 20:32 [ET]
Event Date: 04/22/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CALIFORNIA AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

The following information was excerpted from a report received from the state of California via email:

"[A] potential medical event occurred during an HDR [high dose rate] brachytherapy procedure in which the Tandem Ovoid [was] inserted into the patient. The patient was there to receive the 3rd dose of 8 Gy (for a total of 24 Gy) to the uterus. Instead, because all of the guide tubes were 132 cm instead of 120 cm in length, the entire 8 Gy of this last fraction was delivered to the vagina. They do not believe that the uterus received any of the prescribed 8 Gy, and all of it was delivered to non-target organ. The patient and her treating physician were informed, and she is going to return to the hospital for monitoring. Since this was the last of 3 fractions, the uterus has only received 16 Gy, not 24, while the unplanned dose to non-target organ was 8 Gy.

"A site visit will be conducted Monday, 4/29/2019, [by the California Department of Public Health, Radiologic Health Branch]."

CA 5010 Number: 042319

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.

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Power Reactor Event Number: 54037
Facility: INDIAN POINT
Region: 1     State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: WAYNE GRIFFIN
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 04/30/2019
Notification Time: 07:37 [ET]
Event Date: 04/29/2019
Event Time: 12:30 [EDT]
Last Update Date: 04/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JON LILLIENDAHL (R1DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

NON-LICENSED SUPERVISOR FAILED FOLLOW-UP TESTING

"A non-licensed employee supervisor had a confirmed positive test for a prohibited substance during a follow-up fitness-for-duty test. The individual's unescorted access to the plant has been terminated.

"The NRC Senior Resident Inspector was notified by the licensee."

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Non-Power Reactor Event Number: 54038
Facility: NATIONAL INST OF STANDARDS & TECH
RX Type: 20000 KW TEST
Comments:
Region: 0
City: GAITHERSBURG   State: MD
County: MONTGOMERY
License #: TR-5
Agreement: Y
Docket: 05000184
NRC Notified By: TOM NEWTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/30/2019
Notification Time: 14:17 [ET]
Event Date: 04/30/2019
Event Time: 09:00 [EDT]
Last Update Date: 04/30/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1) - DEVIATION FROM T SPEC
Person (Organization):
XIAOSONG YIN (NRR DLP)
ELIZABETH REED (NRR DLP)

Event Text

TECHNICAL SPECIFICATION VIOLATION DUE TO USING THE WRONG PROCEDURE

"On April 30, 2019 at approximately 0900 EDT at the National Bureau of Standards Test Reactor (NBSR) a Senior Reactor Operator (SRO) was discussing proposed changes to the area radiation monitor system with NBSR Instrumentation and Control personnel. During this discussion, the SRO realized that the surveillance standard for the radiation monitors had changed in September 2018. The Technical Specification 3.7.1(4) states 'The reactor shall not be operated unless: Two area radiation monitors are operable on floors C-100 and C-200'. To verify operability Technical Specification 4.7.1(4)(b) states 'The Area Radiation Monitors shall be channel tested monthly and channel calibrated annually'. The SRO informed the Chief of Reactor Operations (CRO) that they had incorrectly performed the required monthly channel test in December 2018 and January 2019. The channel test was properly performed in November 2018 and February 2019. The Reactor operated between 12/05/2018 and 12/21/2018 and again between 02/05/2019 and 02/15/2019."


Page Last Reviewed/Updated Wednesday, May 01, 2019
Wednesday, May 01, 2019