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Event Notification Report for May 02, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/1/2019 - 5/2/2019

** EVENT NUMBERS **


5400454022540235402554040


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.


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)


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.


Agreement State Event Number: 54025
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: PALL HAUPPAUGE
Region: 1
City: HAUPPAUGE   State: NY
County:
License #: C1935
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: HOWIE CROUCH 		Notification Date: 04/24/2019
Notification Time: 13:55 [ET]
Event Date: 04/23/2019
Event Time: 09:00 [EDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NEW YORK AGREEMENT STATE REPORT - PANORAMIC IRRADIATOR SOURCE FAILED TO RETRACT

The following information was received from the state of New York via facsimile:

"The New York State Department of Health (NYSDOH) was notified by [the radiation safety officer] (RSO) of Pall Hauppauge (C1935) that they had an incident where the source did not retract completely leaving the source partially exposed for a period of time.

"According to the RSO, he was notified on April 23, 2019, at approx. [0900 hrs. EDT] of a fault at Vault 4, and arrived approximately 15 minutes later and found that the source had gotten stuck very slightly above the down (safe) position when the cycle ended. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action.

"The RSO contacted Nordion to discuss the situation and he was able to free the source and get it into the safe position without any issue. The RSO then checked the radiation levels in the irradiator and found that they were normal. There was no risk of personnel or public exposure at any time during this incident, nor was there any risk of contamination.

"The root cause for the source getting stuck has not been yet determined. The RSO will be working with Nordion to assess the equipment and decide the course of action.

"DOH will continue to monitor this incident.

"Pall Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."

NY Event Report ID No.: NY-19-06


Power Reactor Event Number: 54040
Facility: FARLEY
Region: 2     State: AL
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICHARD LANGFORD
HQ OPS Officer: JEFF HERRERA 		Notification Date: 05/01/2019
Notification Time: 21:03 [ET]
Event Date: 05/01/2019
Event Time: 16:43 [CDT]
Last Update Date: 05/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JAMIE HEISSERER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 0 Startup 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO MISALIGNED CONTROL ROD

"At 1643 [CDT], with Unit 2 in Mode 2 during low power physics testing, the reactor was manually tripped per procedure due to a misaligned control rod. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the atmosphere using the atmospheric relief valves. Unit 1 is not affected.

"Due to the Reactor Protection System actuation, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 24, 2021