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Event Notification Report for September 19, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/18/2019 - 9/19/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54265
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: FUGRO USA LAND INC CONSULTANTS Region: 4 City: FORT WORTH State: TX County: License #: L05843 Agreement: Y Docket: NRC Notified By: ART TUCKER HQ OPS Officer: DONALD NORWOOD	Notification Date: 09/10/2019 Notification Time: 11:47 [ET] Event Date: 09/09/2019 Event Time: 00:00 [CDT] Last Update Date: 09/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) CNSNS (MEXICO) (EMAIL) ADAM TUCKER (ILTAB)

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

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE / DENSITY GAUGE

The following information was received from the Texas Department of State Health Services via E-mail:

"On September 10, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee that on September 9, 2019, one of its technicians had lost a Troxler model 3440 moisture/density gauge. The gauge contained a 40 milliCurie americium-241 source and an eight milliCurie cesium-137 source.

"The licensee stated the technician had been working at a temporary job site and had placed the gauge on the tailgate of the truck. The technician left the job site, to get a meal, with the gauge still setting on the tailgate. After traveling about three miles the technician noted the tailgate was down and found the gauge was missing. The technician searched on foot the path they had driven, but did not locate the gauge. On the morning of September 10, 2019, the licensee searched the path traveled by the technician, but did not find the gauge.

"The licensee stated that the gauge was not in a transport case and the operating rod did not have a lock on it. Therefore, they could not say that there is no chance for an exposure to a member of the general public. The licensee stated they did not know if local law enforcement had been notified at the time of the call to the Agency, but would make sure that they call them and informed them of the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9708

* * * UPDATE FROM ARTHUR TUCKER TO BRIAN LIN AT 0753 EDT ON 9/12/2019 * * *
The following information was received via E-mail:

"On September 11, 2019, the licensee left a phone message informing the Agency [Texas Department of State health Services] that the gauge had been recovered. No additional information was provided. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Alexander), NMSS Events Notification E-mail group, CNSNS (Mexico), and ILTAB (Tucker).

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/Pub122

* * * UPDATE AT 0959 EDT ON 9/12/19 FROM ART TUCKER TO JEFF HERRERA * * *

The following update was received from the Texas Department of State Health Services via email:

"On September 12, 2019, the Agency was contacted by the licensee and informed that the gauge had been recovered by a member of the general public on the day of the event (September 10, 2019). The individual who found the gauge contacted the licensee using the information provided on the gauge on September 11, 2019. The individual who recovered the gauge stated they found the gauge near the location the licensee had been using the gauge. The individual who found the gauge did not provide a reason they did not call before September 11, 2019.

"The gauge was inspected and was not damaged. The source was in the fully shielded position. A source leak test has been completed and sent for analysis. The individual who recovered the gauge stated they did not attempt to operate the gauge. The licensee stated they did not believe the individual who have been exposed because of this event. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Alexander), NMSS Events Notification E-mail group, CNSNS (Mexico), and ILTAB (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://wwwpub.iaea.org/MTCD/publications/PDF/Pub122

Agreement State	Event Number: 54269
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: PHYSICIANS SURGICAL CENTER OF FORT WORTH LLP Region: 4 City: FORT WORTH State: TX County: License #: L05863 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: DONALD NORWOOD	Notification Date: 09/11/2019 Notification Time: 18:23 [ET] Event Date: 09/11/2019 Event Time: 00:00 [CDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MEDICAL EVENT - PALLADIUM-103 SEEDS IMPLANTED TO WRONG TARGET AREA

The following information was received from the Texas Department of State Health Services via E-mail:

"On September 11, 2019, the Agency [Texas Department of State Health Services] was notified that the licensee had identified that a medical event had occurred at its facility. The licensee reported it had discovered that the 52 palladium-103 seeds (1.292 mCi each) that had been implanted into a patient on August 1, 2019, which were intended to deliver 100 gray to the prostate, were all inferior to the patient's prostate approximately four centimeters.

"The licensee has notified the referring physician and patient. The licensee stated the current plan is to implant the prostate. There are no significant adverse effects expected.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

* * * UPDATE RECEIVED FROM ART TUCKER TO OSSY FONT ON 09/13/19 AT 1752 EDT * * *

"On September 13, 2019, the Agency received additional information on this event. The licensee's report stated that on August 1, 2019, the physician was using ultrasound imaging to locate the prostate [and] misidentified the penile bulb as the prostate. The licensee stated this occurred because the penile bulb was very similar in size (10.8 cc versus 12 cc for the prostate) and they were very close to each other. As a result, 52, 1.292 milliCurie (67.2 milliCurie total) Palladium-103 seeds were placed four centimeters inferior to the prostate. The error was not discovered until September 11, 2019 during the post-implant dosimetry review.

"The estimated exposure to 90 percent of the penile bulb is 73 gray. The report stated that the patient is elderly and not sexually active; therefore, there is no increased risk of erectile dysfunction. The licensee identified the urethral structure as additional tissue at risk, but expected the effects to be the same as if the seeds had been properly placed at the prostate. The estimated dose to the prostate was 0 gray. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9710

Notified R4DO (Alexander) and NMSS Events Notification E-mail group.

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: 54270
Rep Org: ARIZONA RADIATION REGULATORY AGENCY Licensee: AMC#102 Region: 4 City: PHOENIX State: AZ County: License #: GENERAL LICENSE Agreement: Y Docket: NRC Notified By: BRIAN GORETZKI HQ OPS Officer: DONALD NORWOOD	Notification Date: 09/11/2019 Notification Time: 19:00 [ET] Event Date: 09/11/2019 Event Time: 00:00 [MST] Last Update Date: 09/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RYAN ALEXANDER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) CNSNS (MEXICO) (EMAIL)

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

Event Text

LOST / STOLEN TRITIUM EXIT SIGN

The following information was received from the Arizona Department of Health Services via E-mail:

"The Department [Arizona Department of Health Services] received notification that a tritium exit sign has been lost/stolen. The model is an Isolite 2040 with an activity of approximately 7.5 curies. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 19-018

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: 54284
Facility: SOUTH TEXAS Region: 4 State: TX Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: SCOTT SAYLORS HQ OPS Officer: OSSY FONT	Notification Date: 09/18/2019 Notification Time: 13:42 [ET] Event Date: 09/18/2019 Event Time: 07:50 [CDT] Last Update Date: 09/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): GREG PICK (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

100

Power Operation

100

Power Operation

Event Text

LOSS OF COMMUNICATION WITH EMERGENCY OPERATIONS FACILITY

"At 0750 CDT, on September 18, 2019, South Texas Project Electric Generating Station (STPEGS) experienced an unplanned loss of the Integrated Computer System (ICS) to the Emergency Operations Facility (EOF). The loss of ICS resulted in a major loss of emergency assessment capability to the STPEGS EOF for greater than 90 minutes. Assessment capability has been verified to be available in the Unit 2 Technical Support Center (TSC) and the Unit 1 and Unit 2 Control Rooms. ICS was restored to the EOF at 0932 CDT on September 18, 2019.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(xiii) as any event that resulted in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability.

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

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Wednesday, March 24, 2021