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Event Notification Report for September 20, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/19/2019 - 9/20/2019

** EVENT NUMBERS **


54269 54270 54286

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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.

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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

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Power Reactor Event Number: 54286
Facility: CATAWBA
Region: 2     State: SC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILL FOWLER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 09/19/2019
Notification Time: 14:08 [ET]
Event Date: 07/06/2019
Event Time: 01:56 [EDT]
Last Update Date: 09/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRIAN BONSER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

BOTH TRAINS OF COMPONENT COOLING WATER DETERMINED INOPERABLE

"10 CFR 50.72(b)(3)(v)(A, B, and D) - Event or Condition that Could Have Prevented the Fulfillment of a Safety Function Unit 2 Component Cooling water system inoperable.

"On July 6, 2019, from 0156 to 1545 [EDT], it was determined that both trains of the unit 2 component cooling water system were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The affected safety function was restored on July 6, 2019, at 1545 [EDT] when the 2B component cooling train was restored to operable.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

At the time of the event no other safety related systems were inoperable. The event had no impact on Unit 1.


Page Last Reviewed/Updated Friday, September 20, 2019
Friday, September 20, 2019