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Event Notification Report for November 15, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/14/2019 - 11/15/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54372
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: GEISINGER HOLY SPIRIT CANCER CENTER Region: 1 City: MECHANICSBURG State: PA County: License #: PA-0249A Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: ERIC SIMPSON	Notification Date: 11/06/2019 Notification Time: 09:12 [ET] Event Date: 11/04/2019 Event Time: 00:00 [EST] Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE FAILS TO FUNCTION AS DESIGNED

The following information was received via fax:

"On November 4, 2019 the licensee was performing a mask treatment with the Elekta Gamma Knife Icon containing Cobalt 60. The treatment was interrupted when the High Definition Motion Management tracking system lost communication with 1 minute and 29 seconds remaining from shot B6, (planned for 2 minutes 13 seconds) and 2 minutes 36 seconds remaining for B3 (No treatment was delivered from this shot). The sources safely retracted into their home position and the software message prompted the user to reinitiate the Gamma Knife system; however, an error message occurred on each attempt to reinitiate. The system was then rebooted; however, the same error occurred again. The patient was removed from the treatment vault and a service call was made to Elekta. The onsite service engineer arrived that same day to troubleshoot and new parts were ordered and arrived on November 5, 2019. The intent is to complete the remaining treatment on November 5, 2019 once the Gamma knife repair and subsequent QA is completed. The doctor and patient were informed immediately. No overdose to anyone has occurred and no harm is expected to the patient. The [PA Bureau of Radiation Protection] will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190025

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: 54373
Rep Org: COLORADO DEPT OF HEALTH Licensee: CHILDREN'S HOSPITAL COLORADO Region: 4 City: AURORA State: CO County: License #: CO 075-02 Agreement: Y Docket: NRC Notified By: PHILLIP PETERSON HQ OPS Officer: OSSY FONT	Notification Date: 11/06/2019 Notification Time: 16:34 [ET] Event Date: 11/01/2019 Event Time: 00:00 [MST] Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION DUE TO DISLODGED CATHETER

The following was received from the Colorado Radioactive Materials Unit via email:

"On 11/6/19, the Colorado Department of Public Health and Environment was notified of a potential reportable contamination event. On 11/1/19, approximately 12 hours after an I-131 MIBG [meta-iodobenzylguanidine] administration (293.6 mCi) on 10/31/19, the patient's catheter was dislodged [while asleep]. I-131 contaminated urine spilled out of the catheter and contaminated the patient, bed, bedding, and floor under the bed. Most of the spill was located under the bed. The patient was decontaminated after the spill was identified and has since been released from the facility. After the patient was released, the extent of the spill was identified by the licensee. The treatment room has not been released for unrestricted use as of 11/6/19. Dose rates taken by the licensee indicate the potential for greater than 5 times the ALI [annual limit on intake] prior to decontamination efforts."

Colorado Event Report No: CO190018

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: 54374
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: APEX ENVIRONMENTAL Region: 4 City: LENEXA State: KS County: License #: 22-B791 Agreement: Y Docket: NRC Notified By: DAVID LAWRENZ HQ OPS Officer: OSSY FONT	Notification Date: 11/06/2019 Notification Time: 17:04 [ET] Event Date: 11/06/2019 Event Time: 00:00 [CST] Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - POTENTIAL LOST SOURCE

The following is a summary of an email received from the Kansas Department of Health and Environment's Radioactive Materials Team:

Apex Environmental reported that they sent their X-ray fluorescence to Massachusetts via a common carrier to be resourced. They have a delivery receipt, but have been unsuccessful in contacting the company. Perhaps the device is being held for payment. The State has requested additional information from Apex and will follow up with Massachusetts' Radiation Control Program and the vendor to determine the status of the device.

Kansas Event Report ID No: KS190010

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: 54376
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: LEHIGH VALLEY HEALTH NETWORK Region: 1 City: ALLENTOWN State: PA County: License #: PA-0232 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: BRIAN P. SMITH	Notification Date: 11/07/2019 Notification Time: 14:08 [ET] Event Date: 11/05/2019 Event Time: 00:00 [EST] Last Update Date: 11/07/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Commonwealth of Pennsylvania via email:

"The Department [Pennsylvania Department of Environmental Protection] received notification from a licensee on November 6, 2019 that on October 8, 2019 they performed a prostate seed implant on a patient including seventy (70) stranded I-125 seeds that were implanted into the prostate treatment volume. They were Best Medical, Model 2301, Lot 48917, at 0.350 mCi per seed and 24.5 mCi total activity. The patient had an appointment on November 5, 2019 for a 30-day post-plan analysis. The CT from November 5, 2019 noted 2 seeds that were outside the prostate volume in the peri-prostatic fat. The post-plan analysis showed that 68 of 70 seeds are within the treatment volume and 94.4 percent of the treatment volume is covered by the prescription dose, which are within appropriate specifications for a prostate seed implant. The two seeds in question are considered discontiguous from the treatment volume. The licensee believes when the needle was retracted, the strand of seeds drug back with the needle and was deposited inferior from their intended location. An analysis was performed by the licensee and no adverse effects to the patient are expected. Both the patient and referring physician were notified. The Department will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190026

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: 54377
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: DESERT NDT LLC Region: 4 City: SONORA State: TX County: License #: L06462 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: HOWIE CROUCH	Notification Date: 11/07/2019 Notification Time: 14:55 [ET] Event Date: 11/06/2019 Event Time: 00:00 [CST] Last Update Date: 11/07/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

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

"On November 7, 2019, the licensee's radiation safety officer (RSO) notified the Agency [Texas Department of State Health Services] that at approximately 2000 CST on November 6, 2019, one of their industrial radiography crews had been unable to retract a 113 Curie iridium-192 source (model 702, SN: TT2307) into a QSA 880 Delta exposure device (SN: D7727) at a temporary job site in Sonora, Texas. The RSO stated the drive cable had broken at the ball stop. Source retrieval was performed by authorized employees. The initial radiographers' and another of the licensee employee's self-reading pocket dosimeters read 13 and 14 mR. The two authorized source retrievers' self-reading pocket dosimeters had readings of approximately 300 mR. All dosimetry badges are being sent for immediate processing. There were no other persons in the area so there was no risk of exposure to any member of the public. The RSO and staff will examine the crank assembly and drive cable when it gets to their location on November 8, 2019. The RSO also plans to send the crank assembly/drive cable for evaluation by a third party service/repair company. The exposure device was tested multiple times using a different set of cranks following the retrieval and it operated properly. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No: 9723

Power Reactor	Event Number: 54382
Facility: BROWNS FERRY Region: 2 State: AL Unit: [1] [2] [3] RX Type: [1] GE-4,[2] GE-4,[3] GE-4 NRC Notified By: ANGEL YARBROUGH HQ OPS Officer: THOMAS KENDZIA	Notification Date: 11/12/2019 Notification Time: 10:32 [ET] Event Date: 11/12/2019 Event Time: 06:00 [CST] Last Update Date: 11/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): ERIC MICHEL (R2DO)

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

100

Power Operation

100

Power Operation

Event Text

EN Revision Imported Date : 11/15/2019

EN Revision Text: EMERGENCY OPERATIONS FACILITY OUT OF SERVICE

"On November 12, 2019, the Central Emergency Control Center (CECC) was removed from service for a planned facility upgrade project. The CECC is a common Emergency Operations Facility (EOF) for the TVA Nuclear sites (Browns Ferry / Sequoyah / Watts Bar). The duration of the upgrade project is approximately 75 days.

"If an emergency is declared requiring CECC activation during this period, an alternate CECC will be used. During this period, the alternate CECC will be staffed and activated using existing emergency procedures.

"This is an eight-hour, non-emergency notification for a Loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the CECC will be unavailable for more than 72 hours.

"The Emergency Response Organization has been notified that the CECC will be unavailable during the upgrade project and to report to the alternate CECC in the event of an emergency. There is no impact on the health and safety of the public or plant employees.

"The NRC Resident Inspector has been notified."

* * * UPDATE AT 1316 EST ON 11/14/19 FROM BARUCH CALKIN TO JEFF HERRERA * * *

The event information was updated to indicate that the event occurred at 0700 EST.

The NRC Resident Inspector has been notified.

Notified the R2DO(Musser).

Page Last Reviewed/Updated Thursday, March 25, 2021