Event Notification Report for November 27, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/26/2019 - 11/27/2019
Agreement State
Event Number: 54416
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: ARKEMA INC.
Region: 1
City: CALVERT CITY State: KY
County:
License #: 201-308-56
Agreement: Y
Docket:
NRC Notified By: AJ BHATTACHARYYA
HQ OPS Officer: BRIAN LIN
Licensee: ARKEMA INC.
Region: 1
City: CALVERT CITY State: KY
County:
License #: 201-308-56
Agreement: Y
Docket:
NRC Notified By: AJ BHATTACHARYYA
HQ OPS Officer: BRIAN LIN
Notification Date: 11/29/2019
Notification Time: 09:47 [ET]
Event Date: 11/27/2019
Event Time: 00:00 [CST]
Last Update Date: 11/29/2019
Notification Time: 09:47 [ET]
Event Date: 11/27/2019
Event Time: 00:00 [CST]
Last Update Date: 11/29/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Commonwealth of Kentucky via email:
"Kentucky Radiation Health Branch (KYRHB) was notified by email on November 27, 2019, of an on/off shutter equipment failure on two separate fixed gauging devices (Ronan SA1-F37, Serial Numbers 9472GK and 1079GK; Cs-137 activity 500 milliCi each). Kentucky Licensee, Arkema, Inc. reports November 27, 2019 during a required 6-month check, techs discovered the shutter was not closing. Verified by survey meter, the readings did not close fully as expected. Survey numbers were not reported, but a full report will be submitted on December 2, 2019. The Licensee RSO [Radiation Safety Officer] notified plant operations department and the safety department that entry into the vessels is only via a sealed manway, and that entry is not permitted until the shutter mechanism has been repaired, or the gauges have been replaced. Ronan Engineering is scheduled to be notified after the Thanksgiving break. The licensee will provide timely updates to the KYRHB and the licensee will reinstruct employees of event reporting criteria."
Kentucky Event Report ID No.: KY190011
The following was received from the Commonwealth of Kentucky via email:
"Kentucky Radiation Health Branch (KYRHB) was notified by email on November 27, 2019, of an on/off shutter equipment failure on two separate fixed gauging devices (Ronan SA1-F37, Serial Numbers 9472GK and 1079GK; Cs-137 activity 500 milliCi each). Kentucky Licensee, Arkema, Inc. reports November 27, 2019 during a required 6-month check, techs discovered the shutter was not closing. Verified by survey meter, the readings did not close fully as expected. Survey numbers were not reported, but a full report will be submitted on December 2, 2019. The Licensee RSO [Radiation Safety Officer] notified plant operations department and the safety department that entry into the vessels is only via a sealed manway, and that entry is not permitted until the shutter mechanism has been repaired, or the gauges have been replaced. Ronan Engineering is scheduled to be notified after the Thanksgiving break. The licensee will provide timely updates to the KYRHB and the licensee will reinstruct employees of event reporting criteria."
Kentucky Event Report ID No.: KY190011
Agreement State
Event Number: 54468
Rep Org: VT DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF VERMONT MEDICAL CENTER
Region: 1
City: State: VT
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANCIS O'NEILL
HQ OPS Officer: MICHAEL BLOODGOOD
Licensee: UNIVERSITY OF VERMONT MEDICAL CENTER
Region: 1
City: State: VT
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANCIS O'NEILL
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 01/09/2020
Notification Time: 07:33 [ET]
Event Date: 11/27/2019
Event Time: 00:00 [EST]
Last Update Date: 01/09/2020
Notification Time: 07:33 [ET]
Event Date: 11/27/2019
Event Time: 00:00 [EST]
Last Update Date: 01/09/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - IODINE-125 PROSTATE IMPLANT SEED
The following is a synopsis of a report from the Vermont (VT) Department of Health (the Department):
On November 27, 2019, a prostate seed implant (PSI) procedure using Iodine-125 (I-125) seeds was performed. During the latter part of the procedure, while loading one last, extra needle for the radiation oncologist (the Authorized User), the authorized medical physicist (AMP) lost control of one I-125 seed.
A number of surveys were conducted immediately following the loss of the seed, producing only background readings.
On December 4, 2019, a Department Senior Radiological Health Specialist conducted a follow-up survey in the PSI procedure room and waste storage areas. The lost seed was not located.
As a corrective action, the licensee may consider ordering additional seeds in the form of preloaded needles to avoid handling individual prostate seeds.
The lost prostate seed is believed to have fallen into the bore of the implanting needle and was subsequently implanted into the prostate. This is not believed to have any clinical significance on the resulting absorbed dose to the prostate, urethra, or rectum. The patient had 76 prostate seeds planned to be implanted and a single extra seed would result in approximately 1 percent additional absorbed dose to the treatment volume.
As verification, a post-implant treatment plan was calculated with an extra prostate seed placed near the location of the last needle within the treatment volume. The resulting dose metrics confirmed that absorbed doses increased by about 1 percent.
The potential radiation exposure to an individual that is continuously present near the lost seed was evaluated and determined to be less than the 0.1 rem annual public exposure limit.
No personnel contamination occurred as a result of this event.
VT Incident Number: VT19-002
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.
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
The following is a synopsis of a report from the Vermont (VT) Department of Health (the Department):
On November 27, 2019, a prostate seed implant (PSI) procedure using Iodine-125 (I-125) seeds was performed. During the latter part of the procedure, while loading one last, extra needle for the radiation oncologist (the Authorized User), the authorized medical physicist (AMP) lost control of one I-125 seed.
A number of surveys were conducted immediately following the loss of the seed, producing only background readings.
On December 4, 2019, a Department Senior Radiological Health Specialist conducted a follow-up survey in the PSI procedure room and waste storage areas. The lost seed was not located.
As a corrective action, the licensee may consider ordering additional seeds in the form of preloaded needles to avoid handling individual prostate seeds.
The lost prostate seed is believed to have fallen into the bore of the implanting needle and was subsequently implanted into the prostate. This is not believed to have any clinical significance on the resulting absorbed dose to the prostate, urethra, or rectum. The patient had 76 prostate seeds planned to be implanted and a single extra seed would result in approximately 1 percent additional absorbed dose to the treatment volume.
As verification, a post-implant treatment plan was calculated with an extra prostate seed placed near the location of the last needle within the treatment volume. The resulting dose metrics confirmed that absorbed doses increased by about 1 percent.
The potential radiation exposure to an individual that is continuously present near the lost seed was evaluated and determined to be less than the 0.1 rem annual public exposure limit.
No personnel contamination occurred as a result of this event.
VT Incident Number: VT19-002
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.
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