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Event Notification Report for December 23, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/20/2019 - 12/23/2019

** EVENT NUMBERS **


54432 54439 54441 54442 54443 54444 54445 54453

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 54432
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: DELONG COMPANY
Region: 4
City: Omaha   State: NE
County:
License #: GO-0788
Agreement: Y
Docket:
NRC Notified By: DEB WILSON
HQ OPS Officer: BRIAN LIN
Notification Date: 12/10/2019
Notification Time: 10:14 [ET]
Event Date: 12/09/2019
Event Time: 00:00 [CST]
Last Update Date: 12/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text



EN Revision Imported Date : 12/23/2019

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

This is a summary of information received from the state of Nebraska via a phone call:

On December 2, 2019, the state of Nebraska identified a lost tritium exit sign that was improperly transferred by the licensee to the state of Wisconsin. The general licensee indicated that they transferred the exit sign to a electronics company in Wisconsin, which was not licensed to possess radioactive materials. It is believed that the sign was reused by the electric company. The company was contacted and is working with the Wisconsin Department of Health on ascertaining the exit sign's location.

The tritium exit sign is a Isolite model 2000 (S/N: H114041) with an activity of 12.57 Ci.

No further investigation is planned at this time and Nebraska has closed the event.

Nebraska incident number: NE190006

* * * RETRACTION ON 12/20/2019 AT 1011 EST FROM DEB WILSON TO ANDREW WAUGH * * *

This is a summary of information received from the state of Nebraska via email:

On 12/12/2019 the Wisconsin Radioactive Program confirmed the sign (S/N: H114041) had been found and installed in Joliet, IL.

Notified R4DO (Drake) and NMSS Events (email).

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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Agreement State Event Number: 54439
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SOUTHERN BAPTIST HOSPITAL OF FLORIDA
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: 0155-4
Agreement: Y
Docket:
NRC Notified By: RENO J FABII
HQ OPS Officer: OSSY FONT
Notification Date: 12/12/2019
Notification Time: 12:26 [ET]
Event Date: 12/12/2019
Event Time: 00:00 [EST]
Last Update Date: 12/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week."

Incident Number: FL19-146

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: 54441
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: AUGUSTA UNIVERSITY HEALTH SYSTEM
Region: 1
City: AUGUSTA   State: GA
County:
License #: GA 1110-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: KARL DIEDERICH
Notification Date: 12/13/2019
Notification Time: 10:17 [ET]
Event Date: 12/05/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MIS-ADMINISTRATION

The following report was received from the Georgia radioactive materials program environmental protection division via email:

"Augusta University Medical Center had an incident yesterday (December 5, 2019) in the Interventional Radiology (IR) Suite during a Y-90 TheraSphere procedure.

"The Y-90 TheraSphere delivery was performed in the usual fashion, per TheraSphere protocol, with 3 flushes of the administration vial. Both delivery and nuclear medicine pre-procedure preparation was performed per standard radiopharmaceutical (TheraSphere) protocol. During administration, the remaining undelivered dose became stuck/trapped in the transport vial and could not be administered.

"About 40 percent of the prescribed radiation dose was delivered to the patient, which is less than the criteria in Rule 391-3-17-.05.(115)a.1(i), which states, 'The total dose delivered differs from the prescribed dose by 20 percent or more.'

"A small amount of the Y-90 microspheres spilled onto the administration table, which was covered with absorbent towels. Augusta University staff isolated the contamination, scanned all IR Suite staff to ensure the contamination was not spread outside the immediate area, and called for assistance with clean-up. All contamination was located and cleaned-up, and all swipes have been counted and the results show no residual contamination in the suite or on any equipment in the suite. All radioactive material has been collected and is being stored and managed as radioactive waste.

"A formal written notification to your office will be submitted within 15 days of the event. This formal written notification will include all of the information required by Rule 391-3-17-.05.(115)."

Georgia Incident No.: 22

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: 54442
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI   State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 12/13/2019
Notification Time: 14:39 [ET]
Event Date: 11/22/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"At [licensee], on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate."

Incident Number: FL19-141

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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Non-Agreement State Event Number: 54443
Rep Org: BASF CORPORATION
Licensee: BASF CORPORATION
Region: 3
City: WYANDOTTE   State: MI
County:
License #: 21-00627-02
Agreement: N
Docket:
NRC Notified By: DEREK HETES
HQ OPS Officer: BETHANY CECERE
Notification Date: 12/13/2019
Notification Time: 14:46 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
KENNETH RIEMER (R3DO)
LAURA PEARSON (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST TRITIUM EXIT SIGNS

The following is a synopsis of a telephonic report:

An electrical contractor did not follow disposal instructions and disposed of eight (8) tritium exit signs (approximately 9.5 Ci each) in a dumpster on 12/2/19. The dumpster was removed on 12/4/19. The licensee discovered the error on 12/13/19 when they could locate two of the ten signs planned for removal.

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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Agreement State Event Number: 54444
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON REGIONAL HOSPITAL
Region: 1
City: BOCA RATON   State: FL
County:
License #: 550-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 12/13/2019
Notification Time: 14:50 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - I-125 SEED MISTAKENLY INCINERATED

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"I-125 therapy seed (243 microCi) was mistakenly incinerated with medical waste. Pathologist mistook metal clip for seed and included it in the material to be incinerated. This information is from a preliminary phone report [to the Bureau]; a full written report with radioactive source info will be submitted via email."

Incident Number: FL19-148

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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Non-Agreement State Event Number: 54445
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS   State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: BETHANY CECERE
Notification Date: 12/13/2019
Notification Time: 20:37 [ET]
Event Date: 12/13/2019
Event Time: 00:00 [CST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MICROSPHERES DEPOSITED TO DIFFERENT SEGMENT OF LIVER

The following is a synopsis of a telephonic report:

On 12/6/19, a patient was administered Y-90 microspheres, intended for segment 4 of the liver.

On 12/13/19, the post-administration imaging was interpreted and examined. It was determined that, despite taking precautions of blood vessel embolization to limit the microspheres from other segments, some of the microspheres deposited in segment 2 as well as segment 4. The patient was notified. No adverse effects are expected as the microspheres all went to the same lobe of the liver, and within about 95 percent of the prescribed dose.

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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Non-Power Reactor Event Number: 54453
Facility: UNIV OF MISSOURI-COLUMBIA
RX Type: 10000 KW TANK
Comments:
Region: 0
City: COLUMBIA   State: MO
County: BOONE
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: JEREMY CUSTER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/20/2019
Notification Time: 06:43 [ET]
Event Date: 12/19/2019
Event Time: 21:21 [CST]
Last Update Date: 12/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
GEOFFREY WERTZ (NRR PM)
BETH REED (NRR)

Event Text

TECHNICAL SPECIFICATION DEVIATION

"On December 19, 2019, at 2121 CST, the University of Missouri-Columbia Research Reactor (MURR) was shut down due to a seized servomotor on the regulating blade drive mechanism during reactor operation. This notification is required per MURR Technical Specification (TS) 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by TS 1.1, had occurred. MURR was not in compliance with all Limiting Conditions for Operations (LCOs), specifically TS 3.2.a, which states, 'All control blades, including the regulating blade, shall be operable during reactor operation.' The regulating blade drive mechanism was removed, a new motor installed, and then the regulating blade drive mechanism was reinstalled and all its functions were tested satisfactorily. Permission from the Reactor Facility Director was obtained per TS 6.6.c(4) prior to starting up the reactor later on December 20.

"A detailed event report will follow within 14 days as required by TS 6.6.c(3)."


Page Last Reviewed/Updated Monday, December 23, 2019
Monday, December 23, 2019