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Event Notification Report for December 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/24/2019 - 12/25/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54448
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: MOUNT NITTANY MEDICAL CENTER Region: 1 City: STATE COLLEGE State: PA County: License #: PA-0126 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: CATY NOLAN	Notification Date: 12/17/2019 Notification Time: 10:44 [ET] Event Date: 12/13/2019 Event Time: 00:00 [EST] Last Update Date: 12/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - HIGH DOSE RATE APPLICATOR DISLODGED

The following was received from the PA Department Bureau of Radiation Protection (DEP) via fax:

"On December 16, 2019, the medical physicist for the licensee verbally reported that during an HDR [high dose rate] treatment using a Varian Model VariSource IX with a Tandem & Ovoid applicator, the applicator was found dislodged at the end of the treatment period. This was fraction 4 of 5 planned fractions. It is unknown at this time how long the applicator was not in the planned position or what caused it to move. The prescribed dose was 600 cGy from a 5.126 Ci Iridium-192 source. No further information is available at this time. The DEP will update this event as soon as more information is provided."

Event Report ID No: PA190029

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: 54450
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: ECS-FLORIDA, L.L.C. Region: 1 City: SOUTH DAYTONA State: FL County: License #: 3440-4 Agreement: Y Docket: NRC Notified By: PAUL NORMAN HQ OPS Officer: OSSY FONT	Notification Date: 12/17/2019 Notification Time: 22:42 [ET] Event Date: 12/17/2019 Event Time: 14:50 [EST] Last Update Date: 12/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVE WERKHEISER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the Florida Department of Health via email:

"[The Radiation Safety Officer (RSO)] reported an incident involving a damaged Troxler Soil Moisture Density Gauge. The 2 sources [Cs-137 (8 mCi); Am-Be (40 mCi)] were not damaged or dislodged. The only damage was to the operator handle. At approximately [1450 EST], the gauge was bumped by a bulldozer [at a temporary work site in Ocala, FL], damaging the handle. The gauge is repairable. [The RSO] will follow-up his initial report with a written report on Wednesday, December 18, 2019. No further action is required."

Event Incident Number: FL19-151

* * * UPDATE ON 12/18/2019 AT 1110 EST FROM MATTHEW SENISON TO ANDREW WAUGH * * *

The following was received from the Florida Department of Health via email:

The sources are currently in the licensee's possession. The State will dispatch an inspector for this incident and pictures of the gauge, a leak test, and a report including corrective actions taken to prevent re-occurrence will be required.

Notified R1DO (Werkheiser) and NMSS Events (email).

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