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Event Notification Report for January 10, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/9/2020 - 1/10/2020

** EVENT NUMBERS **


54448 54461 54470

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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: 01/09/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 1/10/2020

EN Revision 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.

* * * UPDATE ON 1/9/20 AT 1:17 PM FROM JOHN CHIPPO TO KARL DIEDERICH * * *

The following information was received from the Agreement State via fax:

"The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event."

Notified R1DO (Schroeder) and NMSS group (via e-mail).

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Non-Agreement State Event Number: 54461
Rep Org: ALLIANCE HEALTH SERVICES
Licensee: ALLIANCE HEALTH SERVICES
Region: 1
City: BECKLEY   State: WV
County:
License #: 47-25570
Agreement: N
Docket:
NRC Notified By: KAY KASSEL
HQ OPS Officer: CATY NOLAN
Notification Date: 01/02/2020
Notification Time: 13:47 [ET]
Event Date: 01/02/2020
Event Time: 07:00 [EST]
Last Update Date: 01/02/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JOSEPH DEBOER (R1DO)

Event Text

UNPLANNED CONTAMINATION ON PET CT SCANNER MOBILE UNIT

The following is a summary of information received from Alliance Health Services (Alliance) via the phone:

At approximately 0800 CST on January 2, 2020, a mobile PET CT scanner unit was received by Alliance from CardioNavix at the Henry Ford Medical Center in West Bloomfield, MI with rubidium-82 contamination on the top exterior surface of the generator cart. The initial wipes on the surface of the generator cart were 17,697 dpm and 112,368 dpm (2 different areas of the top of the cart). No other contamination was found. The contaminated generator cart is located inside the mobile unit with limited access. The unit has not been used since the discovery of contamination. No personnel were contaminated. The licensee notified CardioNavix and the unit will be picked up by CardioNavix later today.

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Power Reactor Event Number: 54470
Facility: RIVER BEND
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JASON ARNS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 01/09/2020
Notification Time: 19:25 [ET]
Event Date: 01/09/2020
Event Time: 11:32 [CST]
Last Update Date: 01/09/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
HEATHER GEPFORD (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF CHILLERS

"The Division I Control Building Chiller 'A' failed to start during post maintenance testing. By design, the Division II Control Building Chiller 'B' should have started automatically but did not. Operators then manually placed the Division I Control Building Chiller 'C' in service.

"This condition rendered both Divisions of the Control Building Air Conditioning System Inoperable. The applicable LCO was entered and exited 10 minutes later with all required actions and completion times met. The cause of the failure is not known at this time. The plant was at 100% power at the time of the event and is currently stable at 100% power."

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Friday, January 10, 2020
Friday, January 10, 2020