Event Notification Report for January 10, 2020
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U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 54448 | 54461 | 54470 |
| 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). |
| 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. |
| 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 Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021