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Event Notification Report for April 01, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/31/2020 - 4/1/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54598
Rep Org: COLORADO DEPT OF HEALTH Licensee: THE VIEWHOUSE Region: 4 City: DENVER State: CO County: License #: GL002342 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/23/2020 Notification Time: 11:30 [ET] Event Date: 06/13/2019 Event Time: 00:00 [MDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following is a summary of information received from the state of Colorado via email:

Two tritium exit signs (6.5 Ci each) were not found during a walk down of the facility. Management claims they were not received or installed.

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

Agreement State	Event Number: 54600
Rep Org: COLORADO DEPT OF HEALTH Licensee: WARWICK HOTEL Region: 4 City: DENVER State: CO County: License #: GL000858 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: OSSY FONT	Notification Date: 03/23/2020 Notification Time: 14:53 [ET] Event Date: 12/20/2017 Event Time: 00:00 [MDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following summary was received from the state of Colorado via email:

Four tritium exit signs, containing 7.5 Ci each, were determined lost, disposed of before the current manager took the management position.

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

Agreement State	Event Number: 54601
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH Licensee: RHODE ISLAND HOSPITAL Region: 1 City: PROVIDENCE State: RI County: License #: 7A-051-02 Agreement: Y Docket: NRC Notified By: MARIA BARNES HQ OPS Officer: OSSY FONT	Notification Date: 03/23/2020 Notification Time: 16:58 [ET] Event Date: 03/03/2020 Event Time: 00:00 [EDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) MICHAEL LAYTON (DD) KEVIN WILLIAMS (EMAIL) PATRICIA MILLIGAN (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION (ABNORMAL OCCURRENCE)

The following was received from the Rhode Island Department of Health (RIDOH; the Department) via email:

"On March 4, 2020, the Department's staff at RIDOH, Radiation Control Program became aware of a medical event (ME) that occurred at the Rhode Island Hospital, Department of Radiation Oncology in Providence on March 3, 2020. The ME is reportable as per 10 CFR 35.3045(a)(1)(i)(A) and meets the criteria for an Abnormal Occurrence.

"On March 3, 2020, a patient underwent Gamma Knife treatment of a left vestibular schwannoma. At the conclusion of the treatment it was discovered that the location of the anterior screws securing the patient's head in the treatment position had moved. Before the patient was moved from the treatment table, the patient's position was observed by the radiation oncologist, neurosurgeon, and medical physicist. It is unknown at this time what contributed to the event and how the screws securing the patient in the treatment position had shifted from the initial position. Based on information provided by the patient and other participants associated with this event, a delivered dose was estimated using the GammaPlan Treatment Planning System. The estimated delivery to the target coverage area (volume of tissue receiving dose) was 44 percent. The estimated dose to the target was 4 Gy (400 rad). An unintended dose to a region of the left temporal lobe within the brain was estimated to be 13.6 Gy (1,360 rad). On the day of the incident, the attending neurosurgeon spoke directly with the patient informing the patient that the stereotactic frame had disengaged from his head at some point midway through the treatment and resulted in an unclear radiation dose to the tumor. The patient was informed of the estimated dose and told of the licensee's plan to obtain a follow-up brain MRI within 1-2 weeks after treatment and approximately 3 months after treatment."

The licensee is taking a number of corrective actions, including having the radiation therapist ensure that the patient understands that any movement of their head within the headframe is not anticipated and should be communicated immediately.

Event Report ID No: RI2020-01

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: 54602
Rep Org: COLORADO DEPT OF HEALTH Licensee: FUNKY BUDDHA LOUNGE Region: 4 City: DENVER State: CO County: License #: GL000883 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/24/2020 Notification Time: 09:11 [ET] Event Date: 11/30/2017 Event Time: 00:00 [MDT] Last Update Date: 03/24/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following summary was received from the state of Colorado via email:

Three tritium exit signs, containing 11.5 Ci each, were determined lost. They were apparently removed during a renovation in 2002.

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

Agreement State	Event Number: 54604
Rep Org: COLORADO DEPT OF HEALTH Licensee: JBZ LLC / PHYSICAL THERAPY Region: 4 City: DENVER State: CO County: License #: GL001127 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: KERBY SCALES	Notification Date: 03/24/2020 Notification Time: 16:31 [ET] Event Date: 06/19/2019 Event Time: 00:00 [MDT] Last Update Date: 03/24/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following summary was received from the state of Colorado via email:

The State is reporting one lost tritium exit sign, containing 9.21 Ci. The sign was confirmed lost during a walkdown for annual registration.

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

Agreement State	Event Number: 54606
Rep Org: COLORADO DEPT OF HEALTH Licensee: SOUTH PLATTE WATER RENEWAL PARTNERS Region: 4 City: ENGLEWOOD State: CO County: License #: GL001320 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: BETHANY CECERE	Notification Date: 03/24/2020 Notification Time: 17:25 [ET] Event Date: 06/21/2019 Event Time: 00:00 [MDT] Last Update Date: 03/24/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following summary was received from the state of Colorado via email:

The State is reporting four (4) lost tritium exit signs, containing 10 Ci each. The signs were not accounted for during annual registration. The licensee stated that the signs were never installed in the facility.

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

Non-Power Reactor	Event Number: 54625
Facility: UNIV OF UTAH RX Type: 100 KW TRIGA MARK I Comments: Region: 0 City: SALT LAKE CITY State: UT County: SALT LAKE License #: R-126 Agreement: Y Docket: 05000407 NRC Notified By: MATTHEW LUND HQ OPS Officer: BRIAN LIN	Notification Date: 03/31/2020 Notification Time: 15:44 [ET] Event Date: 03/31/2020 Event Time: 12:17 [MDT] Last Update Date: 03/31/2020
Emergency Class: NON EMERGENCY 10 CFR Section: NON-POWER REACTOR EVENT	Person (Organization): NRR PM (EMAIL) ELIZABETH REED (EMAIL)

Event Text

TECHNICAL SPECIFICATION NON-COMPLIANCE

The following is a summary of information received from the University of Utah Reactor Facility via email:

At 1217 MDT, on 3/31/2020, during a test of reactor systems, operators discovered that the safety control rod would not drop as expected after magnet power was secured. The safety control rod was manually driven from the 100 percent to 98 percent withdraw position, where it then dropped on its own to the fully inserted position. The reactor was shutdown during safety control rod testing, with the shim and regulating rod fully inserted. As a result, the licensee was not in compliance with Technical Specification 3.2.1.2, which requires the scram time to not exceed two seconds. The reactor will remain shutdown until the rod is inspected and repaired.

The licensee notified the NRR Project Manager (Yin).

Page Last Reviewed/Updated Wednesday, March 24, 2021