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Event Notification Report for April 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/23/2020 - 4/24/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54643
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: PERKINELMER, INC Region: 1 City: BOSTON State: MA County: License #: 00-3200 Agreement: Y Docket: NRC Notified By: ANTHONY CARPENITO HQ OPS Officer: KERBY SCALES	Notification Date: 04/06/2020 Notification Time: 15:52 [ET] Event Date: 04/06/2020 Event Time: 00:00 [EDT] Last Update Date: 04/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (R1DO) 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 MATERIAL IN TRANSIT

The following is summarized from an e-mail received from the Commonwealth of Massachusetts:

The licensee reported on 4/6/20 that three UN2915 White I label packages, shipped from Germany via common carrier, each containing 21.14 Ci Sulfur-35, did not arrive on 3/29/20 as expected. Upon inquiry on 3/31/20, the common carrier informed the licensee that the packages arrived at JFK Airport, NY, and had not yet been forwarded. The common carrier informed the licensee on 4/6/20 that the three packages could not be located within its system, all flights were cancelled from JFK to Boston due to the COVID-19 situation, and affected freight would be forwarded via ground. The licensee continues to work with the common carrier to locate the packages. There is no significant public health and safety concern due to the package radiation levels being at background.

* * * UPDATE ON 4/9/2020 AT 1410 EDT FROM ANTHONY CARPENITO TO JEFFREY WHITED * * *

The following was received from the Commonwealth of Massachusetts via email:

"The licensee (PerkinElmer) on 4/9/2020 reported to this Agency [the Massachusetts Radiation Control Program] that three packages previously reported as missing were found in [the common] carrier's warehouse at JFK Airport in NY. The licensee stated that the packages were reportedly intact, unopened and undamaged. The licensee stated that the packages are expected to be ground transported to licensee in Boston for arrival on 4/10/2020. The licensee stated that a comprehensive incoming package survey will be performed on packages upon arrival at licensee facility. This Agency considers this event to still be OPEN until licensee confirmation of package arrival in regulatory-acceptable condition."

Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.

* * * UPDATE ON 4/10/2020 AT 1635 EDT FROM ANTHONY CARPENITO TO OSSY FONT * * *

The following was received from the Commonwealth of Massachusetts via email:

"The licensee (PerkinElmer) on 4/10/2020 reported to this Agency that three subject packages were received at the licensee's facility on the afternoon of 4/10/20. The licensee performed an incoming package survey and determined the outside of the packages were not radioactively contaminated, there was no physical damage to the packages, and the inner packaging and contents remained intact. The Agency expects this event to remain OPEN until all details, including action docket numbers, are compiled and relevant documentation is completed."

Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.

* * * UPDATE ON 4/23/2020 AT 1435 EDT FROM ANTHONY CARPENITO TO CATY NOLAN * * *

The following was received from the Commonwealth of Massachusetts via email:

"Carrier corrective action includes retraining of employees. Agency considers this event to be CLOSED."

Massachusetts Event Number: 16-4134. NMED Item Number: 200171

Notified R1DO (Arner), NMSS Event Notifications, and ILTAB via email.

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: 54667
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: THE METHODIST HOSPITAL Region: 4 City: HOUSTON State: TX County: License #: l-00457 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: THOMAS KENDZIA	Notification Date: 04/15/2020 Notification Time: 09:20 [ET] Event Date: 04/09/2020 Event Time: 00:00 [CDT] Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEFFREY JOSEY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE NOT DELIVERED TO THE CORRECT LOCATION DURING BRACHYTHERAPY TREATMENT

The following was received from the state of Texas via email and by telephone:

"On April 10, 2020, the licensee reported to the Agency [Texas Department of State Health Services] that it had an event on April 9, 2020, involving a Novoste device in which the source train had not advanced to the designated treatment site during two attempts to deliver intravascular brachytherapy to a patient. It was unclear if the source train had actually entered the patient and the Agency requested confirmation and more information. On April 14, 2020, the licensee reported back to the Agency confirming that the source train had stopped moving after it had entered the patient. During the first attempt, the source train of 16 Strontium-90 sources in the Novoste device failed to go to the expected treatment position and instead got stuck in the beta-rail catheter proximally to the treatment area for 6 minutes 54 seconds. The device was checked and a second attempt was made during which the source got stuck in the beta-rail catheter proximally to the desired treatment area for 3 minutes 41 seconds. The source train was stuck at different positions in the catheter for the two attempts and each time the physicians worked with the catheter to try and get the source train to move to the treatment site. Doses calculated for each of the locations: first location = 26.2 Gy at 2 mm; second location = 14.2 Gy at 2 mm. The licensee was able to fully retract the source into the device each time. The vendor is expected onsite next week to check the device and investigate the cause. The licensee has suspended this particular treatment program indefinitely pending identification of cause.

"Device Information:
Novoste device SN: 89670
Source train SN: ZA925
Active source train length: 40 mm
Number of Sr-90 sources: 16
Total activity: 2 GBq calibrated on 8/16/2002

"Treatment Information:
Vessel description: RCA
Vessel diameter: 4 mm
Lesion length: 30 mm
Radiation dose: 23 Gy
Dwell time: 5 minutes and 57 seconds

"Dose to staff was negligible since the source train was inside the patient. Effects to the patient, if any, as a result of this event were not reported with this initial information. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9760

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: 54668
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: UNIVERSITY OF LOUISVILLE HOSPITAL Region: 1 City: LOUISVILLE State: KY County: License #: 202-029-22 Agreement: Y Docket: NRC Notified By: ANGELA WILBERS HQ OPS Officer: BRIAN P. SMITH	Notification Date: 04/15/2020 Notification Time: 10:12 [ET] Event Date: 04/14/2020 Event Time: 13:15 [EDT] Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EVENT OF Y-90 SIRTEX

The following is a summary of an email received from the Kentucky Department of Radiation:

At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box.

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: 54669
Rep Org: MAINE RADIATION CONTROL PROGRAM Licensee: PIXELLE ANDROSCOGGIN LLC FORMERLY VERSO ANDROSCOGGIN MILL Region: 1 City: JAY State: ME County: License #: ME 07405 Agreement: Y Docket: NRC Notified By: CATHERINE PERHAM HQ OPS Officer: DONALD NORWOOD	Notification Date: 04/15/2020 Notification Time: 14:50 [ET] Event Date: 04/15/2020 Event Time: 12:56 [EDT] Last Update Date: 04/15/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EXPLOSION OF BUILDING CONTAINING NUCLEAR GAUGES

The following information was received via e-mail:

"The State of Maine Radiation Control Program became aware of a breaking news item, reporting that the Pixelle Androscoggin paper mill in Jay, Maine had suffered an explosion. https://www.wabi.tv/content/news/Explosion-reported-at-Jay-mill-details-limited-569661451.html

"The precise location of the explosion is unknown at this time but it may be the boiler or power plant. Later report from MEMA - Maine Emergency Management Agency - says that it was 'the Digester of Pulp Mill A or maybe B.' The Maine Radiation Control Program will confirm the information as it comes in. There were no fatalities or injuries reported.

"'A' Pulp Mill contains six gauges, 'B' Pulp Mill contains three gauges, and the Power Plant/Boiler contains five gauges. There could be from three to six gauges involved in the explosion, depending on which building exploded.

"The Maine Radiation Control Program has not been notified by the mill. This report is the first written notification to NMED."

Maine Event Report ID No.: ME 20-003

Agreement State	Event Number: 54671
Rep Org: COLORADO DEPT OF HEALTH Licensee: LDS CHURCH - ARVADA Region: 4 City: ARVADA State: CO County: License #: GL002098 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: CATY NOLAN	Notification Date: 04/16/2020 Notification Time: 15:34 [ET] Event Date: 06/14/2018 Event Time: 00:00 [MDT] Last Update Date: 04/16/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEFFREY JOSEY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) LAURA PEARSON (ILTAB)

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 e-mail:

The licensee is unable to locate two tritium exit signs each with an activity of 10.0 Ci. The two exit signs were not able to be accounted for during 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

Page Last Reviewed/Updated Thursday, March 25, 2021