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Event Notification Report for April 27, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/24/2020 - 4/27/2020

** EVENT NUMBERS **
 
54671 54672 54673 54680

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

Non-Agreement State Event Number: 54672
Rep Org: CHRISTIANA CARE HEALTH SERVICES
Licensee: CHRISTIANA CARE HEALTH SERVICES
Region: 1
City: WILMINGTON   State: DE
County:
License #: 07-12153-02
Agreement: N
Docket:
NRC Notified By: KAROL WEN
HQ OPS Officer: CATY NOLAN		 Notification Date: 04/17/2020
Notification Time: 12:37 [ET]
Event Date: 04/16/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/17/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE		 Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNDERDOSE TO PATIENT

The following is a summary of information received via telephone:

On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device.

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: 54673
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: SAINT JOSEPH'S HOSPITAL AND MEDICAL CENTER
Region: 4
City: PHOENIX   State: AZ
County:
License #: 07-024
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: BRIAN LIN		 Notification Date: 04/18/2020
Notification Time: 12:20 [ET]
Event Date: 04/17/2020
Event Time: 18:00 [MST]
Last Update Date: 04/18/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE		 Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT

The following was received from the state of Arizona via email:

"On April 17, 2020, at approximately 1800 [MDT], the Department [Arizona Department of Health Services] received notification from the licensee of a possible medical event involving Yttrium-90 radiolabeled glass microspheres (Therasphere). The dose on the written directive was 150 Gy and the pre-treatment measurement was approximately 4.6 GBq. Following the delivery, the nuclear medicine technologist took readings of the waste containers and got an average of 4.58 mR/hr (highest of 11.8 mR/hr) from the first jar and an average of 1.39 mR/hr (highest of 2.6 mR/hr) from the second jar. The licensee is investigating the irregular waste readings and attempting to calculate the actual dose to the patient.

"The Department has requested additional information and continues to investigate the event."

Arizona Event No. 20-009

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.

Power Reactor Event Number: 54680
Facility: BEAVER VALLEY
Region: 1     State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JUSTIN E. CROCKER
HQ OPS Officer: HOWIE CROUCH		 Notification Date: 04/24/2020
Notification Time: 07:00 [ET]
Event Date: 04/24/2020
Event Time: 01:30 [EDT]
Last Update Date: 04/24/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION		 Person (Organization):
FRANK ARNER (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY DEGRADED

"At 0130 [EDT] on April 24, 2020, during the Beaver Valley Power Station, Unit 2 refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that one penetration could not be dispositioned as acceptable per ASME Code Section XI. Penetration 37 will require repair prior to returning the vessel head to service. The indication was not through wall and there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. The examinations were being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-4 to find potential flaws/indications before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, March 25, 2021