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Event Notification Report for May 29, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/28/2020 - 5/29/2020

** EVENT NUMBERS **


54439 54722 54723 54731

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Agreement State Event Number: 54439
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SOUTHERN BAPTIST HOSPITAL OF FLORIDA
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: 0155-4
Agreement: Y
Docket:
NRC Notified By: RENO J FABII
HQ OPS Officer: OSSY FONT
Notification Date: 12/12/2019
Notification Time: 12:26 [ET]
Event Date: 12/11/2019
Event Time: 00:00 [EST]
Last Update Date: 05/28/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week."

Incident Number: FL19-146

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 MAY 28, 2020 AT 0820 EDT FROM MATT SENISON TO BRIAN LIN * * *

The following update was received from the Bureau via email:

"[On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. After attempts were unsuccessful at restoring function, the user terminated the procedure before the full implant could be completed. Of the 50 Seeds planned for implantation, 30 were successfully inserted into the patient. No I-125 seeds were lost and no spills or contamination occurred. Radiological review of seed placement determined that an adequate number of seeds were placed and dosing achieved in the target area. No further surgical intervention indicated. The patient will be followed with radiological studies and with PSA [prostate specific antigen] labs as previously planned."

Notified R1DO (DeBoer) and NMSS Events Notification via e-mail.

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Agreement State Event Number: 54722
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PerkinElmer, Inc.
Region: 1
City: Atlanta   State: GA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Brian P. Smith
Notification Date: 05/20/2020
Notification Time: 21:34 [ET]
Event Date: 05/20/2020
Event Time: 15:52 [EDT]
Last Update Date: 05/20/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FRED BOWER (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 PACKAGE IN TRANSIT

The following is taken from the Massachusetts Radiation Control Report abstract:

"PerkinElmer reported on May 20, 2020, that one UN2910 package, Transport Index 0.0, shipped from the licensee's Billerica, Massachusetts facility via a common carrier, containing 5.73 mCi I-125, was reported missing by the carrier on May 20, 2020. The last known location of the package was at the Atlanta, Georgia, airport on May 15, 2020 (when the carrier reported to the licensee that the package was still being held in place awaiting transfer). The package, measuring 10x6x6 inches and weighing approximately 2 kg, was one of a 22-package shipment destined for a customer in the Netherlands. The package was left behind in Atlanta on May 6, 2020, due to external package damage and the other twenty-one packages continued to the customer. There was no reported external package radioactive contamination or loss of radioactive material. The licensee continues to work with the carrier to locate package. No significant public health and safety concern exists based on the package radiation measured at background levels.

"This situation is an immediately reportable event per regulation. The Agency (Massachusetts Radiation Control Program) currently considers this docket to still be OPEN."

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

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Agreement State Event Number: 54723
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Alliance Geotechnical Group Inc.
Region: 4
City: Dallas   State: TX
County:
License #: L 05314
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 05/21/2020
Notification Time: 16:39 [ET]
Event Date: 05/21/2020
Event Time: 00:00 [CDT]
Last Update Date: 05/21/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSNS (MEXICO) (FAX)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

"On May 21, 2020, the Agency (Texas Department of State Health Services) was contacted by the licensee's radiation safety officer (RSO) and notified that a Humboldt 5000 EZ moisture/density gauge had been lost by one of its technicians. The gauge contained a 40 milliCuries americium-241 source and a 10 milliCuries cesium-137 source. The RSO stated the technician had completed a job and placed the gauge back in the transport case. After completing their paperwork, they got into the cab of their truck and drove off, leaving the tailgate down and the gauge on the tailgate. The gauge came off at the intersection which was at a farmers' market. The technician drove to the next job site and discovered the gauge was missing. The technician backtracked and started looking for the gauge. The technician found an individual at the farmers' market that saw the gauge fall off the truck and someone pull up, grab the gauge, and drive off. The individual took a picture of the vehicle and captured part of the license plate. The technician contacted the RSO who responded to that location. The licensee contacted local law enforcement. The RSO stated the cesium source rod was locked in the shielded position, but was not sure if the transport case was locked. Additional information will be provided as it is received in accordance with SA-300."

Texas event number I-9770

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

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Power Reactor Event Number: 54731
Facility: Seabrook
Region: 1     State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Jack Connolly
HQ OPS Officer: Brian P. Smith
Notification Date: 05/29/2020
Notification Time: 16:41 [ET]
Event Date: 05/29/2020
Event Time: 14:03 [EDT]
Last Update Date: 05/29/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
JOSEPH DEBOER (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL TRIP DUE TO ROD BANK UNEXPECTEDLY INSERTING

"At 1403 EDT, with the unit in Mode 1 and 100 percent power, the reactor was manually tripped due to Group 1 of Control Rod Bank 'B' unexpectedly inserting. All systems responded normally post-trip. Operations stabilized the plant in Mode 3 at 557 degrees Fahrenheit. Decay heat removal is being accomplished via the steam dumps in the steam pressure mode to the main condenser. Emergency feedwater actuated due to low low steam generator level as expected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR (b)(3)(iv)(A). The NRC Senior Resident Inspector has been notified."


Page Last Reviewed/Updated Friday, June 19, 2020
Friday, June 19, 2020