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Event Notification Report for August 12, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/11/2020 - 8/12/2020

** EVENT NUMBERS **


54526 54811 54813 54814 54815 54828 54829

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Agreement State Event Number: 54526
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: Boston   State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2020
Notification Time: 16:01 [ET]
Event Date: 02/13/2020
Event Time: 13:45 [EST]
Last Update Date: 08/11/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 8/12/2020

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3).

"The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program. "

* * * UPDATE ON 8/11/2020 AT 1715 EDT FROM SZYMON MUDREWICZ TO BETHANY CECERE * * *

"Medical event no. 14-4085 was reported to the Massachusetts Radiation Control Program (hereafter, 'Agency') by Massachusetts General Hospital (hereafter, 'licensee') on 02/14/2020 involving administration of TheraSphere Y-90 microspheres to a patient for liver cancer treatment. The patient was scheduled to receive two doses on 02/13/2020 to the right lobe and segment 4 of the liver; 1.59 GBq and 0.29 GBq, respectively. Administration of both doses went accordingly and no unusual signs were observed by the authorized used conducting the administration. There were no problems with the flow of liquid through the microcatheter, no excessive pressure was needed to push the spheres, no leaks were observed, and there were no visual indicators that spheres were collecting at junctions in the tubing. The RADOS dosimeter, supplied with the delivery system, was reading 0.0 mR/hr at conclusion of each dose delivery indicating minimal residual activity inside the delivery system. After each dose the microcatheter and delivery system tubing are placed in a waste container - for storage to decay - where the dose is measured to calculate the activity of any residual microspheres that were not delivered. The calculations were performed the morning of 02/14/2020 and it was determined that only 0.512 GBq (33.7%) of the first dose was delivered to the target site, whereas as 0.273 GBq (95.9%) of the second was delivered to the target site. These calculations identified a possible occlusion in either the microcatheter or delivery set tubing and also identified a malfunctioning dosimeter. No physiological risk to patient health was identified.

"The Agency considers this event closed."

Notified R1DO (Gray) and NMSS Events Notification (email)

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.

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Agreement State Event Number: 54811
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Tucson Electric Power Company
Region: 4
City: Springerville   State: AZ
County:
License #: 01-006
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bethany Cecere
Notification Date: 08/03/2020
Notification Time: 21:55 [ET]
Event Date: 08/03/2020
Event Time: 00:00 [MST]
Last Update Date: 08/03/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISSING SHUTTER ON FIXED GAUGE

"On August 3, 2020, during a routine inspection, the Department [Arizona Department of Health Services] discovered that the licensee had a shutter go missing from a fixed gauge in November of 2016. The radiation safety officer was attempting to perform a lock-out procedure when he realized that the entire shutter mechanism was missing from the unit. The gauge was a Texas Nuclear Corporation Model 5192, SN: B4192, containing 100 milliCuries of Cs-137.

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

Arizona Incident: 20-013.

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Agreement State Event Number: 54813
Rep Org: ALABAMA RADIATION CONTROL
Licensee: Applied Technical Services, Inc.
Region: 1
City: Mobile   State: AL
County:
License #: 1454
Agreement: Y
Docket:
NRC Notified By: Neil Maryland
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 13:29 [ET]
Event Date: 08/03/2020
Event Time: 17:00 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following is a summary of information received from the Alabama Department of Public Health via telephone:

On August 3, 2020 at approximately 1700 CDT, the licensee was working at an asphalt plant in Mulga, AL, when one of its radiography cameras was damaged. The source of the radiography camera was being exposed when a magnetic stand, which was attached to the source, fell and crushed part of the guide tube. Multiple efforts to retrieve the source were unsuccessful. The licensee's radiation safety officer (RSO) responded to the scene. The RSO was able to retract the source after cutting part of the guide tube.

No un-badged personnel received any dose as part of the event and applicable dosimetry badges have been sent for emergency processing. The camera is being sent to the manufacturer for investigation.

Alabama Incident Report No.: 20-16

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Agreement State Event Number: 54814
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS Group, Inc.
Region: 4
City: Geismar   State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 15:38 [ET]
Event Date: 08/04/2020
Event Time: 11:20 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following is a summary of information that was received from the Louisiana Department of Environmental Quality via email:

On August 4, 2020, at 1120 CDT, at a job site in New Iberia, LA, the drive cable on one of the licensee's industrial radiography cameras broke six inches from the drive cable to source cable connector. The radiographers set up a 2mR boundary after being unable to retract the source into a shielded position. One of the licensee's radiation safety officers (RSO) was called to the scene and was able to retrieve the source. During this event the RSO received a dose of 313 mR and the crew received 16 and 11 mR according to their insta-dose badges.

The radiography camera is a SPEC 150 (s/n: 2131) with a 56 Ci Ir-192 source (s/n: BF2401).

Event Report ID No.: LA20200007

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Agreement State Event Number: 54815
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Methodist Hospitals of Dallas
Region: 4
City: Dallas   State: TX
County:
License #: L 00659
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Andrew Waugh
Notification Date: 08/04/2020
Notification Time: 21:21 [ET]
Event Date: 08/03/2020
Event Time: 00:00 [CDT]
Last Update Date: 08/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On August 4, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that an event occurred during the administration of Y-90 TheraSpheres on August 3, 2020. The RSO stated the written directive prescribed dosage was 22.3 mCi. During the administration of the TheraSpheres, the pressure observed by the Authorized User (AU) became significantly less than expected, and activity leaving the dose administration vial into the catheter decreased significantly before the entire dose could be delivered. The RSO stated a TheraSpheres (Boston Scientific) representative was present during the procedure and assisted the authorized user through troubleshooting, and remote consultation with TheraSpheres medical specialists. However, flow from the dose administration vial could not be re-initiated. The AU chose to end the procedure.

"Following survey of the dose administration vial in the hot lab, it was determined that approximately 7.1 mCi (31.8 percent) was delivered to the patient. The RSO stated that their initial assessment is that this was the result of a device malfunction. There were no adverse effects to the patient. It is likely that a second procedure will be scheduled to complete the procedure. The RSO stated that the patient and referring physician were notified.

"This is the first event involving TheraSpheres reported to the Agency by this licensee.

"The RSO stated additional information on the event will be provided within the next 10 days. Additional information will be provided as it is received by the Agency in accordance with SA-300."

Texas Incident Number: 9782

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.

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Power Reactor Event Number: 54828
Facility: Diablo Canyon
Region: 4     State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Don Townsend
HQ OPS Officer: Brian Lin
Notification Date: 08/11/2020
Notification Time: 11:12 [ET]
Event Date: 08/10/2020
Event Time: 09:15 [PDT]
Last Update Date: 08/11/2020
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
DAVID PROULX (R4DO)
FFD GROUP (EMAIL)
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

FITNESS-FOR-DUTY TEST POSITIVE FOR NON-LICENSED SUPERVISOR

"At 0915 PDT, on August 10, 2020, Pacific Gas and Electric determined a non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

"The NRC Senior Resident Inspector has been notified."

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Power Reactor Event Number: 54829
Facility: Peach Bottom
Region: 1     State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: John Whelan
HQ OPS Officer: Brian P. Smith
Notification Date: 08/11/2020
Notification Time: 20:22 [ET]
Event Date: 08/11/2020
Event Time: 13:34 [EDT]
Last Update Date: 08/11/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
MEL GRAY (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 97 Power Operation 97 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF TECHNICAL SUPPORT CENTER VENTILATION SYSTEM

"At 1334 EDT on Tuesday August 11th, the Peach Bottom Atomic Power Station (PBAPS) Technical Support Center (TSC) Ventilation System lost power due to a trip of the Station Blackout (SBO) electric power supply breaker. The trip was due to a fault at the Conowingo Dam and Conowingo was not able to realign electric power to the SBO within an hour. Power restoration is complete and TSC Ventilation was restored at 1725 EDT.

"This report is being submitted pursuant to 10CFR 50.72(b)(3)(xiii) as a Major Loss of Emergency Preparedness Capabilities due to a reduction in the effectiveness of the Onsite Technical Support Center (TSC).

"The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Wednesday, August 12, 2020
Wednesday, August 12, 2020