Event Notification Report for October 29, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/28/2020 - 10/29/2020
Agreement State
Event Number: 54974
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: Irene Bennett
HQ OPS Officer: Thomas Kendzia
Licensee: Emory University
Region: 1
City: Atlanta State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: Irene Bennett
HQ OPS Officer: Thomas Kendzia
Notification Date: 10/30/2020
Notification Time: 15:34 [ET]
Event Date: 10/29/2020
Event Time: 00:00 [EDT]
Last Update Date: 10/30/2020
Notification Time: 15:34 [ET]
Event Date: 10/29/2020
Event Time: 00:00 [EDT]
Last Update Date: 10/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY GREATER THAN 20 PERCENT
The following was received from Georgia Radioactive Materials Program (GA RMP) via email:
"On Oct 30, 2020, [GA RMP] received an email, from the Assistant RSO [Radiation Safety Officer, Emory University], informing [GA RMP] that a second Y-90 TheraSpheres event occurred on Oct 29, 2020.
"A patient was administered with 16.2 mCi of Y-90 TheraSpheres using a high flow microcatheter and a larger syringe. The product representative from Boston Scientific was there to consult with the authorized users and technologist prior to treatment. Once it appeared that the micro catheter and Y-90 line and vial were in proper positioning, the Y-90 was administered. Subsequently, the line was flushed three times using approximately 50-60 ml of saline.
"After the procedure, all items were surveyed and calculated that only 7.3 mCi of Y-90 was administered. Since all waste was surveyed as a whole and not independently from each item, the Assistant RSO did not have the information to discern whether residual Y-90 remained in each product (micro-catheter, line, and vial).
"Until they can determine the causes of the misadministration, Emory has halted TheraSpheres administration at Emory at Midtown, and substituted Y-90 Sirspheres where they can. Emory University Hospital also uses TheraSpheres, but has not reported any problems. Emory investigation is ongoing. [GA RMP] will provide follow-up information as it is obtained."
Georgia Incident No: 32
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.
The following was received from Georgia Radioactive Materials Program (GA RMP) via email:
"On Oct 30, 2020, [GA RMP] received an email, from the Assistant RSO [Radiation Safety Officer, Emory University], informing [GA RMP] that a second Y-90 TheraSpheres event occurred on Oct 29, 2020.
"A patient was administered with 16.2 mCi of Y-90 TheraSpheres using a high flow microcatheter and a larger syringe. The product representative from Boston Scientific was there to consult with the authorized users and technologist prior to treatment. Once it appeared that the micro catheter and Y-90 line and vial were in proper positioning, the Y-90 was administered. Subsequently, the line was flushed three times using approximately 50-60 ml of saline.
"After the procedure, all items were surveyed and calculated that only 7.3 mCi of Y-90 was administered. Since all waste was surveyed as a whole and not independently from each item, the Assistant RSO did not have the information to discern whether residual Y-90 remained in each product (micro-catheter, line, and vial).
"Until they can determine the causes of the misadministration, Emory has halted TheraSpheres administration at Emory at Midtown, and substituted Y-90 Sirspheres where they can. Emory University Hospital also uses TheraSpheres, but has not reported any problems. Emory investigation is ongoing. [GA RMP] will provide follow-up information as it is obtained."
Georgia Incident No: 32
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: 54971
Facility: Peach Bottom
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Paul Bokus
HQ OPS Officer: Thomas Kendzia
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Paul Bokus
HQ OPS Officer: Thomas Kendzia
Notification Date: 10/29/2020
Notification Time: 15:12 [ET]
Event Date: 10/29/2020
Event Time: 10:30 [EDT]
Last Update Date: 10/29/2020
Notification Time: 15:12 [ET]
Event Date: 10/29/2020
Event Time: 10:30 [EDT]
Last Update Date: 10/29/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
MATT YOUNG (R1DO)
MATT YOUNG (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
THROUGH-WALL LEAKAGE IDENTIFIED ON REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DURING TESTING
"At 1030 EDT on Thursday, October 29, 2020, during the performance of Peach Bottom Atomic Power Station leakage testing of the reactor pressure vessel and associated piping, a through-wall leak [non-isolable] was identified on an instrument line connected to the N16A nozzle.
"The reactor will be maintained shutdown until pipe repairs and testing are complete.
"The NRC resident inspector has been informed."
"At 1030 EDT on Thursday, October 29, 2020, during the performance of Peach Bottom Atomic Power Station leakage testing of the reactor pressure vessel and associated piping, a through-wall leak [non-isolable] was identified on an instrument line connected to the N16A nozzle.
"The reactor will be maintained shutdown until pipe repairs and testing are complete.
"The NRC resident inspector has been informed."
Agreement State
Event Number: 54972
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Empire Geotechnical Inc.
Region: 4
City: Orange State: CA
County:
License #: 7698-33
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Donald Norwood
Licensee: Empire Geotechnical Inc.
Region: 4
City: Orange State: CA
County:
License #: 7698-33
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Donald Norwood
Notification Date: 10/30/2020
Notification Time: 03:34 [ET]
Event Date: 10/29/2020
Event Time: 00:00 [PDT]
Last Update Date: 10/30/2020
Notification Time: 03:34 [ET]
Event Date: 10/29/2020
Event Time: 00:00 [PDT]
Last Update Date: 10/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
- CNSNS (MEXICO) (FAX)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
- CNSNS (MEXICO) (FAX)
AGREEMENT STATE REPORT - STOLEN CPN MOISTURE / DENSITY GAUGE
The following information was received via E-mail:
"The Radiation Safety Officer (RSO) for Empire Geotechnical reported that his CPN nuclear gauge was stolen from the back of his pickup truck sometime overnight between 2100 EDT on October 28, 2020 and 0630 PDT on October 29, 2020.
"CA Dept. of Public Health Radiologic Health Branch (RHB) inspector contacted the Empire Geotechnical RSO by phone and confirmed the RSO left his truck parked on the street in front of his office with the gauge secured in the rear of the pickup under a locked deck lid. The RSO is in the process of reporting the theft to the Orange Police Department.
"The gauge is a CPN MC1DR, [serial] number MD90204854, that contains two special form sealed sources: 370 MBq (10 mCi) of Cs-137 and 1.85GBq (50 mCi) of Am-241/Be."
California 5010 Number: 102920
Cal OES control number: 20-6025, October 29, 2020
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
The following information was received via E-mail:
"The Radiation Safety Officer (RSO) for Empire Geotechnical reported that his CPN nuclear gauge was stolen from the back of his pickup truck sometime overnight between 2100 EDT on October 28, 2020 and 0630 PDT on October 29, 2020.
"CA Dept. of Public Health Radiologic Health Branch (RHB) inspector contacted the Empire Geotechnical RSO by phone and confirmed the RSO left his truck parked on the street in front of his office with the gauge secured in the rear of the pickup under a locked deck lid. The RSO is in the process of reporting the theft to the Orange Police Department.
"The gauge is a CPN MC1DR, [serial] number MD90204854, that contains two special form sealed sources: 370 MBq (10 mCi) of Cs-137 and 1.85GBq (50 mCi) of Am-241/Be."
California 5010 Number: 102920
Cal OES control number: 20-6025, October 29, 2020
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: 55011
Rep Org: ALLWEST Engineering
Licensee: ALLWEST Testing & Engineering, Inc.
Region: 4
City: Hayden State: ID
County:
License #: 11-27637-01
Agreement: N
Docket:
NRC Notified By: Chris C. Beck
HQ OPS Officer: Howie Crouch
Licensee: ALLWEST Testing & Engineering, Inc.
Region: 4
City: Hayden State: ID
County:
License #: 11-27637-01
Agreement: N
Docket:
NRC Notified By: Chris C. Beck
HQ OPS Officer: Howie Crouch
Notification Date: 11/30/2020
Notification Time: 10:19 [ET]
Event Date: 10/29/2020
Event Time: 11:15 [MDT]
Last Update Date: 12/08/2020
Notification Time: 10:19 [ET]
Event Date: 10/29/2020
Event Time: 11:15 [MDT]
Last Update Date: 12/08/2020
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 12/8/2020
EN Revision Text: DAMAGED MOISTURE DENSITY GAUGE
The following information was received from ALLWEST Testing & Engineering, Inc. via email:
"On October 29, 2020, an ALLWEST employee [the authorized user] was testing the density of freshly placed asphalt on Painted Sky Street in the Spring Hollow Ranch subdivision in Nampa, Idaho using a CPN MC-1 portable nuclear densometer (SN 9216). At approximately 1115 Mountain Daylight time, the gauge was damaged by a Cat CCS9 combination roller under the direction of Nampa Paving.
"[The authorized user] was in the process of running a density test in AC mode when the roller backed up and impacted the gauge. The roller moved off of the gauge after impact. After impact, the handle was oriented at a 45-degree angle from the base of the gauge and the case was detached from the base. [The authorized user] moved away from the damaged gauge and cordoned off the area to prevent anyone from approaching the damaged gauge.
"[The authorized user] immediately contacted the Meridian office assistant RSO [radiation safety officer] who contacted the Corporate RS. [The assistant RSO] and another ALLWEST employee [the employee] responded to the accident and initiated ALLWEST's emergency protocol. [The assistant RSO] used a survey meter to obtain readings around the damaged gauge. The readings indicated the nuclear sources were not exposed and the shielding was intact. The handle was placed back in the case, and the handle, case and base were placed in the transport box. The transport box was then placed in an overpak barrel and transported back to the ALLWEST office.
"Additional readings were taken using the survey meter around the gauge at the ALLWEST office. All readings were consistent with the sources being in a shielded condition.
"[The assistant RSO] contacted lnstrotek and discussed the condition of the gauge and the readings obtained from the survey meter. lnstrotek representatives indicated it was acceptable to ship the damaged gauge to them for disposal in the transport box. As an additional precaution, [the assistant RSO] and [the employee] wrapped the damaged gauge in lead sheeting and placed the wrapped gauge in the transport box. The transport box with the damaged gauge was then shipped to lnstrotek for disposal.
"ALLWEST sent the personal dosimetry badges for [the authorized user], [the assistant RSO], and [the employee] to Landaeur for immediate evaluation. The radiation dosimetry report from Landauer indicated minimal exposure to all three individuals."
The gauge contained 10 mCi Cs-137 source and a 50 mCi Am-241 source.
EN Revision Text: DAMAGED MOISTURE DENSITY GAUGE
The following information was received from ALLWEST Testing & Engineering, Inc. via email:
"On October 29, 2020, an ALLWEST employee [the authorized user] was testing the density of freshly placed asphalt on Painted Sky Street in the Spring Hollow Ranch subdivision in Nampa, Idaho using a CPN MC-1 portable nuclear densometer (SN 9216). At approximately 1115 Mountain Daylight time, the gauge was damaged by a Cat CCS9 combination roller under the direction of Nampa Paving.
"[The authorized user] was in the process of running a density test in AC mode when the roller backed up and impacted the gauge. The roller moved off of the gauge after impact. After impact, the handle was oriented at a 45-degree angle from the base of the gauge and the case was detached from the base. [The authorized user] moved away from the damaged gauge and cordoned off the area to prevent anyone from approaching the damaged gauge.
"[The authorized user] immediately contacted the Meridian office assistant RSO [radiation safety officer] who contacted the Corporate RS. [The assistant RSO] and another ALLWEST employee [the employee] responded to the accident and initiated ALLWEST's emergency protocol. [The assistant RSO] used a survey meter to obtain readings around the damaged gauge. The readings indicated the nuclear sources were not exposed and the shielding was intact. The handle was placed back in the case, and the handle, case and base were placed in the transport box. The transport box was then placed in an overpak barrel and transported back to the ALLWEST office.
"Additional readings were taken using the survey meter around the gauge at the ALLWEST office. All readings were consistent with the sources being in a shielded condition.
"[The assistant RSO] contacted lnstrotek and discussed the condition of the gauge and the readings obtained from the survey meter. lnstrotek representatives indicated it was acceptable to ship the damaged gauge to them for disposal in the transport box. As an additional precaution, [the assistant RSO] and [the employee] wrapped the damaged gauge in lead sheeting and placed the wrapped gauge in the transport box. The transport box with the damaged gauge was then shipped to lnstrotek for disposal.
"ALLWEST sent the personal dosimetry badges for [the authorized user], [the assistant RSO], and [the employee] to Landaeur for immediate evaluation. The radiation dosimetry report from Landauer indicated minimal exposure to all three individuals."
The gauge contained 10 mCi Cs-137 source and a 50 mCi Am-241 source.