Event Notification Report for February 25, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
02/24/2021 - 02/25/2021

EVENT NUMBERS
55105 55107 55113
Agreement State
Event Number: 55105
Rep Org: Florida Bureau of Radiation Control
Licensee: Tallahassee Diagnostic Imaging
Region: 1
City: Tallahassee   State: FL
County:
License #: 4601-1
Agreement: Y
Docket:
NRC Notified By: Matthew G. Senison
HQ OPS Officer: Thomas Herrity
Notification Date: 02/17/2021
Notification Time: 09:28 [ET]
Event Date: 02/11/2021
Event Time: 00:00 [EST]
Last Update Date: 02/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DENTEL, GLENN (R1)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.
Event Text
AGREEMENT STATE - LEAKING SEALED SOURCE

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

"A consultant for Tallahassee Diagnostic Imaging Center, notified the BRC of a failed leak test. [An imaging center employee] notified him that the leak test failed on 11 February 2021, which was confirmed by a lab in Atlanta on 16 February 2021. No activity on e-vial or wipes reported to the BRC."

Florida Event No.: FL21-023


Non-Agreement State
Event Number: 55107
Rep Org: Kootenai Health
Licensee: Kootenai Health
Region: 4
City: Coeur d`Alene   State: ID
County:
License #: 11-27307-01
Agreement: N
Docket:
NRC Notified By: Rhonda Powell
HQ OPS Officer: Bethany Cecere
Notification Date: 02/18/2021
Notification Time: 17:02 [ET]
Event Date: 02/18/2021
Event Time: 10:40 [MST]
Last Update Date: 02/18/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
NON-AGREEMENT STATE REPORT - RADIOPHARMECEUTICAL UNDER DOSE

The following was received via phone from the licensee:

At 1040 MST, on 2/18/21, a patient received less than the prescribed dose of 130 gray to the liver due to the catheter and device connection coming apart. The isotope was Y-90 glass microspheres. The calculated dose to the patient was 62.2 gray (47.9 percent of the prescribed dose). All non-delivered material was collected in the catheter and on absorbent material for decay and return to the manufacturer. The patient was notified of the under dose.

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.


Non-Power Reactor
Event Number: 55113
Facility: Ge - Hitachi
RX Type: 100 Kw Ntr (Tank)
Comments:
Region: 0
City: Sunol   State: CA
County: Alameda
License #: R-33
Agreement: Y
Docket: 05000073
NRC Notified By: David Heckman
HQ OPS Officer: Kerby Scales
Notification Date: 02/24/2021
Notification Time: 18:22 [ET]
Event Date: 02/23/2021
Event Time: 15:00 [PST]
Last Update Date: 02/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Non-Power Reactor Event
Person (Organization):
Duane Hardesty (NRR-NPR)
Michael Takacs (NRR-NPR)
Event Text
TECHNICAL SPECIFICATION DEVIATION

"On February 23, 2021, it was discovered that two licensed operators had manipulated the plant between April 30, 2020 and July 20, 2020, without being fully qualified; having exceeded the due date for their annual operating test. This constitutes a deviation from the facility's Technical Specification 6.1.3.1 - 'Minimum staffing'. During that period the reactor was operated normally, there were no unusual occurrences and at no time did the loss of qualifications cause the existence or development of an unsafe condition with regard to reactor operations. Both operators performed and passed their operating test on July 20, 2020.

"The cause of this event is under investigation.

"The licensee has notified their NRC Project Manager."

Page Last Reviewed/Updated Thursday, February 25, 2021