Event Notification Report for March 11, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/10/2021 - 03/11/2021
Agreement State
Event Number: 55142
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNC Hospitals
Region: 1
City: Chapel Hill State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: Ken Bugaj
HQ OPS Officer: Lloyd Desotell
Licensee: UNC Hospitals
Region: 1
City: Chapel Hill State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: Ken Bugaj
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/15/2021
Notification Time: 12:43 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Notification Time: 12:43 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/14/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE
The following was received via an email from the state of North Carolina:
"Licensee reported that on March 11, 2021, a medical event occurred where the dose difference [from Iodine 131 is greater than 20 percent from the prescribed dosage]. The prescribed dosage (by written directive) was 949 milliCuries; but the administered dose is estimated at this time to be about 507 milliCuries, which is 53% of the prescribed dose. The cause was a leaking tube from the infusion system. The bone marrow dose needed by the patient was considered sufficient, so there was no negative impact to the patient. An investigation by the North Carolina Radioactive Materials Branch is ongoing at this time.
"The radiopharmaceutical administered was Iomab-B (Iodine-131)."
North Carolina Tracking Number: 210003.
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.
EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE
The following was received via an email from the state of North Carolina:
"Licensee reported that on March 11, 2021, a medical event occurred where the dose difference [from Iodine 131 is greater than 20 percent from the prescribed dosage]. The prescribed dosage (by written directive) was 949 milliCuries; but the administered dose is estimated at this time to be about 507 milliCuries, which is 53% of the prescribed dose. The cause was a leaking tube from the infusion system. The bone marrow dose needed by the patient was considered sufficient, so there was no negative impact to the patient. An investigation by the North Carolina Radioactive Materials Branch is ongoing at this time.
"The radiopharmaceutical administered was Iomab-B (Iodine-131)."
North Carolina Tracking Number: 210003.
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: 55140
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee:
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Lloyd Desotell
Licensee:
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/15/2021
Notification Time: 11:34 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Notification Time: 11:34 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
ILTAB (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 4/15/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED
The following was received from the state of New York:
"A sealed source (BEST Model 2300) containing iodine -125 with an activity (actual) of 1.79 megabecquerel (48.28 microCurie) on the date of clinical use was implanted into the patient as part of a seed localization procedure on January 8, 2021 and verified by x-ray image as to its location. The patient reported for surgery on January 11, 2021, but the seed could not be located by intra operative radiation probe, portable radiation instrumentation or x-ray. After surveys and discussions with staff and the patient, it is presumed that the seed washed down the drain or removed in household trash while at the patient's home.
"Two scenarios are used to estimate a dose to a member of the public from the lost seed.
"1) Seed washed down the drain evening prior to reporting for surgery. The estimated dose to the public is less than1 millirem.
"2) Seed displaced in home the day prior to reporting for surgery. The estimated deep dose equivalent to an individual from the sealed source based on the activity of the seed before the date of surgery until the date of survey in the residence is approximately 3 mrem. The seed final disposition is presumed removed with household trash.
"Surveys were conducted with the appropriate radiation instrumentation on the patient, in the procedure room, in the implant facility, and at the patient's home.
"Procedures or measures that have been or will be, adopted to ensure against a recurrence of the loss or theft of licensed or registered sources of radiation. Patient education material is updated. Patients instructed to not remove SteriStrip following radioactive seed localization implantation."
New York Event Report ID: NYDOH-21-01
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
EN Revision Text: AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED
The following was received from the state of New York:
"A sealed source (BEST Model 2300) containing iodine -125 with an activity (actual) of 1.79 megabecquerel (48.28 microCurie) on the date of clinical use was implanted into the patient as part of a seed localization procedure on January 8, 2021 and verified by x-ray image as to its location. The patient reported for surgery on January 11, 2021, but the seed could not be located by intra operative radiation probe, portable radiation instrumentation or x-ray. After surveys and discussions with staff and the patient, it is presumed that the seed washed down the drain or removed in household trash while at the patient's home.
"Two scenarios are used to estimate a dose to a member of the public from the lost seed.
"1) Seed washed down the drain evening prior to reporting for surgery. The estimated dose to the public is less than1 millirem.
"2) Seed displaced in home the day prior to reporting for surgery. The estimated deep dose equivalent to an individual from the sealed source based on the activity of the seed before the date of surgery until the date of survey in the residence is approximately 3 mrem. The seed final disposition is presumed removed with household trash.
"Surveys were conducted with the appropriate radiation instrumentation on the patient, in the procedure room, in the implant facility, and at the patient's home.
"Procedures or measures that have been or will be, adopted to ensure against a recurrence of the loss or theft of licensed or registered sources of radiation. Patient education material is updated. Patients instructed to not remove SteriStrip following radioactive seed localization implantation."
New York Event Report ID: NYDOH-21-01
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
Agreement State
Event Number: 55133
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EPIC Piping, LLC
Region: 4
City: Livingston State: LA
County:
License #: LA-13463-L01, Amendment 10, AI# 203655
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Licensee: EPIC Piping, LLC
Region: 4
City: Livingston State: LA
County:
License #: LA-13463-L01, Amendment 10, AI# 203655
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 03/11/2021
Notification Time: 13:50 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [CST]
Last Update Date: 03/11/2021
Notification Time: 13:50 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [CST]
Last Update Date: 03/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/9/2021
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSED WORKER
The following was received from the State of Louisiana via email:
"EPIC Piping, LLC contacted the Louisiana Department of Environmental Quality (LDEQ), Emergency and Radiological Services Division (ERSD), Radiation Section about a Landauer Badge Report indicating an exposure (real or threatened) greater than or equal to 5 Rem. The badge indicated a 7,232 mR exposure. The Landauer Badge Report covered dates of January 15 to February 15, 2021. The source was an Ir-192 using a QSA Global 880D industrial radiography camera. The facility uses permanent industrial radiography shooting cells. The radiographer used potentially different radiography cameras having different sources according to which shooting cell was being used that day."
Louisiana Event Report ID Number: LA 20210004
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSED WORKER
The following was received from the State of Louisiana via email:
"EPIC Piping, LLC contacted the Louisiana Department of Environmental Quality (LDEQ), Emergency and Radiological Services Division (ERSD), Radiation Section about a Landauer Badge Report indicating an exposure (real or threatened) greater than or equal to 5 Rem. The badge indicated a 7,232 mR exposure. The Landauer Badge Report covered dates of January 15 to February 15, 2021. The source was an Ir-192 using a QSA Global 880D industrial radiography camera. The facility uses permanent industrial radiography shooting cells. The radiographer used potentially different radiography cameras having different sources according to which shooting cell was being used that day."
Louisiana Event Report ID Number: LA 20210004
Power Reactor
Event Number: 55134
Facility: Calvert Cliffs
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ervin Lyson
HQ OPS Officer: Kerby Scales
Region: 1 State: MD
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ervin Lyson
HQ OPS Officer: Kerby Scales
Notification Date: 03/12/2021
Notification Time: 12:12 [ET]
Event Date: 03/11/2021
Event Time: 23:15 [EST]
Last Update Date: 03/12/2021
Notification Time: 12:12 [ET]
Event Date: 03/11/2021
Event Time: 23:15 [EST]
Last Update Date: 03/12/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
GRAY, MEL (R1)
FFD GROUP (EMAIL)
GRAY, MEL (R1)
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 |
| 2 | N | N | 0 | Refueling | 0 | Refueling |
EN Revision Imported Date: 4/12/2021
EN Revision Text: FITNESS FOR DUTY REPORT
A licensed operator had a confirmed positive alcohol test during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspectors have been notified.
EN Revision Text: FITNESS FOR DUTY REPORT
A licensed operator had a confirmed positive alcohol test during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspectors have been notified.
Agreement State
Event Number: 55135
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: Globe X-Ray Services, Inc.
Region: 4
City: Tulsa State: OK
County:
License #: OK-15194-02
Agreement: Y
Docket:
NRC Notified By: Libby McCaskill
HQ OPS Officer: Thomas Herrity
Licensee: Globe X-Ray Services, Inc.
Region: 4
City: Tulsa State: OK
County:
License #: OK-15194-02
Agreement: Y
Docket:
NRC Notified By: Libby McCaskill
HQ OPS Officer: Thomas Herrity
Notification Date: 03/12/2021
Notification Time: 11:29 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [CST]
Last Update Date: 03/25/2021
Notification Time: 11:29 [ET]
Event Date: 03/11/2021
Event Time: 00:00 [CST]
Last Update Date: 03/25/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSED WORKER
The following was reported by the state of Oklahoma via email:
"Globe X-ray Services, Inc., a radiography company, reported via phone this morning that a technician's dosimeter received a 5.3 rem dose. The dose was reported on the January dosimetry report and the licensee learned about it yesterday.
"The licensee is currently working with Landauer [badge supplier] to have the badge processed further, and is investigating the exposure.
"No additional information is known at this time, we will provide updates as additional information becomes available."
Oklahoma event Number: Not Assigned
* * * UPDATE ON MARCH 15, 2021, FROM ELIZABETH McCASKILL TO THOMAS HERRITY * * *
The following update was received form the state of Oklahoma via email:
"The badge reading was: 5132 mrem DDE, 5192 mrem LDE and 5192 mrem SDE.
"The RSO stated that they believe the Landauer dosimeter received the dose on January 22, 2021.
"The RSO interviewed the radiographer and it is believed that the Landauer dosimeter was in a jacket pocket in the shooting area during exposures.
"The alarming ratemeter and pocket dosimeter readings were not elevated for January 22, 2021.
"The licensee has contacted Landauer and are awaiting imaging results to determine if the exposure was static."
Notified R4DO (Kellar), and NMSS Events Notification via email.
* * * UPDATE ON MARCH 25, 2021 AT 11:42 EDT FROM ELIZABETH McCASKILL TO THOMAS HERRITY* * *
The following update was received form the state of Oklahoma via email:
"The licensee's investigation determined that the overexposure was to the badge, not to the individual. The licensee reported that the radiographer removed his jacket containing his dosimeter and laid the jacket in the area near where radiographs were being taken. He made approximately 12 exposures with a 56 curie Ir-192 source with the jacket in the area.
"The radiographer's direct reading dosimeter was not off scale and his alarming ratemeter did not alarm. The second radiographer on site also reported that the individual was using his survey meter. Results from Landauer were inconclusive regarding the exposure being static or dynamic. Based on the licensee's findings, they have requested that Landauer adjust the recorded dose to the individual as 114 [milliRem] for January 2021."
Notified R4DO (Werner), and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSED WORKER
The following was reported by the state of Oklahoma via email:
"Globe X-ray Services, Inc., a radiography company, reported via phone this morning that a technician's dosimeter received a 5.3 rem dose. The dose was reported on the January dosimetry report and the licensee learned about it yesterday.
"The licensee is currently working with Landauer [badge supplier] to have the badge processed further, and is investigating the exposure.
"No additional information is known at this time, we will provide updates as additional information becomes available."
Oklahoma event Number: Not Assigned
* * * UPDATE ON MARCH 15, 2021, FROM ELIZABETH McCASKILL TO THOMAS HERRITY * * *
The following update was received form the state of Oklahoma via email:
"The badge reading was: 5132 mrem DDE, 5192 mrem LDE and 5192 mrem SDE.
"The RSO stated that they believe the Landauer dosimeter received the dose on January 22, 2021.
"The RSO interviewed the radiographer and it is believed that the Landauer dosimeter was in a jacket pocket in the shooting area during exposures.
"The alarming ratemeter and pocket dosimeter readings were not elevated for January 22, 2021.
"The licensee has contacted Landauer and are awaiting imaging results to determine if the exposure was static."
Notified R4DO (Kellar), and NMSS Events Notification via email.
* * * UPDATE ON MARCH 25, 2021 AT 11:42 EDT FROM ELIZABETH McCASKILL TO THOMAS HERRITY* * *
The following update was received form the state of Oklahoma via email:
"The licensee's investigation determined that the overexposure was to the badge, not to the individual. The licensee reported that the radiographer removed his jacket containing his dosimeter and laid the jacket in the area near where radiographs were being taken. He made approximately 12 exposures with a 56 curie Ir-192 source with the jacket in the area.
"The radiographer's direct reading dosimeter was not off scale and his alarming ratemeter did not alarm. The second radiographer on site also reported that the individual was using his survey meter. Results from Landauer were inconclusive regarding the exposure being static or dynamic. Based on the licensee's findings, they have requested that Landauer adjust the recorded dose to the individual as 114 [milliRem] for January 2021."
Notified R4DO (Werner), and NMSS Events Notification via email.