Event Notification Report for March 24, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
03/23/2021 - 03/24/2021

!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Power Reactor
Event Number: 55129
Facility: Texas A&M University
RX Type: 1000 Kw Triga (Conversion)
Comments:
Region: 0
City: College Station   State: TX
County: Brazos
License #: R-83
Agreement: Y
Docket: 05000128
NRC Notified By: Sean McDeavitt
HQ OPS Officer: Bethany Cecere
Notification Date: 03/09/2021
Notification Time: 11:22 [ET]
Event Date: 03/08/2021
Event Time: 10:27 [CST]
Last Update Date: 03/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Non-Power Reactor Event
Person (Organization):
Patrick Boyle (NRR PM)
Michael Takacs (NRR ENC)
Event Text
EN Revision Imported Date: 3/24/2021

EN Revision Text: SUSPECTED TECH SPEC POWER LIMIT EXCEEDED

At 1027 CST on 3/8/21, while the reactor was at 900 kW at steady state, a sample was pulled before the planned down power was executed. As a result, the reactor may have exceeded the 1000 kW limit for one second by 1 kW per Tech Spec 3.1. The duration was recorded on the strip chart recorder.

The licensee has notified the NRC Project Manager (Patrick Boyle).

* * * RETRACTION ON 3/23/21 AT 1042 EDT FROM SEAN McDEAVITT TO JEFFREY WHITED * * *

After reviewing the power instrument channels, the licensee determined that they had not exceeded the 1000 kW limit per their license condition. The licensee noted that the channel used for the strip chart recorder is not normally used for operations, but information only.

The licensee has notified the NRC Project Manager (Patrick Boyle)

Notified NRR PM (Boyle) and NRR ENC (Takacs).


Agreement State
Event Number: 55139
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: University of Pittsburgh
Region: 1
City: Pittsburgh   State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/15/2021
Notification Time: 10:48 [ET]
Event Date: 03/12/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/16/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE

The following was received via an email from the state of Pennsylvania:

"The Department [PA Bureau of Radiation Protection] received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere [TM]. The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere [TM] apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA210002

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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.
Event Text
EN Revision Imported Date: 3/16/2021

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


Agreement State
Event Number: 55141
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BASIC ENERGY SERVICES LP
Region: 4
City: Eastland   State: TX
County:
License #: L 06425
Agreement: Y
Docket:
NRC Notified By: Karen Blanchaed
HQ OPS Officer: Thomas Herrity
Notification Date: 03/15/2021
Notification Time: 13:40 [ET]
Event Date: 12/30/2020
Event Time: 00:00 [CST]
Last Update Date: 03/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
RAY KELLAR (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.
Event Text
AGREEMENT STATE REPORT - LOST DENSITY GAUGES

The following was report received from the state of Texas via email:

"On December 30, 2020, the licensee reported that during an in-depth audit it had been unable to locate two ThermoFisher model 5192 densitometers, each containing 200 milliCuries of cesium-137. The licensee had records showing it possessed them at one of its facilities more than two years ago, but it could neither physically locate them nor find any records showing their disposition. The licensee has continued its investigation but still has not determined the location or disposition of the devices. Serial Numbers for the two devices are B7713 and B7850. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident # I-9831.

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: 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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event 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.


Power Reactor
Event Number: 55147
Facility: Calvert Cliffs
Region: 1     State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Mark Watson
HQ OPS Officer: Jeffrey Whited
Notification Date: 03/21/2021
Notification Time: 23:57 [ET]
Event Date: 03/21/2021
Event Time: 22:16 [EDT]
Last Update Date: 03/22/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
CAHILL, CHRISTOPHER (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R N 37 Power Operation 0 Hot Standby
Event Text
MANUAL REACTOR TRIP DUE TO LOWERING STEAM GENERATOR LEVEL

"At 2216 EDT on 3/21/2021, Calvert Cliffs Unit 2 was manually tripped from 37 percent power due to lowering level in the 21 Steam Generator. All systems responded per design. Main Feedwater was secured and Auxiliary Feedwater was manually initiated. The Site Senior Resident has been notified."

The cause of the lowering level in the 21 Steam Generator is under investigation.


Power Reactor
Event Number: 55148
Facility: Susquehanna
Region: 1     State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Darvin Duttry
HQ OPS Officer: Ossy Font
Notification Date: 03/22/2021
Notification Time: 13:16 [ET]
Event Date: 03/22/2021
Event Time: 10:05 [EDT]
Last Update Date: 03/22/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xii) - Offsite Medical
Person (Organization):
JACKSON, DON (R1)
MILLER, CHRIS (NRR EO)
GRANT, JEFFERY (IR)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Shutdown
Event Text
OFFSITE TRANSPORT OF POTENTIALLY CONTAMINATED PERSON

"At 1005 EDT on 3/22/2021, the control room was notified of a personal medical event in the Radiologically Controlled Area.

"An ambulance entered Susquehanna plant property at 1019 and exited at 1028 to transport the individual to a local hospital. Ambulance did not enter the Protected Area.

"The individual was considered potentially contaminated since a complete frisk could not be performed prior to transport. Following transportation to a local hospital, Radiation Protection (RP) technicians confirmed the individual and ambulance were not contaminated.

"This event is reportable under 10CFR50.72(b)(3)(xii).

"An Event of Potential Public Interest (EPPI) was made to the Pennsylvania Emergency Management Agency (PEMA) due to an emergency vehicle accessing plant property."

The NRC Resident Inspector was notified.


Non-Agreement State
Event Number: 55149
Rep Org: Technical Resource Group Inc.
Licensee: Technical Resource Group Inc.
Region: 4
City: Idaho Falls   State: ID
County:
License #: 11-35127-01
Agreement: N
Docket:
NRC Notified By: Tom Clawson
HQ OPS Officer: Ossy Font
Notification Date: 03/22/2021
Notification Time: 17:33 [ET]
Event Date: 02/25/2021
Event Time: 00:00 [MDT]
Last Update Date: 03/22/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
WERNER, GREG (R4DO)
ILTAB, (EMAIL)
DON JACKSON (R1DO)
This material event contains a "Less than Cat 3" level of radioactive material.
Event Text
NON-AGREEMENT STATE REPORT LOST SOURCES IN TRANSIT

The following is a summary of a report received via phone:

On February 25, 2021, the licensee did not receive a shipment of three Cs-137 Brachytherapy sources with an aggregate quantity of 42.9 mCi (activities: 8.8 mCi, 8.7 mCi, and 25.4 mCi). The licensee reached out to the common carrier, who stated that it was still at their Memphis, TN distribution center and delayed due to the ice storm. The licensee has contacted the common carrier a number of times, with the last one taking place on March 18, 2021. The common carrier states they are still looking for the shipment package.


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

Page Last Reviewed/Updated Wednesday, March 24, 2021