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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2021

Event Notification Report for May 18, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/17/2021 - 05/18/2021

EVENT NUMBERS
55245 55246 55248 55249 55261
Hospital
Event Number: 55245
Rep Org: VA National Health Physics Program
Licensee: VA Pittsburgh Healthcare System
Region: 3
City: Little Rock   State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Stan Bravenec
HQ OPS Officer: Bethany Cecere
Notification Date: 05/10/2021
Notification Time: 15:28 [ET]
Event Date: 05/10/2021
Event Time: 07:30 [EST]
Last Update Date: 05/10/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/18/2021

EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE

The following report was received via email from the VA National Health Physics Program (NHPP):

"VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, which holds Permit Number 37-01230-03 under the VA master materials license, reported discovery of a medical event to NHPP at approximately 0730 EDT, May 10, 2021.

"An iodine-131 sodium iodide thyroid ablation therapy administration was performed on Friday, May 7, 2021. The prescribed dose was 60 milliCuries but only 31.2 milliCuries were delivered.

"The patient and the referring physician have been notified.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.

"NHPP notified [their] NRC Region III Project Manager, Bryan Parker."

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: 55246
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Materials Testing Laboratory, Inc.
Region: 1
City: Bronx   State: NY
County:
License #: C2274
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/10/2021
Notification Time: 15:14 [ET]
Event Date: 05/06/2021
Event Time: 00:00 [EDT]
Last Update Date: 05/10/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DIMITRIADIS, ANTHONY (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/18/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN AND RETURNED GAUGE
The following was received from the New York State Department of Health (the Department) via email:

"A regional inspector for the Department received an email at 0341 EDT on 5/7/21 from the RSO of a materials testing lab stating that a Troxler model 4640 thin [layer density gauge], serial number 722, containing 40 mCi of Am-241/Be and 11 mCi of Cs-137, was stolen from a job site in Bronx, NY. The operator left the device unattended for a short period of time and returned to find it missing. The device was in its locked position when it was taken. The area was canvassed, and the police were notified.

"On 5/7/21, the licensee received a phone call from [an individual] stating that they had the device and wanted the reward. The licensee paid the reward and the device is back in the possession of the licensee. The device appears to be in good shape, but it will be leak tested before it is put back into operation."

Event Report ID No.: NYDOH-21-02

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: 55248
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Ohio State University
Region: 3
City: Columbus   State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Kerby Scales
Notification Date: 05/11/2021
Notification Time: 15:46 [ET]
Event Date: 05/10/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
McCRAW, AARON (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/18/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE

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

"A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified."

Ohio Event Number: OH210003

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: 55249
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Dees and Associates, Inc.
Region: 4
City: Santa Cruz   State: CA
County:
License #: 7538-44
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/11/2021
Notification Time: 18:33 [ET]
Event Date: 05/11/2021
Event Time: 00:00 [PDT]
Last Update Date: 05/11/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GADDY, VINCENT (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 5/18/2021

EN Revision Text: AGREEMENT STATE REPORT - DISCOVERED DENSITY GAUGE

The following was received from the California Radiation Control Program via email:

"On 05/11/21 the California Office of Emergency Services (Cal OES) contacted [the Radiologic Health Branch] RHB to report a moisture density gauge that was discovered by [the California Highway Patrol] CHP in Santa Cruz, CA. The message stated that while CHP and [California Department of Transportation] CALTRANS were removing a transient encampment, a Soil Density Gauge (Troxler Model 3430, S/N #38287, containing 9 mCi of Cs-137 and 44 mCi of Am-241) was discovered at the site and the device does not appear to be damaged.

"CHP contacted the gauge vendor, Troxler, and was able to locate the licensee (Dees and Associates, Inc) and inform them of the stolen gauge. CHP took possession of the gauge and [the Radiation Safety Officer] RSO had already picked up the gauge from the CHP facility. According to the RSO, they have noticed a gauge stolen from their storage on 4/15/21. She had immediately notified Santa Cruz Police Department (Case # 21S-02156) and Troxler of the theft at the time of the incident. RHB was unaware of the theft until the Cal OES notification on 5/11/21."

California 5010 Number: 051121

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


Power Reactor
Event Number: 55261
Facility: Peach Bottom
Region: 1     State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Brett Henry
HQ OPS Officer: Brian Lin
Notification Date: 05/17/2021
Notification Time: 13:12 [ET]
Event Date: 05/17/2021
Event Time: 12:38 [EDT]
Last Update Date: 05/17/2021
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
GREIVES, JONATHAN (R1)
LEW, DAVE (R1 RA)
MILLER, CHRIS (NRR EO)
GRANT, JEFFERY (IR)
CASTELVETER, DAVID (PAO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 40 Power Operation 40 Power Operation
Event Text
UNUSUAL EVENT DUE TO A FIRE ALARM INSIDE THE DRYWELL

[Peach Bottom Atomic Power Station declared an unusual event due to a] "receipt of a single fire alarm in the Unit 2 drywell and the existence of the fire not verified in less than 30 minutes of alarm receipt."

The NRC Resident Inspector and State and Local Authorities were notified.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 5/17/21 AT 1423 EDT FROM BRETT HENRY TO HOWIE CROUCH * * *
At 1355 EDT, the licensee terminated the notification of unusual event. The basis for termination was that the smoke has dissipated and there were no signs of fire.

The licensee notified State and Local Authorities and the NRC Resident Inspector.

Notified R1DO (Grieves), NRR EO (Miller), and IRD MOC (Grant). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), FEMA NRCC THD (email) and FEMA NRCC SASC (email).