Event Notification Report for June 15, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/14/2021 - 06/15/2021
Agreement State
Event Number: 55312
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UCI Irvine Medical Center
Region: 4
City: Orange State: CA
County:
License #: 0278-30
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Kendzia
Licensee: UCI Irvine Medical Center
Region: 4
City: Orange State: CA
County:
License #: 0278-30
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Kendzia
Notification Date: 06/17/2021
Notification Time: 10:49 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [PDT]
Last Update Date: 06/17/2021
Notification Time: 10:49 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [PDT]
Last Update Date: 06/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/16/2021
EN Revision Text: AGREEMENT STATE REPORT - PORTION OF THE DOSE DELIVERED TO THE WRONG LOCATION
The following was received from the California Department of Public Health via email:
"On June 16, 2021, the Radiologic Health Branch was notified of a reportable medical event that occurred on June 15, 2021 during a patients' liver metastases treatment with Y-90 Sirtex SIRSpheres. The AU's treatment plan called for treating the left lobe of the liver with 0.29-0.83 GBq of Y-90 SIRSpheres. The reason for the range was that if the liver became saturated, the treatment would be stopped at that point. During the treatment, periodic flushing cycles with contrast and flouroscopy were performed. At a mid-way point, the team discovered contrast material in the right liver lobe, indicating the microcather had moved from the left artery to the right artery. Upon discovery, the procedure was stopped, the microcatherter was removed and a new one was placed and the they began to infuse the left liver lobe again with the remaining Y-90 SIRSpheres without incident. Post treatment, a bremsstrahlung image of the two liver lobes indicated that both lobes had received Y-90 activity. The Radiation Oncologist estimated that the left lobe received less than the intended Y-90 activity. The right lobe received between 33%-67% of the Y-90 activity.
"The actual dose to either lobe has not been calculated, but based on dosimetry information in the package insert, the dose to the right lobe was > 0.5 Gy ( 50 rem). Treatment of the liver's right lobe was not intended during this procedure. On June 1, 2021, the patient had been treated with Y-90 SIRSpheres of the patient's right liver lobe. The patient was informed of the issue and there are no negative consequences expected for the patient."
California Item Number: 061621
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 - PORTION OF THE DOSE DELIVERED TO THE WRONG LOCATION
The following was received from the California Department of Public Health via email:
"On June 16, 2021, the Radiologic Health Branch was notified of a reportable medical event that occurred on June 15, 2021 during a patients' liver metastases treatment with Y-90 Sirtex SIRSpheres. The AU's treatment plan called for treating the left lobe of the liver with 0.29-0.83 GBq of Y-90 SIRSpheres. The reason for the range was that if the liver became saturated, the treatment would be stopped at that point. During the treatment, periodic flushing cycles with contrast and flouroscopy were performed. At a mid-way point, the team discovered contrast material in the right liver lobe, indicating the microcather had moved from the left artery to the right artery. Upon discovery, the procedure was stopped, the microcatherter was removed and a new one was placed and the they began to infuse the left liver lobe again with the remaining Y-90 SIRSpheres without incident. Post treatment, a bremsstrahlung image of the two liver lobes indicated that both lobes had received Y-90 activity. The Radiation Oncologist estimated that the left lobe received less than the intended Y-90 activity. The right lobe received between 33%-67% of the Y-90 activity.
"The actual dose to either lobe has not been calculated, but based on dosimetry information in the package insert, the dose to the right lobe was > 0.5 Gy ( 50 rem). Treatment of the liver's right lobe was not intended during this procedure. On June 1, 2021, the patient had been treated with Y-90 SIRSpheres of the patient's right liver lobe. The patient was informed of the issue and there are no negative consequences expected for the patient."
California Item Number: 061621
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: 55315
Rep Org: NJ DEPT OF ENVIRONMENTAL PROTECTION
Licensee: Private Citizen
Region: 1
City: Mountain Lakes State: NJ
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Jeffrey Whited
Licensee: Private Citizen
Region: 1
City: Mountain Lakes State: NJ
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/17/2021
Notification Time: 18:07 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2021
Notification Time: 18:07 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
LILLIENDAHL, JON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
LILLIENDAHL, JON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/16/2021
EN Revision Text: AGREEMENT STATE REPORT - PRIVATE CITIZEN IN POSSESSION OF NUCLEAR MATERIAL
The following was received from the New Jersey Department of Environmental Protection (DEP) via email:
"On Tuesday evening, June 15, 2021, the DEP was notified that a member of the public had come to the Mountain Lakes police HQ to report that he had in his possession some radioactive material that he had obtained 60 years ago when he worked for Westinghouse as an engineer. The material was reported to be "Nuclear Reactor grade U-238 with 5 percent U-235 enriched". The citizen further stated that the material is wrapped in lead foil and placed in a lead pipe with the ends pinched over. The material allegedly consists of three or four rejected pellets, approximately 3/8 inch diameter. These were rejected because of dimensional irregularities. They are allegedly doughnut shaped with a hole in the center. They were reportedly to be used in Westinghouse nuclear reactors/steam power. The citizen stated that the material in question has been stored for decades in a lead pipe, sealed off at the ends, and then tightly wrapped in lead sheeting. It was also clearly labelled with the word "Radioactive" and then placed inside a large can, which has been securely stored in the citizen's garage for several decades. DEP personnel responded to the citizen's home on June 17, 2021. The material was found stored as the citizen had previously described. The container was not opened. There was no detectable removable contamination on the outside of the container. The material was returned to the garage where it will be secured pending proper disposal."
EN Revision Text: AGREEMENT STATE REPORT - PRIVATE CITIZEN IN POSSESSION OF NUCLEAR MATERIAL
The following was received from the New Jersey Department of Environmental Protection (DEP) via email:
"On Tuesday evening, June 15, 2021, the DEP was notified that a member of the public had come to the Mountain Lakes police HQ to report that he had in his possession some radioactive material that he had obtained 60 years ago when he worked for Westinghouse as an engineer. The material was reported to be "Nuclear Reactor grade U-238 with 5 percent U-235 enriched". The citizen further stated that the material is wrapped in lead foil and placed in a lead pipe with the ends pinched over. The material allegedly consists of three or four rejected pellets, approximately 3/8 inch diameter. These were rejected because of dimensional irregularities. They are allegedly doughnut shaped with a hole in the center. They were reportedly to be used in Westinghouse nuclear reactors/steam power. The citizen stated that the material in question has been stored for decades in a lead pipe, sealed off at the ends, and then tightly wrapped in lead sheeting. It was also clearly labelled with the word "Radioactive" and then placed inside a large can, which has been securely stored in the citizen's garage for several decades. DEP personnel responded to the citizen's home on June 17, 2021. The material was found stored as the citizen had previously described. The container was not opened. There was no detectable removable contamination on the outside of the container. The material was returned to the garage where it will be secured pending proper disposal."
Power Reactor
Event Number: 55306
Facility: Fort Calhoun
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: Bill Rice
HQ OPS Officer: Jeffrey Whited
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: Bill Rice
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/15/2021
Notification Time: 15:38 [ET]
Event Date: 06/15/2021
Event Time: 12:30 [CDT]
Last Update Date: 06/15/2021
Notification Time: 15:38 [ET]
Event Date: 06/15/2021
Event Time: 12:30 [CDT]
Last Update Date: 06/15/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
JOSEY, JEFFREY (R4)
JOSEY, JEFFREY (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
EN Revision Imported Date: 7/15/2021
EN Revision Text: OFFSITE NOTIFICATION
"At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4).
"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."
The licensee notified the NRC Region IV Office.
EN Revision Text: OFFSITE NOTIFICATION
"At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4).
"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."
The licensee notified the NRC Region IV Office.
Non-Agreement State
Event Number: 55308
Rep Org: G2 Consulting
Licensee: G2 Consulting
Region: 3
City: Troy State: MI
County:
License #: 21-26593-01
Agreement: N
Docket:
NRC Notified By: Bruce Wibeding
HQ OPS Officer: Thomas Herrity
Licensee: G2 Consulting
Region: 3
City: Troy State: MI
County:
License #: 21-26593-01
Agreement: N
Docket:
NRC Notified By: Bruce Wibeding
HQ OPS Officer: Thomas Herrity
Notification Date: 06/15/2021
Notification Time: 15:57 [ET]
Event Date: 06/15/2021
Event Time: 15:30 [EDT]
Last Update Date: 06/15/2021
Notification Time: 15:57 [ET]
Event Date: 06/15/2021
Event Time: 15:30 [EDT]
Last Update Date: 06/15/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
Person (Organization):
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
EN Revision Imported Date: 7/15/2021
EN Revision Text: NON-AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE
The following was received from the licensee via email:
"On Monday afternoon June 14, 2021, [the licensee] went to perform a leak test on Troxler gauge 70894 (Model No. 3430; Cs-137 8 milliCurie; Am-241/Be 40 milliCurie), which was due for a leak test the same date 6/14/21. [The licensee] looked in [their] system to see which employee had the gauge. It was not checked out by anyone that day so [the licensee] went through the storage room in Ann Arbor and then Troy to find the gauge and perform the test. The gauge was not present in either location. [The licensee] began making phone calls to employees to see if an employee had the gauge and it was just not checked out properly in [their] system.
"[The licensee] reviewed [their] system and determined the gauge was last used by a former employee on January 5, 2021. [The licensee] was able to reach that person and he indicated he returned the gauge to the locked storage room in [the] Ann Arbor office on January 6, 2021. The gauge was not shown as having been used by any employee since that date within [the] system. [The licensee does] not know when the gauge went missing or how the gauge was removed from the office. [The licensee] also cannot confirm if the former employee actually returned the gauge on January 6, 2021. Calibration and leak tests were performed in December 2020 by ATSNUC, Inc. [The licensee] contacted all of the service facilities that [they] use to see if it might be in for service but [the licensee has] been unable to locate the gauge. [The licensee is] also checking with all service centers listed on the APNGA website to see if by chance some other party has sent in/returned this gauge to one of those facilities. It was determined today, 6/15/21, at approximately 1534 EDT (less than 24 hours after the initial discovery) that [the licensee] could not locate the gauge."
The licensee notified the NRC Region III Office.
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: NON-AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE
The following was received from the licensee via email:
"On Monday afternoon June 14, 2021, [the licensee] went to perform a leak test on Troxler gauge 70894 (Model No. 3430; Cs-137 8 milliCurie; Am-241/Be 40 milliCurie), which was due for a leak test the same date 6/14/21. [The licensee] looked in [their] system to see which employee had the gauge. It was not checked out by anyone that day so [the licensee] went through the storage room in Ann Arbor and then Troy to find the gauge and perform the test. The gauge was not present in either location. [The licensee] began making phone calls to employees to see if an employee had the gauge and it was just not checked out properly in [their] system.
"[The licensee] reviewed [their] system and determined the gauge was last used by a former employee on January 5, 2021. [The licensee] was able to reach that person and he indicated he returned the gauge to the locked storage room in [the] Ann Arbor office on January 6, 2021. The gauge was not shown as having been used by any employee since that date within [the] system. [The licensee does] not know when the gauge went missing or how the gauge was removed from the office. [The licensee] also cannot confirm if the former employee actually returned the gauge on January 6, 2021. Calibration and leak tests were performed in December 2020 by ATSNUC, Inc. [The licensee] contacted all of the service facilities that [they] use to see if it might be in for service but [the licensee has] been unable to locate the gauge. [The licensee is] also checking with all service centers listed on the APNGA website to see if by chance some other party has sent in/returned this gauge to one of those facilities. It was determined today, 6/15/21, at approximately 1534 EDT (less than 24 hours after the initial discovery) that [the licensee] could not locate the gauge."
The licensee notified the NRC Region III Office.
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: 55310
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: University of Chicago Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jeffrey Whited
Licensee: University of Chicago Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/16/2021
Notification Time: 13:10 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2021
Notification Time: 13:10 [ET]
Event Date: 06/15/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
HILLS, DAVID (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/16/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours.
"IEMA inspectors will perform a reactive inspection on June 17, 2021. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated once additional details become available on 6/17/21."
Item Number: IL210019
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 - MEDICAL EVENT - UNDERDOSE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours.
"IEMA inspectors will perform a reactive inspection on June 17, 2021. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated once additional details become available on 6/17/21."
Item Number: IL210019
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.