Event Notification Report for July 09, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/08/2021 - 07/09/2021
Agreement State
Event Number: 55475
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Brodie Management
Region: 4
City: Westminster State: CO
County:
License #: GL002447
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: Brodie Management
Region: 4
City: Westminster State: CO
County:
License #: GL002447
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 10/15/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration. There was a change of ownership in 2019. The sign was lost or replaced prior to new ownership."
NMED No.: CO210025
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 TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration. There was a change of ownership in 2019. The sign was lost or replaced prior to new ownership."
NMED No.: CO210025
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: 55348
Rep Org: ALABAMA RADIATION CONTROL
Licensee: International Paper Company
Region: 1
City: Pine Hill State: AL
County:
License #: 222
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Ossy Font
Licensee: International Paper Company
Region: 1
City: Pine Hill State: AL
County:
License #: 222
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Ossy Font
Notification Date: 07/09/2021
Notification Time: 16:15 [ET]
Event Date: 07/09/2021
Event Time: 10:00 [CDT]
Last Update Date: 07/09/2021
Notification Time: 16:15 [ET]
Event Date: 07/09/2021
Event Time: 10:00 [CDT]
Last Update Date: 07/09/2021
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: 8/9/2021
EN Revision Text: AGREEMENT STATE REPORT - SHUTTER STUCK OPEN
The following was received from the Alabama Department of Public Health (the agency) via email:
"An agency representative received a call about 1400 CDT from the RSO (Radiation Safety Officer) of International Paper Company, license no. 222, in Pine Hill, Alabama. The RSO stated that a fixed gauge was discovered with its shutter stuck open about 1000 CDT on 7/9/2021. The RSO stated that the gauge is located on functioning process equipment; there are no health and safety issues. The RSO stated that the gauge will have shielding added, be removed, and placed in storage on the plant site, on Monday, 7/12/2021.
"The gauge is an Ohmart SH-L1-0 s/n M6846 with a cesium-137 source, 80 mCi on 8/1992."
Alabama Event 21-22
EN Revision Text: AGREEMENT STATE REPORT - SHUTTER STUCK OPEN
The following was received from the Alabama Department of Public Health (the agency) via email:
"An agency representative received a call about 1400 CDT from the RSO (Radiation Safety Officer) of International Paper Company, license no. 222, in Pine Hill, Alabama. The RSO stated that a fixed gauge was discovered with its shutter stuck open about 1000 CDT on 7/9/2021. The RSO stated that the gauge is located on functioning process equipment; there are no health and safety issues. The RSO stated that the gauge will have shielding added, be removed, and placed in storage on the plant site, on Monday, 7/12/2021.
"The gauge is an Ohmart SH-L1-0 s/n M6846 with a cesium-137 source, 80 mCi on 8/1992."
Alabama Event 21-22
Fuel Cycle Facility
Event Number: 55349
Facility: Global Nuclear Fuel - Americas
Region: 2 State: NC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Leu Fabrication
Lwr Commerical Fuel
NRC Notified By: Phillip Ollis
HQ OPS Officer: Brian P. Smith
Region: 2 State: NC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Leu Fabrication
Lwr Commerical Fuel
NRC Notified By: Phillip Ollis
HQ OPS Officer: Brian P. Smith
Notification Date: 07/10/2021
Notification Time: 14:58 [ET]
Event Date: 07/09/2021
Event Time: 17:30 [EDT]
Last Update Date: 07/10/2021
Notification Time: 14:58 [ET]
Event Date: 07/09/2021
Event Time: 17:30 [EDT]
Last Update Date: 07/10/2021
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
EN Revision Imported Date: 8/10/2021
EN Revision Text: FIRE SUPPRESSION SYSTEM IMPAIRED
"At approximately 1730 (EDT) on July 9, 2021, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. The backup diesel fire pump experienced a cooling system failure. As a result, the diesel fire pump was placed in the manual 'Off' position. The diesel fire pump could still be operated manually in an emergency for a short time. The electric fire pump remains fully operational and available to perform its safety function. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."
From the discussion between the licensee and the Headquarters Operations Officer, the vendor plans to be onsite Monday July 12, 2021 to conduct repairs.
EN Revision Text: FIRE SUPPRESSION SYSTEM IMPAIRED
"At approximately 1730 (EDT) on July 9, 2021, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. The backup diesel fire pump experienced a cooling system failure. As a result, the diesel fire pump was placed in the manual 'Off' position. The diesel fire pump could still be operated manually in an emergency for a short time. The electric fire pump remains fully operational and available to perform its safety function. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."
From the discussion between the licensee and the Headquarters Operations Officer, the vendor plans to be onsite Monday July 12, 2021 to conduct repairs.
Agreement State
Event Number: 55351
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Permanente Medical Group, Inc.
Region: 4
City: San Francisco State: CA
County:
License #: 0269-38
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Joanna Bridge
Licensee: Permanente Medical Group, Inc.
Region: 4
City: San Francisco State: CA
County:
License #: 0269-38
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Joanna Bridge
Notification Date: 07/12/2021
Notification Time: 18:13 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2021
Notification Time: 18:13 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
TAYLOR, NICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/12/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following was received from the state of California via e-mail:
"On Monday, July 12, 2021, [Radiation Health Branch] (RHB) Licensing Unit forwarded a July 9, 2021 email from [Radiation Safety Officer] (RSO) [redacted] (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver.
"RHB contacted the RSO [redacted] for additional information on July 12, 2021. The RSO [redacted] emailed a statement from the Authorized User (AU), Interventional Radiologist, [redacted], stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained.
"AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs.
"A written report will be provided to RHB within two weeks.
"CA Incident No.: 070921"
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 UNDERDOSE
The following was received from the state of California via e-mail:
"On Monday, July 12, 2021, [Radiation Health Branch] (RHB) Licensing Unit forwarded a July 9, 2021 email from [Radiation Safety Officer] (RSO) [redacted] (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver.
"RHB contacted the RSO [redacted] for additional information on July 12, 2021. The RSO [redacted] emailed a statement from the Authorized User (AU), Interventional Radiologist, [redacted], stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained.
"AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs.
"A written report will be provided to RHB within two weeks.
"CA Incident No.: 070921"
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.