Event Notification Report for July 26, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/25/2021 - 07/26/2021
Non-Power Reactor
Event Number: 55380
Rep Org: Univ Of Missouri-Columbia
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Bruce Meffert
HQ OPS Officer: Thomas Herrity
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Bruce Meffert
HQ OPS Officer: Thomas Herrity
Notification Date: 07/27/2021
Notification Time: 13:56 [ET]
Event Date: 07/26/2021
Event Time: 17:31 [CDT]
Last Update Date: 07/27/2021
Notification Time: 13:56 [ET]
Event Date: 07/26/2021
Event Time: 17:31 [CDT]
Last Update Date: 07/27/2021
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Wertz, Geoffrey (HQ PM )
Helvenston, Edward Edward (HQ PM )
Takacs, Michael (NPR Even)
Schuster, William (NPR Even)
Wertz, Geoffrey (HQ PM )
Helvenston, Edward Edward (HQ PM )
Takacs, Michael (NPR Even)
Schuster, William (NPR Even)
EN Revision Imported Date: 8/27/2021
EN Revision Text: REACTOR SHUTDOWN DUE TO CONTROL ROD DRIVE FAILURE
"On July 26, 2021 at 1731 CDT, while the reactor was subcritical during a reactor startup, the University of Missouri-Columbia Research Reactor (MURR) was manually shut down due to the failure of the control rod drive mechanism for shim control blade B. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'
"A spare control rod drive mechanism was installed for control blade B, post-installation operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on July 26, 2021. Currently, MURR is operating at 10 MW [full power]. A detailed event report will follow within 14 days."
EN Revision Text: REACTOR SHUTDOWN DUE TO CONTROL ROD DRIVE FAILURE
"On July 26, 2021 at 1731 CDT, while the reactor was subcritical during a reactor startup, the University of Missouri-Columbia Research Reactor (MURR) was manually shut down due to the failure of the control rod drive mechanism for shim control blade B. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'
"A spare control rod drive mechanism was installed for control blade B, post-installation operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on July 26, 2021. Currently, MURR is operating at 10 MW [full power]. A detailed event report will follow within 14 days."
Agreement State
Event Number: 55410
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: Polyclinic
Region: 4
City: Seattle State: WA
County:
License #: WN-M0218
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Kerby Scales
Licensee: Polyclinic
Region: 4
City: Seattle State: WA
County:
License #: WN-M0218
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Kerby Scales
Notification Date: 08/17/2021
Notification Time: 15:33 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [PDT]
Last Update Date: 08/17/2021
Notification Time: 15:33 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [PDT]
Last Update Date: 08/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
DEESE, RICK (R4)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/17/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS
The following is a summary of a report received from the state of Washington via email:
On Monday, 7/26/2021, nuclear cardiology personnel identified and reported a loss of Radioactive Seed Localization (RSL) seeds.
Background: RSL seeds are obtained by the Polyclinic as individually loaded implant needles containing one seed, in sterile, one needle use packs. Nuclear cardiology personnel receive the seed shipments, conduct the required surveys and maintain a seed inventory. Needle packs are distributed to mammography personnel on days of RSL seed implant.
On Wednesday, 7/21/2021, the seed was obtained by mammography personnel. The intent was not for RSL implant, but rather to utilize the needle for qualification of new Hologic mammography equipment. The needle pack was provided to the Hologic applications technologist for the qualification. Mammography personnel indicated that the Hologic applications technologist unexpectedly opened the needle pack and ejected the seed within the plastic sterile pack as she needed the needle not the RSL seed. Mammography personnel took the pack, and seed, and stored the pack. At the end of the day, mammography personnel indicated they taped the pack closed and returned the pack to the nuclear cardiology hot lab.
On Thursday, 7/22/2021, mammography personnel again took the needle pack from the hot lab, and utilized the needle for equipment qualification, indicating that the pack, and seed, was returned again to the nuclear cardiology hot lab at the end of the day. Mammography personnel indicate that the seed was visible in the pack at the end of the day.
On Monday, 7/26/2021, nuclear cardiology personnel indicated that the subject pack was visually inspected and no seed was identified. Nuclear cardiology personnel indicated the needle pack was surveyed with an exposure rate calibrated Ludlum 14C w/ 44-9 GM pancake and no evidence of the seed was identified. Nuclear cardiology personnel also indicated the lead foil shielded box was similarly visually inspected and surveyed and no evidence of the seed was identified.
On Tuesday, 7/27/2021, nuclear cardiology personnel surveyed the Nuclear Cardiology hot lab and other areas. Nuclear cardiology personnel indicated that no evidence of the seed presence was identified.
Washington State Incident Number: WA-21-019
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 IODINE-125 SEEDS
The following is a summary of a report received from the state of Washington via email:
On Monday, 7/26/2021, nuclear cardiology personnel identified and reported a loss of Radioactive Seed Localization (RSL) seeds.
Background: RSL seeds are obtained by the Polyclinic as individually loaded implant needles containing one seed, in sterile, one needle use packs. Nuclear cardiology personnel receive the seed shipments, conduct the required surveys and maintain a seed inventory. Needle packs are distributed to mammography personnel on days of RSL seed implant.
On Wednesday, 7/21/2021, the seed was obtained by mammography personnel. The intent was not for RSL implant, but rather to utilize the needle for qualification of new Hologic mammography equipment. The needle pack was provided to the Hologic applications technologist for the qualification. Mammography personnel indicated that the Hologic applications technologist unexpectedly opened the needle pack and ejected the seed within the plastic sterile pack as she needed the needle not the RSL seed. Mammography personnel took the pack, and seed, and stored the pack. At the end of the day, mammography personnel indicated they taped the pack closed and returned the pack to the nuclear cardiology hot lab.
On Thursday, 7/22/2021, mammography personnel again took the needle pack from the hot lab, and utilized the needle for equipment qualification, indicating that the pack, and seed, was returned again to the nuclear cardiology hot lab at the end of the day. Mammography personnel indicate that the seed was visible in the pack at the end of the day.
On Monday, 7/26/2021, nuclear cardiology personnel indicated that the subject pack was visually inspected and no seed was identified. Nuclear cardiology personnel indicated the needle pack was surveyed with an exposure rate calibrated Ludlum 14C w/ 44-9 GM pancake and no evidence of the seed was identified. Nuclear cardiology personnel also indicated the lead foil shielded box was similarly visually inspected and surveyed and no evidence of the seed was identified.
On Tuesday, 7/27/2021, nuclear cardiology personnel surveyed the Nuclear Cardiology hot lab and other areas. Nuclear cardiology personnel indicated that no evidence of the seed presence was identified.
Washington State Incident Number: WA-21-019
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: 55419
Rep Org: NORTH CAROLINA DIV OF RAD PROTECTIO
Licensee: Moses Cone Health System
Region: 1
City: Greensboro State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Howie Crouch
Licensee: Moses Cone Health System
Region: 1
City: Greensboro State: NC
County:
License #: 041-0021-3
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Howie Crouch
Notification Date: 08/20/2021
Notification Time: 10:05 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/20/2021
Notification Time: 10:05 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 08/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
EN Revision Imported Date: 9/20/2021
EN Revision Text: AGREEMENT STATE REPORT - UNINTENDED DOSE TO AN ORGAN
The following information was received from the state of North Carolina via email:
"A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate.
"An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated.
"Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures."
NMED Report No.: NC210014
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 - UNINTENDED DOSE TO AN ORGAN
The following information was received from the state of North Carolina via email:
"A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate.
"An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated.
"Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures."
NMED Report No.: NC210014
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.