Event Notification Report for August 30, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
08/27/2021 - 08/30/2021

EVENT NUMBERS
55419 55422 55424 55435
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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
Event Text
EN Revision Imported Date: 8/30/2021

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.


Agreement State
Event Number: 55422
Rep Org: ALABAMA RADIATION CONTROL
Licensee: Applied Technical Services
Region: 1
City: Mobile   State: AL
County:
License #: 1454
Agreement: Y
Docket:
NRC Notified By: Carson Coan
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/20/2021
Notification Time: 17:59 [ET]
Event Date: 08/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 8/30/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF PROTECTIVE COVER OVER LOCKING MECHANISM

The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:

"During the Agency's inspection on 8/12/2021, of licensee Applied Technical Services, license no. 1454, the representative stated that a technician lost the protective cover over the locking mechanism on a QSA 880D exposure device. The representative stated that the metal lanyard connecting the cover to the device housing snapped, and the cover fell between metal grating. The representative did not remember the date of this occurrence. The representative stated that no exposures to personnel or members of the public resulted from the lost cover. The Agency has followed up with Applied Technical Services for more information, with no more information at this time. The Agency is continuing to investigate.

"Device QSA 880-Delta, Ir-192 source, source activity and device serial number is not available at this time."

Alabama Event 21-28


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 55424
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: Oregon Health and Science University
Region: 4
City: Portland   State: OR
County: Multnomah
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Mike Stafford
Notification Date: 08/23/2021
Notification Time: 15:20 [ET]
Event Date: 08/21/2021
Event Time: 13:00 [PDT]
Last Update Date: 08/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 8/30/2021

EN Revision Text: AGREEMENT STATE REPORT - PRESCRIBED DOSE EXCEEDED

The following is a summary of information received from the State of Oregon:

Licensee miscalculated and administered more radiation to a patient's spine than the prescription allowed. Radiation dose to the patient was intended to be 800 centigray but the actual dose delivered exceeded this by 21%.

Oregon Emergency Response System Incident Number: 2021-2250

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.

* * * RETRACTION ON 24 AUGUST 2021 AT 1550 EDT FROM DARYL LEON TO KAREN COTTON * * *

The following is a synopsis of information received via e-mail from the state of Oregon via e-mail:

After obtaining direct information from the responsible party, the radiation dose above the prescribed 800 centigray was from an x-ray generating device and is therefore a nonreportable event to NRC but is being investigated at the State (Oregon) level. This is not a reportable event to the NRC.

Notified R4DO (KOZAL) and NMSS Events (by email).


Power Reactor
Event Number: 55435
Facility: Waterford
Region: 4     State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Samantha Smith
HQ OPS Officer: Ossy Font
Notification Date: 08/29/2021
Notification Time: 19:49 [ET]
Event Date: 08/29/2021
Event Time: 18:12 [CDT]
Last Update Date: 08/29/2021
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
KOZAL, JASON (R4)
MORRIS, SCOTT (R4)
VEIL, ANDREA (HQ)
GRANT, JEFFERY (IR)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Shutdown 0 Hot Shutdown
Event Text
EN Revision Imported Date: 8/30/2021

EN Revision Text: NOTIFICATION OF UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER

Waterford 3 shut down the reactor in preparation for Hurricane Ida landfall prior to this event.

At 1812 CDT, Waterford 3 declared a notification of unusual event under EAL S.U. 1.1 due to a loss of offsite power as a result of hurricane Ida. Plant power is being provided via emergency diesel generators. The NRC Activated at 2016 EDT with Region IV in the lead.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, DHS Nuclear SSA (email), FEMA NWC (email), and FEMA NRCC SASC (email).

Page Last Reviewed/Updated Monday, August 30, 2021