Event Notification Report for November 24, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/23/2021 - 11/24/2021
Agreement State
Event Number: 55613
Rep Org: Virginia Rad Materials Program
Licensee: University of Virginia
Region: 1
City: Charlottesville State: VA
County: Albemarle
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: Sheila Nelson
HQ OPS Officer: Mike Stafford
Licensee: University of Virginia
Region: 1
City: Charlottesville State: VA
County: Albemarle
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: Sheila Nelson
HQ OPS Officer: Mike Stafford
Notification Date: 11/29/2021
Notification Time: 10:24 [ET]
Event Date: 11/24/2021
Event Time: 00:00 [EST]
Last Update Date: 11/29/2021
Notification Time: 10:24 [ET]
Event Date: 11/24/2021
Event Time: 00:00 [EST]
Last Update Date: 11/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1)
NMSS_Events_Notification, (EMAIL)
Lally, Christopher (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/29/2021
EN Revision Text: AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE POSITION ERROR
The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email:
"On November 24, 2021, the agency was notified by the [radiation safety officer] at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR [high dose rate brachytherapy] had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit.
"This report will be updated when the licensee submits their final investigation report."
Virginia Event Report ID No.: VA-21-0007
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 - BRACHYTHERAPY SOURCE POSITION ERROR
The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email:
"On November 24, 2021, the agency was notified by the [radiation safety officer] at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR [high dose rate brachytherapy] had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit.
"This report will be updated when the licensee submits their final investigation report."
Virginia Event Report ID No.: VA-21-0007
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.
Power Reactor
Event Number: 55610
Facility: Comanche Peak
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Christopher Metz
HQ OPS Officer: Brian P. Smith
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Christopher Metz
HQ OPS Officer: Brian P. Smith
Notification Date: 11/24/2021
Notification Time: 21:42 [ET]
Event Date: 11/24/2021
Event Time: 07:00 [CST]
Last Update Date: 11/24/2021
Notification Time: 21:42 [ET]
Event Date: 11/24/2021
Event Time: 07:00 [CST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Werner, Greg (R4)
FFD Group, (EMAIL)
Werner, Greg (R4)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 12/23/2021
EN Revision Text: FITNESS-FOR-DUTY REPORT
A violation occurred concerning Comanche's Peak's Fitness-For-Duty Program. Two empty mini-bottles of alcohol were discovered in a trash can within the protected area. The event has been documented in the corrective action program.
The resident inspector has been notified.
EN Revision Text: FITNESS-FOR-DUTY REPORT
A violation occurred concerning Comanche's Peak's Fitness-For-Duty Program. Two empty mini-bottles of alcohol were discovered in a trash can within the protected area. The event has been documented in the corrective action program.
The resident inspector has been notified.
Non-Agreement State
Event Number: 55611
Rep Org: Clearwater Paper Corporation
Licensee: Clearwater Paper Corporation
Region: 4
City: Lewiston State: ID
County:
License #: 11-27075-01
Agreement: N
Docket:
NRC Notified By: Bill Hoesman
HQ OPS Officer: Lloyd Desotell
Licensee: Clearwater Paper Corporation
Region: 4
City: Lewiston State: ID
County:
License #: 11-27075-01
Agreement: N
Docket:
NRC Notified By: Bill Hoesman
HQ OPS Officer: Lloyd Desotell
Notification Date: 11/25/2021
Notification Time: 12:15 [ET]
Event Date: 11/24/2021
Event Time: 14:00 [MST]
Last Update Date: 11/25/2021
Notification Time: 12:15 [ET]
Event Date: 11/24/2021
Event Time: 14:00 [MST]
Last Update Date: 11/25/2021
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: NON-AGREEMENT STATE REPORT - STUCK SOURCE
The following event synopsis was received by the licensee via phone call and email:
The Headquarters Operations Officer was notified by the licensee that during radiography operations, a source was stuck in the guide tube. The radiography operations were conducted by a contractor (Northwest Inspection).
The contractor established a 2 mrem/hr perimeter prior to conducting the radiography work. When the source became stuck in the guide tube, the contractor Radiation Safety Officer deployed to the site was able to successfully retrieve the source without incident.
Gauge : QSA Model 880 containing a 17.4 Ci Ir-192 source.
EN Revision Text: NON-AGREEMENT STATE REPORT - STUCK SOURCE
The following event synopsis was received by the licensee via phone call and email:
The Headquarters Operations Officer was notified by the licensee that during radiography operations, a source was stuck in the guide tube. The radiography operations were conducted by a contractor (Northwest Inspection).
The contractor established a 2 mrem/hr perimeter prior to conducting the radiography work. When the source became stuck in the guide tube, the contractor Radiation Safety Officer deployed to the site was able to successfully retrieve the source without incident.
Gauge : QSA Model 880 containing a 17.4 Ci Ir-192 source.