Event Notification Report for November 30, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/29/2021 - 11/30/2021
Agreement State
Event Number: 55598
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Cohen Brothers
Region: 3
City: Middletown State: OH
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Thomas Kendzia
Licensee: Cohen Brothers
Region: 3
City: Middletown State: OH
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Thomas Kendzia
Notification Date: 11/22/2021
Notification Time: 09:57 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [EST]
Last Update Date: 11/22/2021
Notification Time: 09:57 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [EST]
Last Update Date: 11/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Peterson, Hironori (R3DO)
NMSS_Events_Notification (EMAIL)
ILTAB (EMAIL)
Peterson, Hironori (R3DO)
NMSS_Events_Notification (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 11/30/2021
EN Revision Text: AGREEMENT STATE REPORT - FOUND SOURCE
The following was received from the Ohio Department of Health Bureau of Radiation Protection (ODH) via email:
"Cohen Brothers, scrap metal facility in Middletown, informed ODH on November 19, 2021, that they discovered two devices containing radioactive material at their facility. An ODH inspector responded and identified the devices as Industrial Dynamics Filtec 3-G devices, each containing a 100 mCi Am-241 sealed source.
"Dose rates on the devices were 30 microR/hr. No contamination was detected. The gauges are secured at Cohen Brothers pending proper disposal.
"ODH is working with Industrial Dynamics to determine the owner of the devices."
The Filtec 3-G gauge serial numbers are 121015 and 121016.
Ohio Item Number: OH2100010
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 - FOUND SOURCE
The following was received from the Ohio Department of Health Bureau of Radiation Protection (ODH) via email:
"Cohen Brothers, scrap metal facility in Middletown, informed ODH on November 19, 2021, that they discovered two devices containing radioactive material at their facility. An ODH inspector responded and identified the devices as Industrial Dynamics Filtec 3-G devices, each containing a 100 mCi Am-241 sealed source.
"Dose rates on the devices were 30 microR/hr. No contamination was detected. The gauges are secured at Cohen Brothers pending proper disposal.
"ODH is working with Industrial Dynamics to determine the owner of the devices."
The Filtec 3-G gauge serial numbers are 121015 and 121016.
Ohio Item Number: OH2100010
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: 55599
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Medical Center of Oshkosh
Region: 3
City: Oshkosh State: WI
County:
License #: 139-1025-01
Agreement: Y
Docket:
NRC Notified By: Luther Loehrke
HQ OPS Officer: Brian Lin
Licensee: Aurora Medical Center of Oshkosh
Region: 3
City: Oshkosh State: WI
County:
License #: 139-1025-01
Agreement: Y
Docket:
NRC Notified By: Luther Loehrke
HQ OPS Officer: Brian Lin
Notification Date: 11/22/2021
Notification Time: 14:09 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [CST]
Last Update Date: 11/22/2021
Notification Time: 14:09 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [CST]
Last Update Date: 11/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Peterson, Hironori (R3)
NMSS_Events_Notification, (EMAIL)
Fisher, Jennifer (NMSS DAY) (NMSS DAY)
Peterson, Hironori (R3)
NMSS_Events_Notification, (EMAIL)
Fisher, Jennifer (NMSS DAY) (NMSS DAY)
EN Revision Imported Date: 11/30/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the state of Wisconsin via email:
"On November 22, 2021, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on November 19, 2021. A patient had been prescribed two administrations to different segments of the liver of 126 Gy and 138 Gy. However, the licensee has estimated that the administered doses were 256 Gy (103 percent [over]) and 294 Gy (113 percent [over]). The administered doses had been ordered with an incorrect calibration date. A full dose projection is ongoing by the vendor. The State will perform a reactive inspection."
Wisconsin event no.: WI210010
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 - DOSE MISADMINISTRATION
The following information was received from the state of Wisconsin via email:
"On November 22, 2021, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on November 19, 2021. A patient had been prescribed two administrations to different segments of the liver of 126 Gy and 138 Gy. However, the licensee has estimated that the administered doses were 256 Gy (103 percent [over]) and 294 Gy (113 percent [over]). The administered doses had been ordered with an incorrect calibration date. A full dose projection is ongoing by the vendor. The State will perform a reactive inspection."
Wisconsin event no.: WI210010
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: 55600
Rep Org: California Radiation Control Prgm
Licensee: Regents of the University of CA-LA
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Bethany Cecere
Licensee: Regents of the University of CA-LA
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Bethany Cecere
Notification Date: 11/22/2021
Notification Time: 15:14 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [PST]
Last Update Date: 11/22/2021
Notification Time: 15:14 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [PST]
Last Update Date: 11/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 11/30/2021
EN Revision Text: AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following was received from the California Department of Public Health (CDPH) by email:
"On Saturday, November 20, 2021, at 0928 [PST], a CDPH-Radiologic Health Branch inspector was notified by e-mail that a medical event had occurred on Friday, November 19, 2021, at UCLA during a Y-90 liver cancer treatment. There were four liver segments being treated with four vials of Y-90 TheraSpheres. The prescribed dose for 'Segment 2' was 120 Gy, but the dose delivered was 74.9 Gy (or 62.42 percent of the prescribed dose). Segments 3, 6 and 8 were prescribed 120 Gy each and the doses delivered were 108.0 Gy, 110.9 Gy and 107.0 Gy (90 percent, 92.42 percent and 89.17 percent of the prescribed doses, respectively). Using the post treatment radiation surveys of the Nalgene waste container, a UCLA medical physicist determined that a medical event had occurred. The delivered dose to the organ differed by more than 20 percent from the prescribed dose.
"The authorized physician tried unsuccessfully to use a 2.0 Fr Truselect microcatheter for an hour to access the artery to segment 2, but it was extraordinarily small in caliber. He eventually chose to use a 1.7 Fr Echelon microcatheter for the treatment. Other treatment options were considered, but this particular tumor was in a location that was not amenable to ablation or chemoembolization. The patient will have a follow-up MRI scan in 3 months. A 15-day written report will be generated by the UCLA."
CA 5010 Number: 112021
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 - Y-90 UNDERDOSE
The following was received from the California Department of Public Health (CDPH) by email:
"On Saturday, November 20, 2021, at 0928 [PST], a CDPH-Radiologic Health Branch inspector was notified by e-mail that a medical event had occurred on Friday, November 19, 2021, at UCLA during a Y-90 liver cancer treatment. There were four liver segments being treated with four vials of Y-90 TheraSpheres. The prescribed dose for 'Segment 2' was 120 Gy, but the dose delivered was 74.9 Gy (or 62.42 percent of the prescribed dose). Segments 3, 6 and 8 were prescribed 120 Gy each and the doses delivered were 108.0 Gy, 110.9 Gy and 107.0 Gy (90 percent, 92.42 percent and 89.17 percent of the prescribed doses, respectively). Using the post treatment radiation surveys of the Nalgene waste container, a UCLA medical physicist determined that a medical event had occurred. The delivered dose to the organ differed by more than 20 percent from the prescribed dose.
"The authorized physician tried unsuccessfully to use a 2.0 Fr Truselect microcatheter for an hour to access the artery to segment 2, but it was extraordinarily small in caliber. He eventually chose to use a 1.7 Fr Echelon microcatheter for the treatment. Other treatment options were considered, but this particular tumor was in a location that was not amenable to ablation or chemoembolization. The patient will have a follow-up MRI scan in 3 months. A 15-day written report will be generated by the UCLA."
CA 5010 Number: 112021
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.
Non-Agreement State
Event Number: 55601
Rep Org: South Dakota State University
Licensee: South Dakota State University
Region: 4
City: Brookings State: SD
County:
License #: 40-02194-17
Agreement: N
Docket:
NRC Notified By: Gary Yarrow
HQ OPS Officer: Bethany Cecere
Licensee: South Dakota State University
Region: 4
City: Brookings State: SD
County:
License #: 40-02194-17
Agreement: N
Docket:
NRC Notified By: Gary Yarrow
HQ OPS Officer: Bethany Cecere
Notification Date: 11/22/2021
Notification Time: 16:56 [ET]
Event Date: 10/14/2021
Event Time: 00:00 [MST]
Last Update Date: 11/22/2021
Notification Time: 16:56 [ET]
Event Date: 10/14/2021
Event Time: 00:00 [MST]
Last Update Date: 11/22/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 11/30/2021
EN Revision Text: FOUND LICENSED RA-226 SOURCES
The following is a synopsis of a telephonic report from the RSO at South Dakota State University:
On about October 14, 2021, the University was contacted to collect two orphaned Ra-226 sources from a residence of a former employee. One source was within an Ionization Cell Model A-4149, the other was contained in a lead pig. Swipe surveys did not detect any leakage from the sources. Both sources are identical, 0.056 mCi Ra-226, Dated 09-66, Barber-Colman Company, Rockford, Illinois. There are no serial numbers to determine the original owner. The deceased employee also worked in the chemistry department at Southwest Minnesota State University.
The Radiation Safety Officer has properly secured the items and is herby notifying the NRC of the possession of this licensed material, which is allowed by their license.
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: FOUND LICENSED RA-226 SOURCES
The following is a synopsis of a telephonic report from the RSO at South Dakota State University:
On about October 14, 2021, the University was contacted to collect two orphaned Ra-226 sources from a residence of a former employee. One source was within an Ionization Cell Model A-4149, the other was contained in a lead pig. Swipe surveys did not detect any leakage from the sources. Both sources are identical, 0.056 mCi Ra-226, Dated 09-66, Barber-Colman Company, Rockford, Illinois. There are no serial numbers to determine the original owner. The deceased employee also worked in the chemistry department at Southwest Minnesota State University.
The Radiation Safety Officer has properly secured the items and is herby notifying the NRC of the possession of this licensed material, which is allowed by their license.
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: 55603
Rep Org: California Radiation Control Prgm
Licensee: City of Hope
Region: 4
City: Duarte State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: Ana Casaje
HQ OPS Officer: Brian P. Smith
Licensee: City of Hope
Region: 4
City: Duarte State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: Ana Casaje
HQ OPS Officer: Brian P. Smith
Notification Date: 11/23/2021
Notification Time: 19:43 [ET]
Event Date: 11/19/2021
Event Time: 19:45 [PST]
Last Update Date: 11/23/2021
Notification Time: 19:43 [ET]
Event Date: 11/19/2021
Event Time: 19:45 [PST]
Last Update Date: 11/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/1/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT
The following was a summary of an e-mail received by the state of California's Radiation Health Branch (RHB):
"The Radiation Safety Officer (RSO) at the licensee facility contacted the RHB and Los Angeles County Radiation Management (L.A. County) on November 22, 2021, to report a medical event. The event occurred on November 19, 2021. According to the RSO, a patient, who was part of a clinical trial, was under-dosed during a therapeutic treatment procedure for prostate cancer that involved the injection of actinium 225 (Ac-225) in the peripheral vein. The prescribed dose to the patient was 150 microcuries; however, the dose delivered was only 114 microcuries due to an accidental discharge of the radioisotope on the chux pad before it was administered to the patient. There was no spread of contamination. A site visit will be conducted to gain a better understanding of the details of the event."
California Event Number: 112221
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 - UNDERDOSE OF PATIENT
The following was a summary of an e-mail received by the state of California's Radiation Health Branch (RHB):
"The Radiation Safety Officer (RSO) at the licensee facility contacted the RHB and Los Angeles County Radiation Management (L.A. County) on November 22, 2021, to report a medical event. The event occurred on November 19, 2021. According to the RSO, a patient, who was part of a clinical trial, was under-dosed during a therapeutic treatment procedure for prostate cancer that involved the injection of actinium 225 (Ac-225) in the peripheral vein. The prescribed dose to the patient was 150 microcuries; however, the dose delivered was only 114 microcuries due to an accidental discharge of the radioisotope on the chux pad before it was administered to the patient. There was no spread of contamination. A site visit will be conducted to gain a better understanding of the details of the event."
California Event Number: 112221
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: 55614
Facility: Arkansas Nuclear
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Pete Draper
HQ OPS Officer: Karen Cotton-Gross
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Pete Draper
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/29/2021
Notification Time: 18:47 [ET]
Event Date: 11/29/2021
Event Time: 14:58 [CST]
Last Update Date: 11/29/2021
Notification Time: 18:47 [ET]
Event Date: 11/29/2021
Event Time: 14:58 [CST]
Last Update Date: 11/29/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Taylor, Nick (R4)
Taylor, Nick (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 12/1/2021
EN Revision Text: AUTOMATIC REACTOR TRIP
"On November 29, 2021 at 1458 CST, Arkansas Nuclear One, Unit 1, (ANO-1) automatically tripped due to high Reactor Coolant System pressure after the 'A' Main Feedwater Pump was manually tripped due to lowering speed.
"ANO-1 is currently stable in MODE 3 (Hot Standby) maintaining pressure and temperature with the P-75 Auxiliary Feedwater pump and steaming to the Condenser.
"There are no indications of a radiological release on either unit as a result of this event.
"This report satisfies the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A) for the Reactor Protection System actuation.
"The NRC Senior Resident Inspector has been notified."
Unit 2 was not affected.
EN Revision Text: AUTOMATIC REACTOR TRIP
"On November 29, 2021 at 1458 CST, Arkansas Nuclear One, Unit 1, (ANO-1) automatically tripped due to high Reactor Coolant System pressure after the 'A' Main Feedwater Pump was manually tripped due to lowering speed.
"ANO-1 is currently stable in MODE 3 (Hot Standby) maintaining pressure and temperature with the P-75 Auxiliary Feedwater pump and steaming to the Condenser.
"There are no indications of a radiological release on either unit as a result of this event.
"This report satisfies the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A) for the Reactor Protection System actuation.
"The NRC Senior Resident Inspector has been notified."
Unit 2 was not affected.
Agreement State
Event Number: 55604
Rep Org: Mississippi Div of Rad Health
Licensee: DAK Americas Mississippi
Region: 4
City: Bay St. Louis State: MS
County:
License #: MS-871-01
Agreement: Y
Docket:
NRC Notified By: Julia McRoberts
HQ OPS Officer: Ossy Font
Licensee: DAK Americas Mississippi
Region: 4
City: Bay St. Louis State: MS
County:
License #: MS-871-01
Agreement: Y
Docket:
NRC Notified By: Julia McRoberts
HQ OPS Officer: Ossy Font
Notification Date: 11/24/2021
Notification Time: 09:05 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Notification Time: 09:05 [ET]
Event Date: 11/19/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/1/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received via email from the Mississippi State Department of Health (the agency) via email:
"On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The [Berthold Technologies] reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300."
Mississippi Item Number: MS-210003
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received via email from the Mississippi State Department of Health (the agency) via email:
"On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The [Berthold Technologies] reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300."
Mississippi Item Number: MS-210003
Agreement State
Event Number: 55606
Rep Org: MA Radiation Control Program
Licensee: PerkinElmer, Inc.
Region: 1
City: Boston State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Lloyd Desotell
Licensee: PerkinElmer, Inc.
Region: 1
City: Boston State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: Tony Carpenito
HQ OPS Officer: Lloyd Desotell
Notification Date: 11/24/2021
Notification Time: 13:49 [ET]
Event Date: 11/17/2021
Event Time: 00:00 [EST]
Last Update Date: 11/24/2021
Notification Time: 13:49 [ET]
Event Date: 11/17/2021
Event Time: 00:00 [EST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1)
NMSS_Events_Notification, (EMAIL)
Defrancisco, Anne (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/1/2021
EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL MISSING IN TRANSIT THEN RECOVERED
The following was received from the Massachusetts Radiation Control Program [the Agency] via email:
"On 11/17/2021, 1113 EST, the licensee reported 3 packages containing radioactive material were not received at PerkinElmer facility in Groningen, Netherlands. Extensive searches were conducted in Boston, Amsterdam and Zurich. The packages were destined to arrive in Zurich on November 13, 2021. The 3 packages, each with a Transport Index 0.1, were shipped, along with 20 other excepted packages, from Logan International Airport in Boston, MA on 11/12/2021. The transfer of the packages was planned in the following sequence: Logan International Airport, Boston - Zurich - Amsterdam - Groningen, The Netherlands. All 23 packages were received in Zurich on November 13. Only 20 of the 23 packages were recorded as received in Amsterdam. The 3 missing packages were positively identified as the packages labeled as Yellow II with a TI of 0.1 each. The 3 packages contained the following radioactive material: Package 1 had 3 vials of P-32 with total activity of 1.5 mCi, Package 2 had 1 vial of I-125 at 0.160 mCi, and Package 3 had 1 vial of P-32 at 0.800 mCi. Each package was 25 cm x 15 cm x 13 cm in dimension and constructed of white cardboard with Styrofoam packing in shielded vials. A shipping manager at PerkinElmer, Inc., Boston, was first notified via email at 0719 EST on November 17 that the package was not received by the PerkinElmer facility in Groningen, Netherlands. The Radiation Safety Officer was first notified around 0900 EST. On November 19, the licensee notified the Agency that the 3 packages were found in Zurich.
"The Agency considers this matter closed. "
Massachusetts Event Number: 23-4724
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 - RADIOACTIVE MATERIAL MISSING IN TRANSIT THEN RECOVERED
The following was received from the Massachusetts Radiation Control Program [the Agency] via email:
"On 11/17/2021, 1113 EST, the licensee reported 3 packages containing radioactive material were not received at PerkinElmer facility in Groningen, Netherlands. Extensive searches were conducted in Boston, Amsterdam and Zurich. The packages were destined to arrive in Zurich on November 13, 2021. The 3 packages, each with a Transport Index 0.1, were shipped, along with 20 other excepted packages, from Logan International Airport in Boston, MA on 11/12/2021. The transfer of the packages was planned in the following sequence: Logan International Airport, Boston - Zurich - Amsterdam - Groningen, The Netherlands. All 23 packages were received in Zurich on November 13. Only 20 of the 23 packages were recorded as received in Amsterdam. The 3 missing packages were positively identified as the packages labeled as Yellow II with a TI of 0.1 each. The 3 packages contained the following radioactive material: Package 1 had 3 vials of P-32 with total activity of 1.5 mCi, Package 2 had 1 vial of I-125 at 0.160 mCi, and Package 3 had 1 vial of P-32 at 0.800 mCi. Each package was 25 cm x 15 cm x 13 cm in dimension and constructed of white cardboard with Styrofoam packing in shielded vials. A shipping manager at PerkinElmer, Inc., Boston, was first notified via email at 0719 EST on November 17 that the package was not received by the PerkinElmer facility in Groningen, Netherlands. The Radiation Safety Officer was first notified around 0900 EST. On November 19, the licensee notified the Agency that the 3 packages were found in Zurich.
"The Agency considers this matter closed. "
Massachusetts Event Number: 23-4724
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: 55607
Rep Org: NJ Dept of Environmental Protection
Licensee: Valley Hospital Luckow Pavilion
Region: 1
City: Paramus State: NJ
County:
License #: 425378
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Brian P. Smith
Licensee: Valley Hospital Luckow Pavilion
Region: 1
City: Paramus State: NJ
County:
License #: 425378
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Brian P. Smith
Notification Date: 11/24/2021
Notification Time: 14:23 [ET]
Event Date: 11/19/2021
Event Time: 12:00 [EST]
Last Update Date: 11/24/2021
Notification Time: 14:23 [ET]
Event Date: 11/19/2021
Event Time: 12:00 [EST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1)
NMSS_Events_Notification, (EMAIL)
Defrancisco, Anne (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/1/2021
EN Revision Text: AGREEMENT STATE REPORT - GAMMA KNIFE SHUTTER DOORS FAIL TO CLOSE
The following report was received via email from the New Jersey Department of Environmental Protection:
"While conducting the routine spot check prior to patient treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6114, the unit's shutter doors failed to close during the "Emergency Off" button test. The licensee's authorized medical physicist (AMP) followed emergency procedures and entered the room to manually close the doors. The doors closed, but the AMP decided to try again with the same result. The AMP carried a handheld survey meter with them each trip. Their calculated total exposure for their trips based on the exposure rate was 0.575 mR. There was no patient involvement. The unit is secured and Elekta is in the process repairing the unit. The licensee will follow-up with a full report."
EN Revision Text: AGREEMENT STATE REPORT - GAMMA KNIFE SHUTTER DOORS FAIL TO CLOSE
The following report was received via email from the New Jersey Department of Environmental Protection:
"While conducting the routine spot check prior to patient treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6114, the unit's shutter doors failed to close during the "Emergency Off" button test. The licensee's authorized medical physicist (AMP) followed emergency procedures and entered the room to manually close the doors. The doors closed, but the AMP decided to try again with the same result. The AMP carried a handheld survey meter with them each trip. Their calculated total exposure for their trips based on the exposure rate was 0.575 mR. There was no patient involvement. The unit is secured and Elekta is in the process repairing the unit. The licensee will follow-up with a full report."
Agreement State
Event Number: 55608
Rep Org: Texas Dept of State Health Services
Licensee: MEMORIAL HERMANN HEALTH SYSTEM
Region: 4
City: HOUSTON State: TX
County:
License #: L00650
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Licensee: MEMORIAL HERMANN HEALTH SYSTEM
Region: 4
City: HOUSTON State: TX
County:
License #: L00650
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Notification Date: 11/24/2021
Notification Time: 14:41 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Notification Time: 14:41 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 11/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/1/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the state of Texas (the Agency) via email:
"On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries.
Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9896
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 - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the state of Texas (the Agency) via email:
"On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries.
Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9896
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: 55616
Facility: Susquehanna
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Tom Rydzewski
HQ OPS Officer: Karen Cotton-Gross
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Tom Rydzewski
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/30/2021
Notification Time: 16:22 [ET]
Event Date: 11/30/2021
Event Time: 12:54 [EST]
Last Update Date: 11/30/2021
Notification Time: 16:22 [ET]
Event Date: 11/30/2021
Event Time: 12:54 [EST]
Last Update Date: 11/30/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Lally, Christopher (R1)
Lally, Christopher (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 80 | Power Operation | 0 | Hot Standby |
UNIT 1 AUTOMATIC SCRAM
"At 1254 EST on November 30, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed during Turbine Valve Cycling surveillance activities.
"Unit 1 reactor was being operated at approximately 80 percent rated thermal power with turbine valve cycling surveillance activities in progress. The Control Room received indication that both divisions of RPS [reactor protection system] actuated from turbine valve closure signals and all control rods fully inserted. The Main Turbine was manually tripped, and turbine bypass valves opened automatically to control reactor pressure. Reactor water level lowered to -35 inches causing Level 3 and Level 2 isolations. No ECCS [emergency core cooling systems] actuations occurred. RCIC [reactor core isolation cooling] automatically initiated as designed at -30 inches. The Operations crew subsequently maintained reactor water level at the normal operating band using Feedwater pumps and RCIC was placed in a standby lineup.
"The reactor is currently stable in Mode 3. An investigation is in progress into the cause of the turbine valve closure signals.
"The NRC Senior Resident Inspector was notified. A voluntary notification to PEMA [Pennsylvania Emergency Management Agency] will be made.
"This event requires a 4-hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8-hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A)."
Unit 2 was not affected and remains at 100 percent power, Mode 1.
"At 1254 EST on November 30, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed during Turbine Valve Cycling surveillance activities.
"Unit 1 reactor was being operated at approximately 80 percent rated thermal power with turbine valve cycling surveillance activities in progress. The Control Room received indication that both divisions of RPS [reactor protection system] actuated from turbine valve closure signals and all control rods fully inserted. The Main Turbine was manually tripped, and turbine bypass valves opened automatically to control reactor pressure. Reactor water level lowered to -35 inches causing Level 3 and Level 2 isolations. No ECCS [emergency core cooling systems] actuations occurred. RCIC [reactor core isolation cooling] automatically initiated as designed at -30 inches. The Operations crew subsequently maintained reactor water level at the normal operating band using Feedwater pumps and RCIC was placed in a standby lineup.
"The reactor is currently stable in Mode 3. An investigation is in progress into the cause of the turbine valve closure signals.
"The NRC Senior Resident Inspector was notified. A voluntary notification to PEMA [Pennsylvania Emergency Management Agency] will be made.
"This event requires a 4-hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8-hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A)."
Unit 2 was not affected and remains at 100 percent power, Mode 1.