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: 55621
Rep Org: Arizona Dept of Health Services
Licensee: Honor Health dba Deer Valley Medical Center
Region: 4
City: Phoenix State: AZ
County:
License #: 07-311
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Mike Stafford
Licensee: Honor Health dba Deer Valley Medical Center
Region: 4
City: Phoenix State: AZ
County:
License #: 07-311
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Mike Stafford
Notification Date: 12/02/2021
Notification Time: 18:12 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [MST]
Last Update Date: 12/02/2021
Notification Time: 18:12 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [MST]
Last Update Date: 12/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
CNSNS (Mexico), - (FAX)
Taylor, Nick (R4)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
CNSNS (Mexico), - (FAX)
EN Revision Imported Date: 12/30/2021
EN Revision Text: AGREEMENT STATE - LOST I-125 SEED
The following was received from the Arizona Department of Health Services (the Department) via email:
"On December 1, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed [approximately 0.4 mCi] was removed by surgery on 11/30/2021 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 11/30/21. When a nuclear medicine technologist went to retrieve the seed from pathology, the technologist noticed only a marker and not an actual seed. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the missing I-125 seed. The Department has requested additional information and continues to investigate the event."
Arizona Incident Number 21-012
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 - LOST I-125 SEED
The following was received from the Arizona Department of Health Services (the Department) via email:
"On December 1, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed [approximately 0.4 mCi] was removed by surgery on 11/30/2021 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 11/30/21. When a nuclear medicine technologist went to retrieve the seed from pathology, the technologist noticed only a marker and not an actual seed. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the missing I-125 seed. The Department has requested additional information and continues to investigate the event."
Arizona Incident Number 21-012
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 55617
Rep Org: Virginia Rad Materials Program
Licensee: Sentara Norfolk General Hospital
Region: 1
City: Norfolk State: VA
County:
License #: 710-189-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Gerond George
Licensee: Sentara Norfolk General Hospital
Region: 1
City: Norfolk State: VA
County:
License #: 710-189-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Gerond George
Notification Date: 12/01/2021
Notification Time: 14:49 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [EST]
Last Update Date: 12/09/2021
Notification Time: 14:49 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [EST]
Last Update Date: 12/09/2021
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: 1/7/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the Commonwealth of Virginia (the Agency) via email:
"On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."
Virginia Event Report ID No.: VA210008
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 12/09/21 AT 1555 EST FROM ASFAW FENTA TO KAREN COTTON-GROSS * * *
The following retraction was received via email from VA; RMP:
"On December 6, 2021, the RMP investigated the case and determined that the procedure was terminated due to emergent patient conditions (artery spasm). The licensee revised the written directive within 24 hours after the termination of the procedure. This incident did not meet the criteria of medical event reporting. [RMP] requests to retract this report."
Notified R1DO (Dentel) and NMSS Events Notifications via email.
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT
The following was received from the Commonwealth of Virginia (the Agency) via email:
"On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."
Virginia Event Report ID No.: VA210008
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 12/09/21 AT 1555 EST FROM ASFAW FENTA TO KAREN COTTON-GROSS * * *
The following retraction was received via email from VA; RMP:
"On December 6, 2021, the RMP investigated the case and determined that the procedure was terminated due to emergent patient conditions (artery spasm). The licensee revised the written directive within 24 hours after the termination of the procedure. This incident did not meet the criteria of medical event reporting. [RMP] requests to retract this report."
Notified R1DO (Dentel) and NMSS Events Notifications via email.
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 |
EN Revision Imported Date: 12/30/2021
EN Revision Text: 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.
EN Revision Text: 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.
Agreement State
Event Number: 55618
Rep Org: Arizona Dept of Health Services
Licensee: Intel Corporation
Region: 4
City: Chandler State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Mike Stafford
Licensee: Intel Corporation
Region: 4
City: Chandler State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Mike Stafford
Notification Date: 12/01/2021
Notification Time: 17:10 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [MST]
Last Update Date: 12/01/2021
Notification Time: 17:10 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [MST]
Last Update Date: 12/01/2021
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: 12/30/2021
EN Revision Text: AGREEMENT STATE - LEAK TEST EXCEEDS LIMITS
The following was received from the Arizona Department of Health Services (the Department) via email:
"On November 30, 2021, the Department received notification from the licensee of a leak test (0.0129 microCi) that exceeded the regulatory limit of 0.005 microCi. The licensee is going to return it to the manufacturer for repair. The Department has requested additional information and continues to investigate the event.
"Particle Measurement System, Inc.
Air Sentry II Ion Mobility Spectrometer unit
SN# 59369
Cell SN5935
10 mCi of Ni-63"
Arizona Incident Number 21-011
EN Revision Text: AGREEMENT STATE - LEAK TEST EXCEEDS LIMITS
The following was received from the Arizona Department of Health Services (the Department) via email:
"On November 30, 2021, the Department received notification from the licensee of a leak test (0.0129 microCi) that exceeded the regulatory limit of 0.005 microCi. The licensee is going to return it to the manufacturer for repair. The Department has requested additional information and continues to investigate the event.
"Particle Measurement System, Inc.
Air Sentry II Ion Mobility Spectrometer unit
SN# 59369
Cell SN5935
10 mCi of Ni-63"
Arizona Incident Number 21-011
Agreement State
Event Number: 55629
Rep Org: Florida Bureau of Radiation Control
Licensee: Nova Engineering
Region: 1
City: Orlando State: FL
County:
License #: 4603-1
Agreement: Y
Docket:
NRC Notified By: Reno Fabii
HQ OPS Officer: Bethany Cecere
Licensee: Nova Engineering
Region: 1
City: Orlando State: FL
County:
License #: 4603-1
Agreement: Y
Docket:
NRC Notified By: Reno Fabii
HQ OPS Officer: Bethany Cecere
Notification Date: 11/30/2021
Notification Time: 10:24 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [EST]
Last Update Date: 12/08/2021
Notification Time: 10:24 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [EST]
Last Update Date: 12/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 1/7/2022
EN Revision Text: AGREEMENT STATE REPORT - MISSING TROXLER GAUGE
The following was received from the state of Florida by email:
"Received a call from Atlantic Drilling Supply Co. about a missing Troxler gauge (#21834) which has sent to his company for service. The gauge was shipped to the old address of the customer, NOVA Engineering in Tallahassee, FL vice the new address. The shipper cannot locate the gauge. Gauge was shipped 11/18/21 and scheduled for delivery 11/19/21. Gauge was reported missing to Atlantic drilling 11/29/21.
"As of 11/30/21, at 1035 EST, the shipper has found the Troxler gauge on their loading dock and will deliver it to the correct address."
FL Incident number FL21-139
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 - MISSING TROXLER GAUGE
The following was received from the state of Florida by email:
"Received a call from Atlantic Drilling Supply Co. about a missing Troxler gauge (#21834) which has sent to his company for service. The gauge was shipped to the old address of the customer, NOVA Engineering in Tallahassee, FL vice the new address. The shipper cannot locate the gauge. Gauge was shipped 11/18/21 and scheduled for delivery 11/19/21. Gauge was reported missing to Atlantic drilling 11/29/21.
"As of 11/30/21, at 1035 EST, the shipper has found the Troxler gauge on their loading dock and will deliver it to the correct address."
FL Incident number FL21-139
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: 55700
Rep Org: Wisconsin Radiation Protection
Licensee: KCS International Inc
Region: 3
City: Oconto State: WI
County:
License #: GL36868
Agreement: Y
Docket:
NRC Notified By: Luther Loehrke
HQ OPS Officer: Thomas Kendzia
Licensee: KCS International Inc
Region: 3
City: Oconto State: WI
County:
License #: GL36868
Agreement: Y
Docket:
NRC Notified By: Luther Loehrke
HQ OPS Officer: Thomas Kendzia
Notification Date: 01/10/2022
Notification Time: 17:47 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [CST]
Last Update Date: 01/10/2022
Notification Time: 17:47 [ET]
Event Date: 11/30/2021
Event Time: 00:00 [CST]
Last Update Date: 01/10/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB (EMAIL)
CNSC (Canada), - (EMAIL)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB (EMAIL)
CNSC (Canada), - (EMAIL)
EN Revision Imported Date: 2/10/2022
EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATOR DEVICE
The following information was received from the Wisconsin Department of Health Services (DHS) via email:
"On January 10, 2022, DHS received a letter from the licensee stating that a generally licensed static eliminator device, originally shipped to them November 2, 2020, had been missing since November 2021. Activity data was not provided; however, DHS records indicate that all devices at this location contain 10 mCi of Po-210 upon receipt. The licensee did not answer the phone to confirm the written notification information. DHS will continue attempts to contact the licensee and a site inspection will be performed as soon as practical."
Wisconsin Event Number: WI220001
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 - MISSING STATIC ELIMINATOR DEVICE
The following information was received from the Wisconsin Department of Health Services (DHS) via email:
"On January 10, 2022, DHS received a letter from the licensee stating that a generally licensed static eliminator device, originally shipped to them November 2, 2020, had been missing since November 2021. Activity data was not provided; however, DHS records indicate that all devices at this location contain 10 mCi of Po-210 upon receipt. The licensee did not answer the phone to confirm the written notification information. DHS will continue attempts to contact the licensee and a site inspection will be performed as soon as practical."
Wisconsin Event Number: WI220001
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