Event Notification Report for December 15, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/14/2021 - 12/15/2021
Power Reactor
Event Number: 55649
Facility: Harris
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Peter Pyon
HQ OPS Officer: Brian Lin
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Peter Pyon
HQ OPS Officer: Brian Lin
Notification Date: 12/15/2021
Notification Time: 16:45 [ET]
Event Date: 12/15/2021
Event Time: 09:27 [EST]
Last Update Date: 12/15/2021
Notification Time: 16:45 [ET]
Event Date: 12/15/2021
Event Time: 09:27 [EST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2)
FFD Group, (EMAIL)
Miller, Mark (R2)
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 |
EN Revision Imported Date: 1/14/2022
EN Revision Text: FAILED FITNESS FOR DUTY TEST
* The following information was provided by the licensee via email:
"At 0927 EST on December 15, 2021, it was determined that a non-licensed employee supervisor failed a test specified by the fitness for duty (FFD) testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified."
EN Revision Text: FAILED FITNESS FOR DUTY TEST
* The following information was provided by the licensee via email:
"At 0927 EST on December 15, 2021, it was determined that a non-licensed employee supervisor failed a test specified by the fitness for duty (FFD) testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55687
Rep Org: Florida Bureau of Radiation Control
Licensee: Horizon Medical Services
Region: 1
City: Tamarac State: FL
County:
License #: RAML 4
Agreement: Y
Docket:
NRC Notified By: Jason Nicholson
HQ OPS Officer: Ossy Font
Licensee: Horizon Medical Services
Region: 1
City: Tamarac State: FL
County:
License #: RAML 4
Agreement: Y
Docket:
NRC Notified By: Jason Nicholson
HQ OPS Officer: Ossy Font
Notification Date: 01/04/2022
Notification Time: 13:47 [ET]
Event Date: 12/15/2021
Event Time: 00:00 [EST]
Last Update Date: 01/04/2022
Notification Time: 13:47 [ET]
Event Date: 12/15/2021
Event Time: 00:00 [EST]
Last Update Date: 01/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Greives, Jonathan (R1)
NMSS_Events_Notification, (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Greives, Jonathan (R1)
NMSS_Events_Notification, (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
EN Revision Imported Date: 2/4/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO INCORRECT TREATMENT AREA
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
"On Friday, December 31, 2021, the Bureau was contacted by [the Radiation Safety Officer] to report a medical event at Horizon Medical Services that occurred on December 15, 2021. The medical event was the [high dose rate therapy] treatment of the incorrect hand using iridium-192 to a single dose fraction of 250 cGy [(250 rem)] to a depth of 3mm below the skin surface."
The licensee's report to the Bureau stated, "Remedial action included an immediate in-service discussion of this event with the entire clinical staff to verify the correct anatomical treatment site regarding all patient prescriptions. The patient has been informed of this medical event."
Florida Incident No.: FL 21-152
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 - MEDICAL EVENT DUE TO INCORRECT TREATMENT AREA
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
"On Friday, December 31, 2021, the Bureau was contacted by [the Radiation Safety Officer] to report a medical event at Horizon Medical Services that occurred on December 15, 2021. The medical event was the [high dose rate therapy] treatment of the incorrect hand using iridium-192 to a single dose fraction of 250 cGy [(250 rem)] to a depth of 3mm below the skin surface."
The licensee's report to the Bureau stated, "Remedial action included an immediate in-service discussion of this event with the entire clinical staff to verify the correct anatomical treatment site regarding all patient prescriptions. The patient has been informed of this medical event."
Florida Incident No.: FL 21-152
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 55652
Rep Org: U.S. Air Force
Licensee: U.S. Air Force
Region: 4
City: Albuquerque State: NM
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt Col Christina Peace
HQ OPS Officer: Mike Stafford
Licensee: U.S. Air Force
Region: 4
City: Albuquerque State: NM
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt Col Christina Peace
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 20:53 [ET]
Event Date: 12/15/2021
Event Time: 14:38 [MST]
Last Update Date: 02/06/2022
Notification Time: 20:53 [ET]
Event Date: 12/15/2021
Event Time: 14:38 [MST]
Last Update Date: 02/06/2022
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):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/4/2022
EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL
The following is a summary from a phone call with the licensee:
At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
* * * RETRACTION ON 02/06/2022 AT 2211 EST FROM CHRISTINA PEACE TO OSSY FONT * * *
The following retraction was received from the licensee via email:
"On December 15, 2021, [the licensee reported] telephonically about a leaking radium-226 source at the TS-1 site at Kirtland AFB, which prompted a radioactive material incident report. After further examination, the suspected radium dial was identified as a `Delco-Remy Ignition Unit.' Upon re-surveying the unit, only background readings were identified. Due to the newly discovered information, the [(Radioisotope Committee Secretariat)] RICS and Kirtland AFB request to retract the incident."
Notified R4DO (Josey) and NMSS Events Notification via email.
EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL
The following is a summary from a phone call with the licensee:
At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
* * * RETRACTION ON 02/06/2022 AT 2211 EST FROM CHRISTINA PEACE TO OSSY FONT * * *
The following retraction was received from the licensee via email:
"On December 15, 2021, [the licensee reported] telephonically about a leaking radium-226 source at the TS-1 site at Kirtland AFB, which prompted a radioactive material incident report. After further examination, the suspected radium dial was identified as a `Delco-Remy Ignition Unit.' Upon re-surveying the unit, only background readings were identified. Due to the newly discovered information, the [(Radioisotope Committee Secretariat)] RICS and Kirtland AFB request to retract the incident."
Notified R4DO (Josey) and NMSS Events Notification via email.