Event Notification Report for December 30, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/29/2021 - 12/30/2021
Agreement State
Event Number: 55683
Rep Org: Colorado Dept of Health
Licensee: Element Hotel
Region: 4
City: Superior State: CO
County:
License #: GL002594
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Lloyd Desotell
Licensee: Element Hotel
Region: 4
City: Superior State: CO
County:
License #: GL002594
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/03/2022
Notification Time: 12:46 [ET]
Event Date: 12/30/2021
Event Time: 00:00 [MST]
Last Update Date: 01/03/2022
Notification Time: 12:46 [ET]
Event Date: 12/30/2021
Event Time: 00:00 [MST]
Last Update Date: 01/03/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Roldan-Otero, Lizette (R4)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Roldan-Otero, Lizette (R4)
EN Revision Imported Date: 2/3/2022
EN Revision Text: AGREEMENT STATE REPORT - DESTROYED TRITIUM EXIT SIGNS
The following was sent by the state of Colorado by email:
"On 12/30/2021 - 12/31/2021, the Marshall wildfire damaged or destroyed nearly 1000 buildings in the towns of Superior and Louisville, Colorado. On 01/01/2022, Boulder County released a preliminary address list of affected properties. The Element Hotel is listed on the property list as destroyed. The Element Hotel has registered with Colorado 33 tritium exit signs. Based on photos of the Element Hotel, it is assumed that all 33 tritium exit signs were consumed and destroyed in the fire.
"Isotope: Hydrogen-3
"Manufacturer: Isolite Corporation
"Model: 2000
"Serial numbers: H118210, H118212 - H118241, H118243 - H118244
"Activity: 7.62 Ci per sign (251.46 Ci total)"
Event Report ID No.: CO220001
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 - DESTROYED TRITIUM EXIT SIGNS
The following was sent by the state of Colorado by email:
"On 12/30/2021 - 12/31/2021, the Marshall wildfire damaged or destroyed nearly 1000 buildings in the towns of Superior and Louisville, Colorado. On 01/01/2022, Boulder County released a preliminary address list of affected properties. The Element Hotel is listed on the property list as destroyed. The Element Hotel has registered with Colorado 33 tritium exit signs. Based on photos of the Element Hotel, it is assumed that all 33 tritium exit signs were consumed and destroyed in the fire.
"Isotope: Hydrogen-3
"Manufacturer: Isolite Corporation
"Model: 2000
"Serial numbers: H118210, H118212 - H118241, H118243 - H118244
"Activity: 7.62 Ci per sign (251.46 Ci total)"
Event Report ID No.: CO220001
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: 55744
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: The Carle Foundation Hospital
Region: 3
City: Urbana State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Karen Cotton-Gross
Licensee: The Carle Foundation Hospital
Region: 3
City: Urbana State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/17/2022
Notification Time: 15:02 [ET]
Event Date: 12/30/2021
Event Time: 00:00 [CST]
Last Update Date: 02/17/2022
Notification Time: 15:02 [ET]
Event Date: 12/30/2021
Event Time: 00:00 [CST]
Last Update Date: 02/17/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Riemer, Kenneth (R3)
NMSS_Events_Notification, (EMAIL)
Riemer, Kenneth (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/17/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following information was provided by the the state of Illinois via email:
"During a 2/16/22 inspection, inspectors discovered an unreported medical event at The Carle Foundation (IL-01156-01) that occurred on December 30, 2021. No adverse patient impact reported. This was reported to the Headquarters Operations Officers on 2/17/2022.
"DETAILS: Agency inspectors performed a routine inspection on 2/16/2022, of The Carle Foundation d/b/a The Carle Foundation Hospital. During a review of Y-90 Theraspheres procedures on the afternoon of 2/16/2022, inspectors noted an unreported medical event which occurred on December 30, 2021. Inspectors noted that on 12/30/2021, a written directive to deliver 0.30 GBq Y-90 Theraspheres to the left hepatic artery was prepared; however, only 0.11 GBq (37 percent) was delivered. The licensee reported using a smaller microcatheter than usual.
"No further treatment to the patient is planned. The authorized user advised that the dose delivered was medically satisfactory for this case.
"The event remains under investigation."
Item Number: IL220005
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 TO PATIENT
The following information was provided by the the state of Illinois via email:
"During a 2/16/22 inspection, inspectors discovered an unreported medical event at The Carle Foundation (IL-01156-01) that occurred on December 30, 2021. No adverse patient impact reported. This was reported to the Headquarters Operations Officers on 2/17/2022.
"DETAILS: Agency inspectors performed a routine inspection on 2/16/2022, of The Carle Foundation d/b/a The Carle Foundation Hospital. During a review of Y-90 Theraspheres procedures on the afternoon of 2/16/2022, inspectors noted an unreported medical event which occurred on December 30, 2021. Inspectors noted that on 12/30/2021, a written directive to deliver 0.30 GBq Y-90 Theraspheres to the left hepatic artery was prepared; however, only 0.11 GBq (37 percent) was delivered. The licensee reported using a smaller microcatheter than usual.
"No further treatment to the patient is planned. The authorized user advised that the dose delivered was medically satisfactory for this case.
"The event remains under investigation."
Item Number: IL220005
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.