Event Notification Report for March 17, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
03/16/2022 - 03/17/2022

!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55775
Facility: Davis Besse
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Robert Oesterle
HQ OPS Officer: Donald Norwood
Notification Date: 03/09/2022
Notification Time: 00:47 [ET]
Event Date: 03/08/2022
Event Time: 19:19 [EST]
Last Update Date: 03/16/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Hanna, John (R3DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: FITNESS-FOR-DUTY REPORT - CONTRACT SUPERVISOR FAILED FITNESS-FOR-DUTY TEST

The following information was provided by the licensee via phone and email:

A non-licensed, contract employee supervisor had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

* * * RETRACTION FROM GERALD WOLF TO DONALD NORWOOD AT 1448 EDT ON 3/16/2022 * * *

The following information was received from the licensee via E-mail:

"This is a retraction of EN55775. The measured Blood Alcohol Level (BAC) of the individual was below the Fitness-For-Duty program limits, so this event did not constitute a violation of the Fitness-For-Duty program.

"The NRC Resident Inspector has been notified."

Notified R3DO (Hills) and the FFD E-mail group.


Agreement State
Event Number: 55776
Rep Org: Texas Dept of State Health Services
Licensee: ISORX Texas Ltd
Region: 4
City: Lubbock   State: TX
County:
License #: L 05284
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Donald Norwood
Notification Date: 03/09/2022
Notification Time: 07:05 [ET]
Event Date: 01/26/2022
Event Time: 00:00 [CST]
Last Update Date: 03/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text:
AGREEMENT STATE REPORT - POSSIBLE OVER-EXPOSURE

The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:

"On January 26, 2022, the Agency was contacted by the licensee to report they had received an exposure report from its dosimetry processor and one of its employees had received 59.052 rem for December 2021. The licensee believes the exposure is to the badge only. The individual performed duties involving the preparation of iodine-131 therapy pills. The individual involved with the exposure had never received an exposure anywhere near this high in the past.

"The licensee reported the individual was involved in a spill during the preparation of a pill and the licensee believes the badge became contaminated during the spill cleanup. The licensee stated they do not survey the dosimetry prior to sending them to their processor. The license stated the employee wore the badge from December 5, 2021 until December 16, 2021 when they left employment at the licensee's facility. The Agency requested additional information on the event.

"On March 8, 2022, the Agency received the responses to the Agency's request from the licensee. In the response the licensee stated that the spill did restrict access to the area for more than 24 hours. The licensee stated its investigation determined the exposure recorded on the badge was a result of the badge becoming contaminated during the spill cleanup. The licensee also stated the dose assigned to the individual was 1.385 rem based on previous months exposures. The licensee stated the individual's workload had not changed compared to previous months. Additional information has been requested by the Agency. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9911


Agreement State
Event Number: 55777
Rep Org: New York State Dept. of Health
Licensee: Airtek Environmental Corporation
Region: 1
City: Bronx   State: NY
County:
License #: C2965
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Howie Crouch
Notification Date: 03/09/2022
Notification Time: 09:55 [ET]
Event Date: 01/26/2022
Event Time: 08:34 [EST]
Last Update Date: 03/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST THEN RECOVERED PORTABLE X-RAY FLUORESCENCE DEVICE

The following information was received from the state of New York via email:

"A portable XRF [x-ray fluorescence] device containing a 6 millicurie Cobalt-57 source was unintentionally left by an authorized user on a public bus in the Castle Hill neighborhood of the Bronx in New York City. Specific device information is below. The licensee contacted the MTA Police as well as Viken, the device manufacturer. The licensee was able to search the buses at the end of the day on January 26, 2022, but the device was not located at that time.

"According to the licensee an individual found the case with the device and contacted Viken. The representative at Viken was then able to get the individual in contact with the licensee. As of 1710 EST on January 27, 2022, the device is back in the licensee's possession and is in working order.

"Device Manufacturer: Viken
Device Model: Pb200i
Device S/N: 2219
Source Manufacturer: Isotope Products Laboratory
Source Model: Model 3901 Series
Source S/N: R4-672
Isotope: Cobalt-57
Activity: 6 millicuries"

NY incident no. NYDOH- 22-01

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: 55778
Rep Org: Tennessee Div of Rad Health
Licensee: Service King Collision Repair
Region: 1
City: Nashville   State: TN
County: Davidson
License #:
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Donald Norwood
Notification Date: 03/09/2022
Notification Time: 10:47 [ET]
Event Date: 03/04/2022
Event Time: 00:00 [EST]
Last Update Date: 03/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS

The following information was received from the Tennessee Division of Radiological Health:

"During a recent inventory at nine different locations of Service King Collision Repair Centers, 9 devices were found to be missing. The units were scheduled for disposal. Upon a search, all nine units were missing. According to company reports, the units were stolen from nine different locations. The nine units were used as static eliminators. It is believed that the static eliminators were stolen by staff. Updated information will be included in a follow-up report.

"The devices were all NRD model P-2021 containing 10 mCi of Po-210.

"Following are the license numbers and serial numbers of the devices:
GL-1195 (Marysville, TN) / SN A2LU555
GL-1198 (Columbia, TN) / SN A2LV463
GL-1199 (Murfreesboro, TN) / SN A2LV464
GL-1200 (Cool Springs, TN) / SN A2LV465
GL-1201 (Jackson, TN) / SN A2LW322
GL-1202 (Bartlett, TN) / SN A2LW325
GL-1204 (Germantown, TN) / SN A2LW327
GL-1205 (Mt. Moriah, TN) / SN A2LW364
1 unregistered (Nashville, TN) / SN A2L2321

Tennessee Event Report ID No.: TN-22-017

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: 55779
Rep Org: New Mexico Rad Control Program
Licensee: Chino Mines Company
Region: 4
City: Vanadium   State: NM
County: Grant
License #: ZA 045 46
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Dan Livermore
Notification Date: 03/09/2022
Notification Time: 16:26 [ET]
Event Date: 03/08/2022
Event Time: 00:00 [MST]
Last Update Date: 03/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGES SHUTTER FAILURES

The following information was provided by the New Mexico Radiation Control Bureau via telephone:

Two Berthold Model LB7440 density gauges installed in a mine were discovered to have shutters stuck in the open position during routine maintenance. The gauges (s/n: 1155 and s/n: DZ253A) contain a 30 millicurie and a 150 millicurie Cs-137 source, respectively, and remain mounted in place in the mine. The licensee is adding warning signage and is controlling any work in the area near the gauges. Radiation Technologies, a contracted service company, is scheduled to repair the gauges on March 21, 2022.


Agreement State
Event Number: 55781
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Elmhurst Hospital
Region: 3
City: Elmhurst   State: IL
County: DuPage
License #: IL-01612-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Dan Livermore
Notification Date: 03/10/2022
Notification Time: 17:10 [ET]
Event Date: 03/09/2022
Event Time: 00:00 [CST]
Last Update Date: 03/10/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Hanna, John (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The radiation safety officer (RSO) for Elmhurst Hospital contacted the Agency on 3/10/22 to advise of a Y-90 microsphere administration in which the patient received only 54 percent of the prescribed dose. The administration occurred on the morning of 3/9/22. The physician felt the delivered dose was clinically effective and no further treatment is planned. No adverse patient impacts are expected.

"The referring physician and patient were notified as required. Agency staff have requested copies of the written directive and associated documentation as details regarding the prescribed activity were not immediately available. Of note, the RSO advised that the authorized user felt resistance during administration and discontinued the procedure. Microspheres were reportedly observed `clumped' within the first two inches of the delivery catheter. A second, smaller vial was obtained and the written directive modified. No contamination or other issues were identified. The Agency will dispatch inspectors, likely at the beginning of next week, to review the procedure and determine root cause. Compliance with Agency regulations regarding modification to a written directive will be reviewed.

"This matter will be reported under NMED number IL220008."

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: 55782
Rep Org: Florida Bureau of Radiation Control
Licensee: H. Lee Moffitt Cancer Center
Region: 1
City: Tampa   State: FL
County: Hillsborough
License #: 1739-1
Agreement: Y
Docket:
NRC Notified By: Chris Brosius
HQ OPS Officer: Dan Livermore
Notification Date: 03/10/2022
Notification Time: 17:22 [ET]
Event Date: 03/10/2022
Event Time: 10:00 [EST]
Last Update Date: 03/10/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/17/2022

EN Revision Text: AGREEMENT STATE - LUTATHERA TREATMENT TERMINATED DUE TO INFUSION LINE LEAK

The following information was provided by the Florida Bureau of Radiation Control (FL BRC) via email:

"Today, 3/10/2022, at 1000 EST, Lutathera treatment was started in a controlled infusion room within the nuclear medicine department of Moffitt Cancer Center with an initial vial assay of 206 mCi, approximately two minutes later the NMT [(nuclear medicine technologist)] noticed a leak in the infusion line and stopped the infusion. Assistance was provided by a fellow technologist and the vial of Lutathera (Lu-177) was re-assayed at 130 mCi. The floor lead technologist notified the prescribing physician and the physician decided to terminate the treatment and to re-treat at a later date. Wipe tests performed by the technologists on the patient including the arm where the IV was showed no evidence of removable contamination. The department supervisor was notified and called the radiation safety officer (RSO) at 1030 EST. The IV was removed from the patient and the tubing was assayed at 36 mCi. The infusion room was surveyed and appropriately decontaminated. Residual waste from decontamination, as well as the vial, lead vial container, and IV/tubing were logged, labeled, and placed into secure storage. An investigation into the cause of the incident will be completed, and corrective actions will be implemented to prevent reoccurrence.

"The prescribing physician spoke with the patient and explained what happened and that there would not be any clinical impact on the patient and no medical risks.

"The referring physician was notified.

"A written report will be provided to the FL BRC, the referring physician, and the individual within 15 days of this event in accordance to 64E-5.345 4(b)."

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.

Page Last Reviewed/Updated Thursday, March 17, 2022