Event Notification Report for April 18, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/17/2022 - 04/18/2022
Agreement State
Event Number: 55832
Rep Org: WA Office of Radiation Protection
Licensee: US Ecology Washington Inc.
Region: 4
City: Richland State: WA
County:
License #: WN-I019-2
Agreement: Y
Docket:
NRC Notified By: Gregorio Rosado
HQ OPS Officer: Brian Lin
Licensee: US Ecology Washington Inc.
Region: 4
City: Richland State: WA
County:
License #: WN-I019-2
Agreement: Y
Docket:
NRC Notified By: Gregorio Rosado
HQ OPS Officer: Brian Lin
Notification Date: 04/08/2022
Notification Time: 14:10 [ET]
Event Date: 04/07/2022
Event Time: 14:40 [PDT]
Last Update Date: 04/08/2022
Notification Time: 14:10 [ET]
Event Date: 04/07/2022
Event Time: 14:40 [PDT]
Last Update Date: 04/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PROPORTIONAL COUNTER FAILURE
The following information was received from the Washington State Department of Health via email:
"The Radiation Protection Manager (RPM) for US Ecology (USE) notified the Washington State Department of Health (WDOH) on April 7, 2022, at 1440 PDT, of equipment which failed to function as designed in accordance with WAC 246-221-250 (2)(d). This was identified during an internal surveillance of the calibration program by the licensee. Specifically, the equipment is a Canberra Series 5 Extreme Low Background Alpha Beta Proportional counter (XLB). The spreadsheet used to calculate alpha efficiency to determine alpha activity from smears and air samples was off by 1 percent. The error for this matter will require USE to review all data from September 2021 through April 6, 2022. The preliminary cause was identified as a human performance error. An investigation is ongoing to determine the impact to health and safety. WDOH is planning a follow up investigation the week of May 9, 2022, to follow up for this matter. No media attention currently."
WA incident no.: WMS-INC-22-01
EN Revision Text: AGREEMENT STATE REPORT - PROPORTIONAL COUNTER FAILURE
The following information was received from the Washington State Department of Health via email:
"The Radiation Protection Manager (RPM) for US Ecology (USE) notified the Washington State Department of Health (WDOH) on April 7, 2022, at 1440 PDT, of equipment which failed to function as designed in accordance with WAC 246-221-250 (2)(d). This was identified during an internal surveillance of the calibration program by the licensee. Specifically, the equipment is a Canberra Series 5 Extreme Low Background Alpha Beta Proportional counter (XLB). The spreadsheet used to calculate alpha efficiency to determine alpha activity from smears and air samples was off by 1 percent. The error for this matter will require USE to review all data from September 2021 through April 6, 2022. The preliminary cause was identified as a human performance error. An investigation is ongoing to determine the impact to health and safety. WDOH is planning a follow up investigation the week of May 9, 2022, to follow up for this matter. No media attention currently."
WA incident no.: WMS-INC-22-01
Agreement State
Event Number: 55833
Rep Org: NC Div of Radiation Protection
Licensee: Kleinfelder
Region: 1
City: Charlotte State: NC
County:
License #: 060-0712-2
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Mike Stafford
Licensee: Kleinfelder
Region: 1
City: Charlotte State: NC
County:
License #: 060-0712-2
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Mike Stafford
Notification Date: 04/11/2022
Notification Time: 11:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Notification Time: 11:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE
The following was received via an email from the state of North Carolina:
"A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box.
"An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report."
North Carolina Tracking Number: 220003.
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 - STOLEN GAUGE
The following was received via an email from the state of North Carolina:
"A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box.
"An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report."
North Carolina Tracking Number: 220003.
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: 55835
Rep Org: Colorado Dept of Health
Licensee: Service King #342
Region: 4
City: Thornton State: CO
County:
License #: GL002621
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Bethany Cecere
Licensee: Service King #342
Region: 4
City: Thornton State: CO
County:
License #: GL002621
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Bethany Cecere
Notification Date: 04/11/2022
Notification Time: 17:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 04/11/2022
Notification Time: 17:20 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [MDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following information was provided by the state of Colorado via email:
"Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found.
"Isotope: Po-210
Manufacturer: NRD, LLC.
Model: P-2021
Device: Static Eliminator
Serial number: A2LT196
Activity: .01 Ci"
CO Event Report ID No.: CO220009
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 - LOST STATIC ELIMINATOR
The following information was provided by the state of Colorado via email:
"Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found.
"Isotope: Po-210
Manufacturer: NRD, LLC.
Model: P-2021
Device: Static Eliminator
Serial number: A2LT196
Activity: .01 Ci"
CO Event Report ID No.: CO220009
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
Power Reactor
Event Number: 55843
Facility: North Anna
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Bob Page
HQ OPS Officer: Kerby Scales
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Bob Page
HQ OPS Officer: Kerby Scales
Notification Date: 04/14/2022
Notification Time: 11:18 [ET]
Event Date: 04/14/2022
Event Time: 09:28 [EDT]
Last Update Date: 04/14/2022
Notification Time: 11:18 [ET]
Event Date: 04/14/2022
Event Time: 09:28 [EDT]
Last Update Date: 04/14/2022
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):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| 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 |
AUTOMATIC REACTOR TRIP DURING CONTROL ROD TESTING
The following information was provided by the licensee via email:
"On April 14, 2022, at 0928 [EDT] hours, Unit 1 automatically tripped from 100 percent power during the control rod operability periodic test. The reactor trip occurred during the manipulation of the rod control mode selector switch as part of the rod operability testing. The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated, and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The Auxiliary Feedwater pumps actuated as designed because of the reactor trip and provide makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater system is reportable per 10 CFR 50.72(b)(3)(iv) (A) for a valid actuation of an ESF [Engineered Safety Features] system. The Auxiliary Feedwater pumps were subsequently secured and returned to automatic. Decay heat is being removed by the condenser steam dump system. Unit 1 is in a normal shutdown electrical lineup. An investigation into the cause of the reactor trip is underway."
The NRC Resident Inspector has been notified.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
There was no affect to Unit 2. Unit 2 is operating at 100 percent power.
The following information was provided by the licensee via email:
"On April 14, 2022, at 0928 [EDT] hours, Unit 1 automatically tripped from 100 percent power during the control rod operability periodic test. The reactor trip occurred during the manipulation of the rod control mode selector switch as part of the rod operability testing. The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated, and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The Auxiliary Feedwater pumps actuated as designed because of the reactor trip and provide makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater system is reportable per 10 CFR 50.72(b)(3)(iv) (A) for a valid actuation of an ESF [Engineered Safety Features] system. The Auxiliary Feedwater pumps were subsequently secured and returned to automatic. Decay heat is being removed by the condenser steam dump system. Unit 1 is in a normal shutdown electrical lineup. An investigation into the cause of the reactor trip is underway."
The NRC Resident Inspector has been notified.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
There was no affect to Unit 2. Unit 2 is operating at 100 percent power.
Power Reactor
Event Number: 55844
Facility: Pilgrim
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: David Noyes
HQ OPS Officer: Brian Parks
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: David Noyes
HQ OPS Officer: Brian Parks
Notification Date: 04/15/2022
Notification Time: 11:31 [ET]
Event Date: 04/15/2022
Event Time: 10:00 [EDT]
Last Update Date: 04/15/2022
Notification Time: 11:31 [ET]
Event Date: 04/15/2022
Event Time: 10:00 [EDT]
Last Update Date: 04/15/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Cahill, Christopher (R1DO)
Cahill, Christopher (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
NOTIFICATION OF ENVIRONMENTAL REPORT TO ANOTHER GOVERNMENT AGENCY
The following information was provided by the licensee via email:
"On April 15, 2022 at 1000 hours (EDT), four off-site notifications were made to the Commonwealth of Massachusetts Department of Environmental ÿProtection (MADEP) in accordance with the Massachusetts Contingency Plan (310 CMR 40.0000). ÿThe notifications document non-radiological contaminants found slightly above reportable concentrations in select soil and groundwater samples collected during site characterization efforts, as part of the decommissioning process, from four parcels of land at the property.ÿ ÿReportable concentrations in soil were identified in a composite sample for Polychlorinated Biphenyls (PCBs). ÿReportable concentrations in groundwater were identified in samples for per- and polyfluoroalkyl substances (PFAS) and Semi Volatile Organic Compound (SVOC). Additionally, the reports include sample results where laboratory reporting limits equaled or exceeded reporting thresholds. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency in accordance with 10 CFR 50.72(b)(2)(xi).ÿ There was no impact on the health and safety of the public or plant personnel. The NRC Lead Decommissioning Inspector and NMSS Project Manager assigned to Pilgrim have been notified."
The following information was provided by the licensee via email:
"On April 15, 2022 at 1000 hours (EDT), four off-site notifications were made to the Commonwealth of Massachusetts Department of Environmental ÿProtection (MADEP) in accordance with the Massachusetts Contingency Plan (310 CMR 40.0000). ÿThe notifications document non-radiological contaminants found slightly above reportable concentrations in select soil and groundwater samples collected during site characterization efforts, as part of the decommissioning process, from four parcels of land at the property.ÿ ÿReportable concentrations in soil were identified in a composite sample for Polychlorinated Biphenyls (PCBs). ÿReportable concentrations in groundwater were identified in samples for per- and polyfluoroalkyl substances (PFAS) and Semi Volatile Organic Compound (SVOC). Additionally, the reports include sample results where laboratory reporting limits equaled or exceeded reporting thresholds. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency in accordance with 10 CFR 50.72(b)(2)(xi).ÿ There was no impact on the health and safety of the public or plant personnel. The NRC Lead Decommissioning Inspector and NMSS Project Manager assigned to Pilgrim have been notified."
Agreement State
Event Number: 55838
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Isomedix Operations, Inc.
Region: 3
City: Libertyville State: IL
County:
License #: IL-01123-02
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Lloyd Desotell
Licensee: Isomedix Operations, Inc.
Region: 3
City: Libertyville State: IL
County:
License #: IL-01123-02
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/12/2022
Notification Time: 12:38 [ET]
Event Date: 04/11/2022
Event Time: 12:00 [CDT]
Last Update Date: 04/12/2022
Notification Time: 12:38 [ET]
Event Date: 04/11/2022
Event Time: 12:00 [CDT]
Last Update Date: 04/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.
"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.
"No personnel injuries or exposures and no adverse effects on the security system were reported."
Item Number: IL220011
EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.
"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.
"No personnel injuries or exposures and no adverse effects on the security system were reported."
Item Number: IL220011
Agreement State
Event Number: 55839
Rep Org: Texas Dept of State Health Services
Licensee: Qal Tek Associates LLC
Region: 4
City: Round Rock State: TX
County: Williamson
License #: L05965
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Brian Parks
Licensee: Qal Tek Associates LLC
Region: 4
City: Round Rock State: TX
County: Williamson
License #: L05965
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Brian Parks
Notification Date: 04/12/2022
Notification Time: 16:37 [ET]
Event Date: 03/25/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/12/2022
Notification Time: 16:37 [ET]
Event Date: 03/25/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - SOURCE NOT SECURE WITHIN GAUGE
The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:
"On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite.
Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300."
Texas Incident Number: I-9925
EN Revision Text: AGREEMENT STATE REPORT - SOURCE NOT SECURE WITHIN GAUGE
The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:
"On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite.
Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300."
Texas Incident Number: I-9925
Agreement State
Event Number: 55840
Rep Org: California Radiation Control Prgm
Licensee: Loma Linda University Health
Region: 4
City: Loma Linda State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Mike Stafford
Licensee: Loma Linda University Health
Region: 4
City: Loma Linda State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Mike Stafford
Notification Date: 04/12/2022
Notification Time: 19:47 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/12/2022
Notification Time: 19:47 [ET]
Event Date: 04/11/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED
The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:
"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."
California Event Number: 041222
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 - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED
The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:
"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."
California Event Number: 041222
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.