Event Notification Report for May 04, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/03/2022 - 05/04/2022
Agreement State
Event Number: 55882
Rep Org: Utah Division of Radiation Control
Licensee: Central Utah Clinic, Revere Health
Region: 4
City: Provo State: UT
County:
License #: UT 2500361
Agreement: Y
Docket:
NRC Notified By: Gwyn Galloway
HQ OPS Officer: Lloyd Desotell
Licensee: Central Utah Clinic, Revere Health
Region: 4
City: Provo State: UT
County:
License #: UT 2500361
Agreement: Y
Docket:
NRC Notified By: Gwyn Galloway
HQ OPS Officer: Lloyd Desotell
Notification Date: 05/05/2022
Notification Time: 15:00 [ET]
Event Date: 05/04/2022
Event Time: 13:00 [MDT]
Last Update Date: 05/05/2022
Notification Time: 15:00 [ET]
Event Date: 05/04/2022
Event Time: 13:00 [MDT]
Last Update Date: 05/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION
The following was received from the Utah Department of Environmental Quality (the Division) via email:
"At approximately 1030 MDT, the [Radiation Safety Officer] for the licensee notified the Division that a patient had been administered an isotope to perform a PET scan. The technician double checked with the ordering physician and found that the order was supposed to have been for a CT scan, not a PET scan. The order received showed it was a PET scan. An investigation is being conducted to see how the order was changed.
"The patient was administered about 10.6 mCi of FDG when a CT scan was to be performed. Therefore, the dose was greater than 20 percent of the prescribed dose. The order received by the radiology department showed that a PET scan had been ordered. The TEDE to the patient was less than 5 rem and the highest organ dose (to the bladder wall), was less than 50 rem. The patient was administered the FDG at about 1300 EDT on May 4, 2022. The FDG was allowed to decay and the patient was later given a CT exam.
"At this time, this is all the information that the Division has, an investigation will be conducted, and an update will be provided at a later date."
Event Report ID No.: UT220004
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.
The following was received from the Utah Department of Environmental Quality (the Division) via email:
"At approximately 1030 MDT, the [Radiation Safety Officer] for the licensee notified the Division that a patient had been administered an isotope to perform a PET scan. The technician double checked with the ordering physician and found that the order was supposed to have been for a CT scan, not a PET scan. The order received showed it was a PET scan. An investigation is being conducted to see how the order was changed.
"The patient was administered about 10.6 mCi of FDG when a CT scan was to be performed. Therefore, the dose was greater than 20 percent of the prescribed dose. The order received by the radiology department showed that a PET scan had been ordered. The TEDE to the patient was less than 5 rem and the highest organ dose (to the bladder wall), was less than 50 rem. The patient was administered the FDG at about 1300 EDT on May 4, 2022. The FDG was allowed to decay and the patient was later given a CT exam.
"At this time, this is all the information that the Division has, an investigation will be conducted, and an update will be provided at a later date."
Event Report ID No.: UT220004
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: 55877
Rep Org: California Radiation Control Prgm
Licensee: Eckert and Ziegler Isotope Products Inc.
Region: 4
City: Valencia State: CA
County:
License #: 1509-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Ossy Font
Licensee: Eckert and Ziegler Isotope Products Inc.
Region: 4
City: Valencia State: CA
County:
License #: 1509-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Ossy Font
Notification Date: 05/04/2022
Notification Time: 20:47 [ET]
Event Date: 05/04/2022
Event Time: 00:00 [PDT]
Last Update Date: 05/04/2022
Notification Time: 20:47 [ET]
Event Date: 05/04/2022
Event Time: 00:00 [PDT]
Last Update Date: 05/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST GD-153 LINE SOURCES
The following was received from the California Department of Public Health, Radiologic Health Branch via email:
"On May 4, 2022, the Radiation Safety Officer for Eckert & Ziegler Isotope Products, Inc. (EZIP) contacted Los Angeles County Radiation Management regarding two missing sources. Pennsylvania licensee Abington Jefferson Health, located in North Wales, PA, shipped a package on October 21, 2021, and [the common carrier] tracking information indicated the package was delivered to EZIP with no receipt signature on October 22, 2021. Abington Jefferson Health contacted EZIP on November 10, 2021, requesting a receipt for confirmation of the returned sources. The sources were two gadolinium-153 line sources, with approximately 13 millicuries (mCi) each (greater than 1000 times the Appendix C value of 10 microCi). EZIP did not have a record of receipt of the package, and a search of the EZIP facility did not find the sources.
"The notification to Los Angeles County Radiation Management by EZIP was delayed due to confusion by EZIP regarding whether the package had been returned to Abington Jefferson Health by [the common carrier]."
5010 Number: 050422
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
The following was received from the California Department of Public Health, Radiologic Health Branch via email:
"On May 4, 2022, the Radiation Safety Officer for Eckert & Ziegler Isotope Products, Inc. (EZIP) contacted Los Angeles County Radiation Management regarding two missing sources. Pennsylvania licensee Abington Jefferson Health, located in North Wales, PA, shipped a package on October 21, 2021, and [the common carrier] tracking information indicated the package was delivered to EZIP with no receipt signature on October 22, 2021. Abington Jefferson Health contacted EZIP on November 10, 2021, requesting a receipt for confirmation of the returned sources. The sources were two gadolinium-153 line sources, with approximately 13 millicuries (mCi) each (greater than 1000 times the Appendix C value of 10 microCi). EZIP did not have a record of receipt of the package, and a search of the EZIP facility did not find the sources.
"The notification to Los Angeles County Radiation Management by EZIP was delayed due to confusion by EZIP regarding whether the package had been returned to Abington Jefferson Health by [the common carrier]."
5010 Number: 050422
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: 55878
Facility: Palo Verde
Region: 4 State: AZ
Unit: [2] [3] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Joshua McDowell
HQ OPS Officer: Brian P. Smith
Region: 4 State: AZ
Unit: [2] [3] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Joshua McDowell
HQ OPS Officer: Brian P. Smith
Notification Date: 05/05/2022
Notification Time: 04:30 [ET]
Event Date: 05/04/2022
Event Time: 19:55 [MST]
Last Update Date: 05/05/2022
Notification Time: 04:30 [ET]
Event Date: 05/04/2022
Event Time: 19:55 [MST]
Last Update Date: 05/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Warnick, Greg (R4DO)
Warnick, Greg (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
VALID ACTUATION OF UNIT 2 AND UNIT 3 EMERGENCY DIESEL GENERATORS AND UNIT 3 AUXILIARY FEEDWATER PUMP
The following information was provided by the licensee via email:
"At 1955 on May 4, 2022, a start-up transformer de-energized, resulting in a loss of power to the Unit 2 Train A 4.16 kV Class 1E Bus and the Unit 3 Train B 4.16 kV Class 1E Bus. The Unit 2 Train A Emergency Diesel Generator (EDG) and Unit 3 Train B EDG automatically started and energized their respective 4.16 kV Class 1E Buses.
"As a result of the Loss of Power on the Unit 3 Train B 4.16 kV Class 1E Bus, the B Auxiliary Feedwater Pump automatically started, as expected. The B Auxiliary Feedwater Pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The B Auxiliary Feedwater Pump did not supply feedwater to the steam generators.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems and an auxiliary feedwater system."
The following information was provided by the licensee via email:
"At 1955 on May 4, 2022, a start-up transformer de-energized, resulting in a loss of power to the Unit 2 Train A 4.16 kV Class 1E Bus and the Unit 3 Train B 4.16 kV Class 1E Bus. The Unit 2 Train A Emergency Diesel Generator (EDG) and Unit 3 Train B EDG automatically started and energized their respective 4.16 kV Class 1E Buses.
"As a result of the Loss of Power on the Unit 3 Train B 4.16 kV Class 1E Bus, the B Auxiliary Feedwater Pump automatically started, as expected. The B Auxiliary Feedwater Pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The B Auxiliary Feedwater Pump did not supply feedwater to the steam generators.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems and an auxiliary feedwater system."
Agreement State
Event Number: 55889
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Karen Cotton-Gross
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 05/07/2022
Notification Time: 09:54 [ET]
Event Date: 05/04/2022
Event Time: 00:00 [EDT]
Last Update Date: 05/07/2022
Notification Time: 09:54 [ET]
Event Date: 05/04/2022
Event Time: 00:00 [EDT]
Last Update Date: 05/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
AGREEMENT STATE REPORT - UNDERDOSE
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (Department) via fax:
"On May 6, 2022, the University of Pennsylvania informed the Department of an underdose incident on May 4, 2022, involving yttrium-90 (Y90) SIR-Spheres. A patient underwent a Y90 SIR-Sphere treatment and the catheter placement changed during a SIR-Spheres administration and the Authorized User intentionally stopped the administration as continuing could have resulted in harm to the patient. The administered activity was 67 percent of the prescribed activity (15.1 mCi vs 22.51 mCi). The Department will perform a reactive inspection and is currently in contact with the University of Pennsylvania. The event will be updated this as soon as more information is provided. It is reportable as per 10 CFR 35.3045(a)(1)(i)."
Pennsylvania Report Number: PA220017
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.
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (Department) via fax:
"On May 6, 2022, the University of Pennsylvania informed the Department of an underdose incident on May 4, 2022, involving yttrium-90 (Y90) SIR-Spheres. A patient underwent a Y90 SIR-Sphere treatment and the catheter placement changed during a SIR-Spheres administration and the Authorized User intentionally stopped the administration as continuing could have resulted in harm to the patient. The administered activity was 67 percent of the prescribed activity (15.1 mCi vs 22.51 mCi). The Department will perform a reactive inspection and is currently in contact with the University of Pennsylvania. The event will be updated this as soon as more information is provided. It is reportable as per 10 CFR 35.3045(a)(1)(i)."
Pennsylvania Report Number: PA220017
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: 55880
Rep Org: Texas Dept of State Health Services
Licensee: Fargo Consultants Inc.
Region: 4
City: Dallas State: TX
County:
License #: L05300
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Brian P. Smith
Licensee: Fargo Consultants Inc.
Region: 4
City: Dallas State: TX
County:
License #: L05300
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 05/05/2022
Notification Time: 08:14 [ET]
Event Date: 05/04/2022
Event Time: 12:00 [CDT]
Last Update Date: 05/05/2022
Notification Time: 08:14 [ET]
Event Date: 05/04/2022
Event Time: 12:00 [CDT]
Last Update Date: 05/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Warnick, Greg (R4DO)
AGREEMENT STATE REPORT - GAUGE STRUCK AND DAMAGED BY BULLDOZER
The following was received from the Texas Department of State Health Services [the Agency] via email:
"On May 4, 2022, the licensee's radiation safety officer contacted the Agency and reported one of it's Humboldt 5001EZ gauges containing an 8 millicurie cs-137 source and a 40 mCi am-241 source had been struck by a bulldozer at a temporary field site. The gauge was damaged, and the licensee stated their engineer was going to the site to inspect and recover the gauge. The RSO contacted the Agency later that day and stated the source was in the shielded position and readings on contact with the transport case was 5 millirem an hour and 2 millirem an hour at three feet. The licensee transported the gauge back to it's facility. The licensee contacted it's service provider who will dispose of the gauge. No significant exposures were received as a result of this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number I-9930
The following was received from the Texas Department of State Health Services [the Agency] via email:
"On May 4, 2022, the licensee's radiation safety officer contacted the Agency and reported one of it's Humboldt 5001EZ gauges containing an 8 millicurie cs-137 source and a 40 mCi am-241 source had been struck by a bulldozer at a temporary field site. The gauge was damaged, and the licensee stated their engineer was going to the site to inspect and recover the gauge. The RSO contacted the Agency later that day and stated the source was in the shielded position and readings on contact with the transport case was 5 millirem an hour and 2 millirem an hour at three feet. The licensee transported the gauge back to it's facility. The licensee contacted it's service provider who will dispose of the gauge. No significant exposures were received as a result of this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number I-9930