Event Notification Report for May 06, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/05/2022 - 05/06/2022
Agreement State
Event Number: 55886
Rep Org: Texas Dept of State Health Services
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: 00 00466
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Jeffrey Whited
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: 00 00466
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/06/2022
Notification Time: 17:08 [ET]
Event Date: 05/06/2022
Event Time: 00:00 [CDT]
Last Update Date: 05/06/2022
Notification Time: 17:08 [ET]
Event Date: 05/06/2022
Event Time: 00:00 [CDT]
Last Update Date: 05/06/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Warnick, Greg (R4DO)
NMSS_Events_Notification, (EMAIL)
Warnick, Greg (R4DO)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - THREE MEDICAL EVENTS - UNDERDOSES
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: I-9931
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 Texas Department of State Health Services (the Agency) via email:
"On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: I-9931
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: 55887
Rep Org: MA Radiation Control Program
Licensee: Thermo Scientific P.A.I., Inc.
Region: 1
City: Tewksbury State: MA
County:
License #: 55-0238
Agreement: Y
Docket:
NRC Notified By: Ellie Choi
HQ OPS Officer: Ossy Font
Licensee: Thermo Scientific P.A.I., Inc.
Region: 1
City: Tewksbury State: MA
County:
License #: 55-0238
Agreement: Y
Docket:
NRC Notified By: Ellie Choi
HQ OPS Officer: Ossy Font
Notification Date: 05/06/2022
Notification Time: 17:21 [ET]
Event Date: 05/06/2022
Event Time: 12:00 [EDT]
Last Update Date: 05/06/2022
Notification Time: 17:21 [ET]
Event Date: 05/06/2022
Event Time: 12:00 [EDT]
Last Update Date: 05/06/2022
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 - LEAKING SEALED SOURCE
The following was received from the Massachusetts Radiation Control Program (the "Agency") via email:
"On 05/06/2022, at 1340 EDT, the Agency received a call from RSO [Radiation Safety Officer] at Thermo Scientific Portable Analytical Instrument, Inc. (the `licensee') reporting a leaking sealed source. The 20-year-old source/device (Thermo Scientific Portable Analytical Instruments, Inc.; Model XLi 969; Device s/n 5243; Source s/n EG-8804) is currently containing 0.12 mCi of Fe-55 (original activity was 20 mCi on 04/07/2002). The RSO received the leak test report on 05/06/2022 and he noticed that the source is leaking as 0.0058 microcuries of removal activity which is in excess of regulatory limits (0.005 microcuries). This device was sent to the licensee for decommissioning and was received from the licensee's customer on 04/21/2022. The source was removed from the device as part of decommissioning. There was no external contamination spread outside of the device or surrounding work area surfaces. The source will be secured and properly disposed of in accordance with the regulations."
The following was received from the Massachusetts Radiation Control Program (the "Agency") via email:
"On 05/06/2022, at 1340 EDT, the Agency received a call from RSO [Radiation Safety Officer] at Thermo Scientific Portable Analytical Instrument, Inc. (the `licensee') reporting a leaking sealed source. The 20-year-old source/device (Thermo Scientific Portable Analytical Instruments, Inc.; Model XLi 969; Device s/n 5243; Source s/n EG-8804) is currently containing 0.12 mCi of Fe-55 (original activity was 20 mCi on 04/07/2002). The RSO received the leak test report on 05/06/2022 and he noticed that the source is leaking as 0.0058 microcuries of removal activity which is in excess of regulatory limits (0.005 microcuries). This device was sent to the licensee for decommissioning and was received from the licensee's customer on 04/21/2022. The source was removed from the device as part of decommissioning. There was no external contamination spread outside of the device or surrounding work area surfaces. The source will be secured and properly disposed of in accordance with the regulations."
Power Reactor
Event Number: 55888
Facility: Oconee
Region: 2 State: SC
Unit: [3] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: L.C. Hayes
HQ OPS Officer: Brian P. Smith
Region: 2 State: SC
Unit: [3] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: L.C. Hayes
HQ OPS Officer: Brian P. Smith
Notification Date: 05/07/2022
Notification Time: 04:37 [ET]
Event Date: 05/06/2022
Event Time: 23:10 [EDT]
Last Update Date: 05/07/2022
Notification Time: 04:37 [ET]
Event Date: 05/06/2022
Event Time: 23:10 [EDT]
Last Update Date: 05/07/2022
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):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Hot Standby | 0 | Hot Standby |
AUTOMATIC ACTUATION OF EMERGENCY FEEDWATER
The following information was provided by the licensee via fax:
"At 2310 EDT on May 6, 2022, with Unit 3 in Mode 3, an actuation of the Emergency Feedwater (EFW) System occurred while entering a planned refueling outage. The reason for the EFW auto-start was a loss of all Main Feedwater (MFDW) Pumps which occurred when the 3A MFDW Pump tripped on steam generator (SG) overfill protection due to high level in the 3B SG. The high level in the 3B SG occurred when a Startup Feedwater Control Valve (3FDW-44) malfunctioned, resulting in excessive feedwater flow to the 3B SG. Investigation and repairs are in progress. Units 1 and 2 were not affected.
"This event is being reported as an 8-hr non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via fax:
"At 2310 EDT on May 6, 2022, with Unit 3 in Mode 3, an actuation of the Emergency Feedwater (EFW) System occurred while entering a planned refueling outage. The reason for the EFW auto-start was a loss of all Main Feedwater (MFDW) Pumps which occurred when the 3A MFDW Pump tripped on steam generator (SG) overfill protection due to high level in the 3B SG. The high level in the 3B SG occurred when a Startup Feedwater Control Valve (3FDW-44) malfunctioned, resulting in excessive feedwater flow to the 3B SG. Investigation and repairs are in progress. Units 1 and 2 were not affected.
"This event is being reported as an 8-hr non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."