Event Notification Report for August 05, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
08/04/2022 - 08/05/2022

EVENT NUMBERS
56020 56021 56022 56028
Hospital
Event Number: 56020
Rep Org: VA National Health Physics Program
Licensee: Tibor Rubin VA Medical Center
Region: 3
City: Little Rock   State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Kim Wiebeck
HQ OPS Officer: Mike Stafford
Notification Date: 07/28/2022
Notification Time: 15:12 [ET]
Event Date: 07/27/2022
Event Time: 11:15 [PDT]
Last Update Date: 07/28/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
MEDICAL EVENT - PATIENT UNDERDOSE

The following report was received via email from the VA National Health Physics Program (NHPP):

"Tibor Rubin VA Medical Center, Long Beach, California, which holds Permit Number 04-00689-07 under the VA master materials license, reported the discovery of a medical event to NHPP at approximately 1450 CDT, July 27, 2022.

"A radium-223 dichloride (Xofigo(R)) therapy administration was performed at approximately 1115 PDT on July 27, 2022. The prescribed dosage was 211 microcuries, to be administered intravenously. Due to leakage at the IV 3-way stopcock, approximately only 160 microcuries was administered, resulting in about 75 percent of the prescribed dosage being delivered. This meets the reporting criteria of 10 CFR 35.3045 (a)(1)(i) and (a)(1)(i)(B).

"The patient and the referring physician have been notified. No harm is expected to the patient.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.

"NHPP notified our NRC Region III Project Manager, Bryan Parker."

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: 56021
Rep Org: Florida Bureau of Radiation Control
Licensee: Indian River County Emergency Operations Center
Region: 1
City: Vero Beach   State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Mark Seidensticker
HQ OPS Officer: Mike Stafford
Notification Date: 07/28/2022
Notification Time: 15:51 [ET]
Event Date: 07/28/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - SOURCES FOUND IN UNLOCKED CONTAINER

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

"Indian River County [Radiological Emergency Preparedness] (REP) [employee] called this afternoon regarding a small cardboard box, about half the size of a shoebox, with several sources inside being stored in a small, unlocked metal storage shed on property of the Emergency Operations Center. Inside the small cardboard box are six small cylindrical containers three of which are labeled `Unrefined uranium minerals emit alpha, beta, and gamma radiation', one 'No Salt' container, and the other three are smaller metal containers not labeled. Also in the box are several typical plastic check sources inside plastic bags and one wooden gamma standard check source. REP reported an 'on contact' reading with the box a dose rate of around 280 microR/hr and with a gloved hand, removed all the items inside the box and reported a contamination reading of just over 400 cpm. REP has requested a response from the BRC to handle. The Central Inspection Office has been notified and will respond."

Florida Incident Number: FL22-086


Non-Agreement State
Event Number: 56022
Rep Org: George Washington University
Licensee: George Washington University Hospital
Region: 1
City: Washington   State: DC
County:
License #: 08-30607-01
Agreement: N
Docket:
NRC Notified By: Sarah Mills
HQ OPS Officer: Mike Stafford
Notification Date: 07/29/2022
Notification Time: 12:52 [ET]
Event Date: 07/01/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/29/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
LOST IODINE-125 IMPLANT SEED

The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

On 7/1/22 a 200 microCurie I-125 implant seed was lost. The seed was discovered to be missing on 7/5/22. Licensee staff verified that the seed had arrived in the pathology lab. A survey of the lab was performed and showed that the seed was not in the lab, in the trash, in the sample, and did not remain in the patient. The licensee believes the seed was most likely washed down a drain.

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: 56028
Facility: Farley
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Gene Slone
HQ OPS Officer: Donald Norwood
Notification Date: 08/03/2022
Notification Time: 16:25 [ET]
Event Date: 08/03/2022
Event Time: 12:58 [CDT]
Last Update Date: 08/03/2022
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
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
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
Event Text
AUTOMATIC REACTOR TRIP DUE TO LOSS OF POWER TO START-UP TRANSFORMER

The following information was provided by the licensee via email:

"At 1258 CDT on August 3, 2022, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to the supply breakers of the 1B startup transformer opening. The fast dead bus transfer for the reactor coolant pumps did not occur during the event. Currently the plant is in Mode 3 on natural circulation.

"Operations responded and stabilized the plant. Decay heat is being removed by steaming with atmospheric relief valves. Unit 2 is not affected.

"An automatic actuation of the 1B diesel occurred because of the power loss to the 1G 4160V bus. Additionally, the actuation of motor driven and turbine driven auxiliary feedwater pumps (AFW) also occurred. AFW auto-start is an expected response from this reactor trip.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 1B diesel and the auxiliary feedwater system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, August 05, 2022