Event Notification Report for September 30, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/29/2022 - 09/30/2022
Agreement State
Event Number: 56145
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Kerby Scales
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Kerby Scales
Notification Date: 10/05/2022
Notification Time: 14:58 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/07/2022
Notification Time: 14:58 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [CDT]
Last Update Date: 10/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Young, Matt (R1DO)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Young, Matt (R1DO)
AGREEMENT STATE REPORT - LOST SHIPMENT
The following was received from the Illinois Emergency Materials Agency (the Agency) via email:
"The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/5/22 indicating the loss of a package containing (10) ten I-125 brachytherapy seeds, accounting for a maximum estimated activity of 7.29 mCi (0.729 mCi per source). The package appears to have been lost at the [common carrier] warehouse in Vermont. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.
"DETAILS: On 9/30/2022, Bard Brachytherapy shipped two boxes to the University of Vermont Medical Center in Burlington, VT. One of the boxes, which contained (10) ten I-125 brachytherapy seeds did not arrive with the shipment. [The common carrier] initially reported that it was still in the VT warehouse. [The common carrier] reportedly conducted a search yesterday and did not find the package and notified Bard Brachytherapy this morning that it was lost."
Illinois Item Number: IL220038
* * * UPDATE ON 10/07/2022 AT 1233 EDT FROM GARY FORSEE TO LLOYD DESOTELL * * *
The following information was provided by the Illinois Emergency Management Agency via email:
"Licensee advised the common carrier located the package and confirmed delivery. This matter is considered closed."
Notified R3DO (Betancourt-Roldan) and R1DO (Ferdas). Notified via email: NMSS Event Notification and ILTAB
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 Illinois Emergency Materials Agency (the Agency) via email:
"The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/5/22 indicating the loss of a package containing (10) ten I-125 brachytherapy seeds, accounting for a maximum estimated activity of 7.29 mCi (0.729 mCi per source). The package appears to have been lost at the [common carrier] warehouse in Vermont. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.
"DETAILS: On 9/30/2022, Bard Brachytherapy shipped two boxes to the University of Vermont Medical Center in Burlington, VT. One of the boxes, which contained (10) ten I-125 brachytherapy seeds did not arrive with the shipment. [The common carrier] initially reported that it was still in the VT warehouse. [The common carrier] reportedly conducted a search yesterday and did not find the package and notified Bard Brachytherapy this morning that it was lost."
Illinois Item Number: IL220038
* * * UPDATE ON 10/07/2022 AT 1233 EDT FROM GARY FORSEE TO LLOYD DESOTELL * * *
The following information was provided by the Illinois Emergency Management Agency via email:
"Licensee advised the common carrier located the package and confirmed delivery. This matter is considered closed."
Notified R3DO (Betancourt-Roldan) and R1DO (Ferdas). Notified via email: NMSS Event Notification and ILTAB
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 56135
Facility: Saint Lucie
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Michael Croteau
HQ OPS Officer: Mike Stafford
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Michael Croteau
HQ OPS Officer: Mike Stafford
Notification Date: 09/30/2022
Notification Time: 17:13 [ET]
Event Date: 09/30/2022
Event Time: 16:08 [EDT]
Last Update Date: 11/11/2022
Notification Time: 17:13 [ET]
Event Date: 09/30/2022
Event Time: 16:08 [EDT]
Last Update Date: 11/11/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
EN Revision Imported Date: 11/14/2022
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1608 [EDT] on September 30, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw inside containment detected during plant pressurization in preparation for startup following a refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10CFR50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EDT ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/30/2022 at 1713 EDT (EN 56135).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH-109 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1608 [EDT] on September 30, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw inside containment detected during plant pressurization in preparation for startup following a refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10CFR50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EDT ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/30/2022 at 1713 EDT (EN 56135).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH-109 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
Power Reactor
Event Number: 56136
Facility: Arkansas Nuclear
Region: 4 State: AR
Unit: [1] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Mathew Goddard
HQ OPS Officer: Ian Howard
Region: 4 State: AR
Unit: [1] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Mathew Goddard
HQ OPS Officer: Ian Howard
Notification Date: 10/01/2022
Notification Time: 00:08 [ET]
Event Date: 09/30/2022
Event Time: 14:45 [CDT]
Last Update Date: 10/04/2022
Notification Time: 00:08 [ET]
Event Date: 09/30/2022
Event Time: 14:45 [CDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Kellar, Ray (R4DO)
FFD Group, (EMAIL)
Kellar, Ray (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 74 | Power Operation | 74 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT (FFD)
A supplemental supervisor violated the station's FFD policy. The individuals access to the plant has been terminated.
The licensee notified the NRC Senior Resident Inspector.
A supplemental supervisor violated the station's FFD policy. The individuals access to the plant has been terminated.
The licensee notified the NRC Senior Resident Inspector.
Agreement State
Event Number: 56300
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Vista Medical Center East
Region: 3
City: Waukegan State: IL
County:
License #: IL-01076-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton
Licensee: Vista Medical Center East
Region: 3
City: Waukegan State: IL
County:
License #: IL-01076-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton
Notification Date: 01/05/2023
Notification Time: 16:35 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [CST]
Last Update Date: 02/15/2023
Notification Time: 16:35 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [CST]
Last Update Date: 02/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 2/16/2023
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On December 28, 2022, the [Radiation Safety Officer] RSO for Vista Medical Center East (RML IL-01076-01, Waukegan IL) emailed a letter to the Agency indicating a nuclear medicine technologist received a whole body dose of approximately 11,307 millirem over the third quarter of 2022. The licensee initiated an investigation and does not believe the exposures indicated on the employee's badge represent a true dose to the nuclear medicine technologist. However, no clear evidence has been provided to the Agency that yet substantiates the licensee's position. As such, the Agency is currently treating this as a reportable occupational exposure. Based on the information available, this exposure does not appear to be related to contamination events, exposure to radiation-producing machines, or a single static exposure to a stationary source. The employee, reportedly, is not working at other licensed facilities. The last seven years of dosimetry for this employee consistently show total annual occupational exposures at or near 10% of the annual limits. Job duties have reportedly not changed.
"Agency inspectors will conduct a reactionary inspection on Monday, January 9, 2023. Inspectors will pursue any additional data which may support the licensee's claims that this was not an overexposure incident. The appropriateness of the technologists continued duties under the license, and sustained occupational exposures, will then be reviewed. Finally, inspectors will review noncompliance with Agency rules for timely reporting (32 Ill. Adm. Code 340.1230)."
Illinois Report Item Number: IL230001
* * * UPDATE ON 2/15/2023 AT 1128 EST FROM GARY FORSEE TO ERNEST WEST * * *
"Agency inspectors conducted a reactionary inspection on January 9, 2023, to pursue any additional data which may support the licensee's claims that this was not an overexposure incident and to review the appropriateness of the technologists continued duties under the license and sustained occupational exposures. Inspectors also reviewed noncompliance with Agency rules for timely reporting (32 Ill. Adm. Code 340.1230).
"Expressed concerns of potential tampering and/or intentional exposure of badges were investigated. However, no evidence could be provided and the licensee elected not to make a formal allegation. No additional information to support the licensee's claims that the exposure was not valid were obtained during the 1/9/2023, reactionary inspection or through additional documentation provided to the Agency. As such the exposures will remain on the individual's exposure record as reported. Inspectors initiated dialogue with the dosimetry processor to determine root cause. Contamination seems unlikely as the dosimeters are screened for gamma radiation upon intake, however, the processor believes the badges were exposed to angular, shielded or collimated radiation. Re-analysis supported the initial exposure reports. The licensee was cited for failing to report timely, failing to limit occupational doses to 5 rem, failing to restrict the employee's additional occupational exposures for the remainder of the year, and failure of the RSO to initiate timely investigation. Required written report received 1/27/23. Pending satisfactory address of the Notice of Violation, this matter may be considered closed."
Notified R3DO (Dickson) and NMSS Events Notification via email
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On December 28, 2022, the [Radiation Safety Officer] RSO for Vista Medical Center East (RML IL-01076-01, Waukegan IL) emailed a letter to the Agency indicating a nuclear medicine technologist received a whole body dose of approximately 11,307 millirem over the third quarter of 2022. The licensee initiated an investigation and does not believe the exposures indicated on the employee's badge represent a true dose to the nuclear medicine technologist. However, no clear evidence has been provided to the Agency that yet substantiates the licensee's position. As such, the Agency is currently treating this as a reportable occupational exposure. Based on the information available, this exposure does not appear to be related to contamination events, exposure to radiation-producing machines, or a single static exposure to a stationary source. The employee, reportedly, is not working at other licensed facilities. The last seven years of dosimetry for this employee consistently show total annual occupational exposures at or near 10% of the annual limits. Job duties have reportedly not changed.
"Agency inspectors will conduct a reactionary inspection on Monday, January 9, 2023. Inspectors will pursue any additional data which may support the licensee's claims that this was not an overexposure incident. The appropriateness of the technologists continued duties under the license, and sustained occupational exposures, will then be reviewed. Finally, inspectors will review noncompliance with Agency rules for timely reporting (32 Ill. Adm. Code 340.1230)."
Illinois Report Item Number: IL230001
* * * UPDATE ON 2/15/2023 AT 1128 EST FROM GARY FORSEE TO ERNEST WEST * * *
"Agency inspectors conducted a reactionary inspection on January 9, 2023, to pursue any additional data which may support the licensee's claims that this was not an overexposure incident and to review the appropriateness of the technologists continued duties under the license and sustained occupational exposures. Inspectors also reviewed noncompliance with Agency rules for timely reporting (32 Ill. Adm. Code 340.1230).
"Expressed concerns of potential tampering and/or intentional exposure of badges were investigated. However, no evidence could be provided and the licensee elected not to make a formal allegation. No additional information to support the licensee's claims that the exposure was not valid were obtained during the 1/9/2023, reactionary inspection or through additional documentation provided to the Agency. As such the exposures will remain on the individual's exposure record as reported. Inspectors initiated dialogue with the dosimetry processor to determine root cause. Contamination seems unlikely as the dosimeters are screened for gamma radiation upon intake, however, the processor believes the badges were exposed to angular, shielded or collimated radiation. Re-analysis supported the initial exposure reports. The licensee was cited for failing to report timely, failing to limit occupational doses to 5 rem, failing to restrict the employee's additional occupational exposures for the remainder of the year, and failure of the RSO to initiate timely investigation. Required written report received 1/27/23. Pending satisfactory address of the Notice of Violation, this matter may be considered closed."
Notified R3DO (Dickson) and NMSS Events Notification via email
Agreement State
Event Number: 56312
Rep Org: Arizona Dept of Health Services
Licensee: HonorHealth Shea
Region: 4
City: Scottsdale State: AZ
County:
License #: 07-265
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Lloyd Desotell
Licensee: HonorHealth Shea
Region: 4
City: Scottsdale State: AZ
County:
License #: 07-265
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/18/2023
Notification Time: 13:34 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [MST]
Last Update Date: 01/18/2023
Notification Time: 13:34 [ET]
Event Date: 09/30/2022
Event Time: 00:00 [MST]
Last Update Date: 01/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"The Department identified a possible medical event involving Y-90 Sir-Spheres during a routine inspection. A patient was prescribed an activity of 0.05 GBq (1.45 mCi) but was delivered 0.02 GBq (0.53 mCi), a percent dose delivered of 36.55 percent. The procedure date was 9/30/2022. The Department has requested additional information and continues to investigate the event."
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 Arizona Department of Health Services (the Department) via email:
"The Department identified a possible medical event involving Y-90 Sir-Spheres during a routine inspection. A patient was prescribed an activity of 0.05 GBq (1.45 mCi) but was delivered 0.02 GBq (0.53 mCi), a percent dose delivered of 36.55 percent. The procedure date was 9/30/2022. The Department has requested additional information and continues to investigate the event."
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.