Event Notification Report for March 23, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/22/2023 - 03/23/2023
Agreement State
Event Number: 56412
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Hackensack University Medical Ctr
Region: 1
City: Hackensack State: NJ
County:
License #: 450695
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Bill Gott
Licensee: Hackensack University Medical Ctr
Region: 1
City: Hackensack State: NJ
County:
License #: 450695
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Bill Gott
Notification Date: 03/15/2023
Notification Time: 13:17 [ET]
Event Date: 03/14/2023
Event Time: 00:00 [EDT]
Last Update Date: 03/16/2023
Notification Time: 13:17 [ET]
Event Date: 03/14/2023
Event Time: 00:00 [EDT]
Last Update Date: 03/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT TREATMENT SUSPENDED PRIOR TO COMPLETION
The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email:
"While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report."
NJ Event Report ID number: NJ-23-0001
* * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *
"Additional information has been obtained related to the initial notification provided on 3/15/23.
"The dose administered to the patient was only approximately 2.9 percent of the dose prescribed.
"The prescribed dose was 15 Gy.
"The unit malfunctioned after only 3 of the planned 13 shots was completed.
"14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred.
"This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a)."
Notified R1DO (Bickett) and NMSS Events Notification.
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 New Jersey Department of Environmental Protection (DEP) via email:
"While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report."
NJ Event Report ID number: NJ-23-0001
* * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *
"Additional information has been obtained related to the initial notification provided on 3/15/23.
"The dose administered to the patient was only approximately 2.9 percent of the dose prescribed.
"The prescribed dose was 15 Gy.
"The unit malfunctioned after only 3 of the planned 13 shots was completed.
"14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred.
"This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a)."
Notified R1DO (Bickett) and NMSS Events Notification.
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: 56416
Rep Org: New Mexico Rad Control Program
Licensee: Chino Mines
Region: 4
City: Bayard State: NM
County:
License #: GA 045 47
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Bill Gott
Licensee: Chino Mines
Region: 4
City: Bayard State: NM
County:
License #: GA 045 47
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Bill Gott
Notification Date: 03/16/2023
Notification Time: 17:04 [ET]
Event Date: 03/15/2023
Event Time: 16:22 [MDT]
Last Update Date: 03/16/2023
Notification Time: 17:04 [ET]
Event Date: 03/15/2023
Event Time: 16:22 [MDT]
Last Update Date: 03/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER FAILURE
The following is a summary of the information provided by the New Mexico Radiation Control Bureau via telephone:
A Berthold Model LB7440 density gauge (serial number 2110) installed in a mine was discovered to have a shutter stuck in the open position while removing the gauge from service. The gauge contains a 20 millicurie Cs-137 source. The licensee installed shielding on the gauge and placed it in a storage container. Radiation surveys around the container are between 0.032 and 0.0525 millirem. An authorized service company is scheduled to repair the gauge on March 27, 2023.
The following is a summary of the information provided by the New Mexico Radiation Control Bureau via telephone:
A Berthold Model LB7440 density gauge (serial number 2110) installed in a mine was discovered to have a shutter stuck in the open position while removing the gauge from service. The gauge contains a 20 millicurie Cs-137 source. The licensee installed shielding on the gauge and placed it in a storage container. Radiation surveys around the container are between 0.032 and 0.0525 millirem. An authorized service company is scheduled to repair the gauge on March 27, 2023.
Agreement State
Event Number: 56418
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Notification Date: 03/17/2023
Notification Time: 14:57 [ET]
Event Date: 03/08/2023
Event Time: 22:47 [CDT]
Last Update Date: 03/17/2023
Notification Time: 14:57 [ET]
Event Date: 03/08/2023
Event Time: 22:47 [CDT]
Last Update Date: 03/17/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST PACKAGES
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified the evening of 3/16/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of two radiopharmaceutical packages that were missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and both have been declared as lost. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. TN and TX program officials have been notified as well. Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC with a required call to the [NRC] Headquarters Operations Officer. Details on the packages are as follows:
"Package 1:
[The package] shipped 3/8/23 to Doctor's Hospital at Renaissance in Edinburg, TX. [The package] contained (1) 10mL shielded vial of I-123. Package activity at the time of shipment was 14.3 mCi. [The package contains] 0.0002 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 2247 CDT on 3/8/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2:
[The package] shipped 3/10/23 to Panhandle Nuclear in Amarillo, TX. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package contains] 0.585 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received."
IL Event Number: IL230007
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 information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified the evening of 3/16/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of two radiopharmaceutical packages that were missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and both have been declared as lost. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. TN and TX program officials have been notified as well. Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC with a required call to the [NRC] Headquarters Operations Officer. Details on the packages are as follows:
"Package 1:
[The package] shipped 3/8/23 to Doctor's Hospital at Renaissance in Edinburg, TX. [The package] contained (1) 10mL shielded vial of I-123. Package activity at the time of shipment was 14.3 mCi. [The package contains] 0.0002 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 2247 CDT on 3/8/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2:
[The package] shipped 3/10/23 to Panhandle Nuclear in Amarillo, TX. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package contains] 0.585 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received."
IL Event Number: IL230007
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: 56419
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Notification Date: 03/17/2023
Notification Time: 16:47 [ET]
Event Date: 03/11/2023
Event Time: 00:09 [CDT]
Last Update Date: 03/17/2023
Notification Time: 16:47 [ET]
Event Date: 03/11/2023
Event Time: 00:09 [CDT]
Last Update Date: 03/17/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Nguyen, April (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST PACKAGES
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"Shortly after reporting the first two missing packages (see EN56418), the Agency was contacted on 3/17/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of a third radiopharmaceutical package that went missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and the package was declared as lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. TN and AL program officials were notified. Details are provided below.
"Package Details:
[The package] shipped on 3/10/23 to Cardinal Health in Birmingham, AL. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package] contains 0.563 mCi [as of 3/17/2023, 1647 EDT]. The last scan occurred at 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC with a required call to the NRC Headquarters Operations Officer."
IL Event Number: IL230008
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 information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"Shortly after reporting the first two missing packages (see EN56418), the Agency was contacted on 3/17/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of a third radiopharmaceutical package that went missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and the package was declared as lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. TN and AL program officials were notified. Details are provided below.
"Package Details:
[The package] shipped on 3/10/23 to Cardinal Health in Birmingham, AL. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package] contains 0.563 mCi [as of 3/17/2023, 1647 EDT]. The last scan occurred at 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received.
"Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC with a required call to the NRC Headquarters Operations Officer."
IL Event Number: IL230008
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: 56428
Facility: River Bend
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Devin Wilson
HQ OPS Officer: Donald Norwood
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Devin Wilson
HQ OPS Officer: Donald Norwood
Notification Date: 03/23/2023
Notification Time: 16:46 [ET]
Event Date: 03/14/2023
Event Time: 09:26 [CDT]
Last Update Date: 03/23/2023
Notification Time: 16:46 [ET]
Event Date: 03/14/2023
Event Time: 09:26 [CDT]
Last Update Date: 03/23/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
O'Keefe, Neil (R4DO)
FFD Group, (EMAIL)
O'Keefe, Neil (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Power Operation | 0 | Power Operation |
FITNESS-FOR-DUTY REPORT - SUBVERSION OF THE FFD PROCESS
A non-licensed contract supervisor was confirmed to have violated the FFD policy by attempting to subvert the testing process. The individual's authorization for site access was immediately terminated.
The licensee notified the R4 Branch Chief (Josey)
A non-licensed contract supervisor was confirmed to have violated the FFD policy by attempting to subvert the testing process. The individual's authorization for site access was immediately terminated.
The licensee notified the R4 Branch Chief (Josey)
Power Reactor
Event Number: 56430
Facility: Susquehanna
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert Bingman
HQ OPS Officer: Brian P. Smith
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert Bingman
HQ OPS Officer: Brian P. Smith
Notification Date: 03/23/2023
Notification Time: 20:40 [ET]
Event Date: 03/23/2023
Event Time: 17:36 [EDT]
Last Update Date: 03/23/2023
Notification Time: 20:40 [ET]
Event Date: 03/23/2023
Event Time: 17:36 [EDT]
Last Update Date: 03/23/2023
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):
Werkheiser, Dave (R1DO)
Werkheiser, Dave (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
EMERGENCY DIESEL GENERATOR ACTUATION
The following information was provided by the licensee via email:
"At 1736 EDT on March 23, 2023, during overcurrent testing of the '2B' [Emergency Safeguards System] ESS Bus, the work group was re-installing tested relays and inadvertently caused a '2B' ESS Bus lockout. This resulted in the '2B' ESS Bus deenergizing and a valid start signal provided to the 'B' Emergency Diesel Generator [EDG]. The 'B' EDG started and functioned as designed.
"This is being reported as an Unplanned Actuation of Systems that Mitigate the Consequences of Significant Events in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 1736 EDT on March 23, 2023, during overcurrent testing of the '2B' [Emergency Safeguards System] ESS Bus, the work group was re-installing tested relays and inadvertently caused a '2B' ESS Bus lockout. This resulted in the '2B' ESS Bus deenergizing and a valid start signal provided to the 'B' Emergency Diesel Generator [EDG]. The 'B' EDG started and functioned as designed.
"This is being reported as an Unplanned Actuation of Systems that Mitigate the Consequences of Significant Events in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."