Event Notification Report for May 09, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/08/2023 - 05/09/2023
Agreement State
Event Number: 56548
Rep Org: North Carolina Department of Health
Licensee: The Breast Center of Greensboro
Region: 1
City: Greensboro State: NC
County:
License #: 041-1542-1
Agreement: Y
Docket:
NRC Notified By: Tawny Morgan
HQ OPS Officer: Sam Colvard
Licensee: The Breast Center of Greensboro
Region: 1
City: Greensboro State: NC
County:
License #: 041-1542-1
Agreement: Y
Docket:
NRC Notified By: Tawny Morgan
HQ OPS Officer: Sam Colvard
Notification Date: 06/01/2023
Notification Time: 12:56 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2023
Notification Time: 12:56 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST MEDICAL SOURCE
The following is a summary of an email received from the North Carolina Department of Health and Human Services:
The Breast Center of Greensboro reported one lost brachytherapy seed (Iodine-125 in a preloaded 7 cm syringe, initial activity 255 microcuries, final activity 176 microcuries, order number 202385558, lot number 85558, satisfactory leak test on April 4, 2023) to the North Carolina Department of Health and Human Services on May 12, 2023. The lost source was identified during an inventory performed on May 9, 2023. An extensive search was performed but the seed was not located. The seed was most likely thrown away in a sharps container and is not believed to be stolen. Each medical procedure performed with this specific seed lot was audited with no abnormalities noted. Corrective actions include identifying each seed with a unique tracking number, updating use procedures, designating waste containers for seed use only, daily seed tracking when seeds are used, and retraining for all seed technicians.
North Carolina Event Number: NC230009
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 is a summary of an email received from the North Carolina Department of Health and Human Services:
The Breast Center of Greensboro reported one lost brachytherapy seed (Iodine-125 in a preloaded 7 cm syringe, initial activity 255 microcuries, final activity 176 microcuries, order number 202385558, lot number 85558, satisfactory leak test on April 4, 2023) to the North Carolina Department of Health and Human Services on May 12, 2023. The lost source was identified during an inventory performed on May 9, 2023. An extensive search was performed but the seed was not located. The seed was most likely thrown away in a sharps container and is not believed to be stolen. Each medical procedure performed with this specific seed lot was audited with no abnormalities noted. Corrective actions include identifying each seed with a unique tracking number, updating use procedures, designating waste containers for seed use only, daily seed tracking when seeds are used, and retraining for all seed technicians.
North Carolina Event Number: NC230009
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: 56748
Rep Org: Texas Dept of State Health Services
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Notification Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE - LOST SOURCE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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 Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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: 56516
Rep Org: Arizona Dept of Health Services
Licensee: Banner University Medical Center - Phoenix
Region: 4
City: Phoenix State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bill Gott
Licensee: Banner University Medical Center - Phoenix
Region: 4
City: Phoenix State: AZ
County:
License #: 07-478
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bill Gott
Notification Date: 05/11/2023
Notification Time: 00:18 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [MST]
Last Update Date: 05/11/2023
Notification Time: 00:18 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [MST]
Last Update Date: 05/11/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona incident number: 23-008
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 Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona incident number: 23-008
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: 56514
Rep Org: Texas Dept of State Health Services
Licensee: Chi St Lukes Hlth Baylor Clg of Med
Region: 4
City: Houston State: TX
County:
License #: L-06661
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Donald Norwood
Licensee: Chi St Lukes Hlth Baylor Clg of Med
Region: 4
City: Houston State: TX
County:
License #: L-06661
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Donald Norwood
Notification Date: 05/10/2023
Notification Time: 13:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2023
Notification Time: 13:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_Events_Notification, (EMAIL)
Werner, Greg (R4DO)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received via email from the Texas Dept. of State Health Services (the Agency):
"On May 9, 2023, the Agency was notified by the licensee that a medical event occurred earlier that day. The licensee stated a patient was prescribed two doses of SIR-Spheres yittrium-90 (Y-90). After the procedure, it was determined that the patient received doses differed from the prescribed doses by more than 20 percent. The patient was prescribed doses of 14.5 mCi and 21.7 mCi. The patient received 5.3 mCi (for the syringe dose of 14.2 mCi) and 12.31 mCi (for the syringe dose of 21.5 mCi). Delivered doses differed by 37.3 percent and 57.2 percent respectively. The prescribing physician and patient were notified of the error. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10017
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 received via email from the Texas Dept. of State Health Services (the Agency):
"On May 9, 2023, the Agency was notified by the licensee that a medical event occurred earlier that day. The licensee stated a patient was prescribed two doses of SIR-Spheres yittrium-90 (Y-90). After the procedure, it was determined that the patient received doses differed from the prescribed doses by more than 20 percent. The patient was prescribed doses of 14.5 mCi and 21.7 mCi. The patient received 5.3 mCi (for the syringe dose of 14.2 mCi) and 12.31 mCi (for the syringe dose of 21.5 mCi). Delivered doses differed by 37.3 percent and 57.2 percent respectively. The prescribing physician and patient were notified of the error. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10017
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.
Power Reactor
Event Number: 56513
Facility: Peach Bottom
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Craig Taulman
HQ OPS Officer: Ian Howard
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Craig Taulman
HQ OPS Officer: Ian Howard
Notification Date: 05/09/2023
Notification Time: 17:41 [ET]
Event Date: 05/09/2023
Event Time: 14:55 [EDT]
Last Update Date: 05/09/2023
Notification Time: 17:41 [ET]
Event Date: 05/09/2023
Event Time: 14:55 [EDT]
Last Update Date: 05/09/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
Deboer, Joseph (R1DO)
Deboer, Joseph (R1DO)
| 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 |
LOSS OF EMERGENCY PREPAREDNESS CAPABILITIES
The following information was provided by the licensee via phone and email:
"At 1455 [EST] on Tuesday May 9, 2023, Peach Bottom Atomic Power Station (PBAPS) technical support center (TSC) ventilation system lost power. Power loss was caused by a tree down on the 361 transmission line. Power was not able to be restored within an hour. At 1639 [EST], power was restored to TSC ventilation, and capability was restored.
"This report is being submitted pursuant to 10 CFR 50.72(b)(3)(xiii) as a major loss of emergency preparedness capabilities due to a reduction in the effectiveness of the onsite TSC.
"NRC Resident has been notified."
The following information was provided by the licensee via phone and email:
"At 1455 [EST] on Tuesday May 9, 2023, Peach Bottom Atomic Power Station (PBAPS) technical support center (TSC) ventilation system lost power. Power loss was caused by a tree down on the 361 transmission line. Power was not able to be restored within an hour. At 1639 [EST], power was restored to TSC ventilation, and capability was restored.
"This report is being submitted pursuant to 10 CFR 50.72(b)(3)(xiii) as a major loss of emergency preparedness capabilities due to a reduction in the effectiveness of the onsite TSC.
"NRC Resident has been notified."