Event Notification Report for August 23, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/22/2023 - 08/23/2023
Agreement State
Event Number: 56695
Rep Org: PA Bureau of Radiation Protection
Licensee: UPMC Horizon, Greenville, PA
Region: 1
City: Greenville State: PA
County:
License #: PA-0057
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Licensee: UPMC Horizon, Greenville, PA
Region: 1
City: Greenville State: PA
County:
License #: PA-0057
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Notification Date: 08/24/2023
Notification Time: 13:03 [ET]
Event Date: 08/23/2023
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2023
Notification Time: 13:03 [ET]
Event Date: 08/23/2023
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):
"On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1).
"On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator.
"Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
Pennsylvania Event Report ID No.: PA230023.
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 Pennsylvania Department of Environmental Protection (the Department):
"On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1).
"On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator.
"Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
Pennsylvania Event Report ID No.: PA230023.
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: 56694
Facility: Vogtle 1/2
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Curits Rabun
HQ OPS Officer: Kerby Scales
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Curits Rabun
HQ OPS Officer: Kerby Scales
Notification Date: 08/24/2023
Notification Time: 08:24 [ET]
Event Date: 08/23/2023
Event Time: 09:39 [EDT]
Last Update Date: 08/24/2023
Notification Time: 08:24 [ET]
Event Date: 08/23/2023
Event Time: 09:39 [EDT]
Last Update Date: 08/24/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Miller, Mark (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the licensee via email:
A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated.
The NRC Resident Inspectors have been notified
The following information was provided by the licensee via email:
A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated.
The NRC Resident Inspectors have been notified
Power Reactor
Event Number: 56696
Facility: Grand Gulf
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jeff Hardy
HQ OPS Officer: Donald Norwood
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jeff Hardy
HQ OPS Officer: Donald Norwood
Notification Date: 08/24/2023
Notification Time: 21:30 [ET]
Event Date: 08/23/2023
Event Time: 21:00 [CDT]
Last Update Date: 08/24/2023
Notification Time: 21:30 [ET]
Event Date: 08/23/2023
Event Time: 21:00 [CDT]
Last Update Date: 08/24/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Dixon, John (R4DO)
FFD Group, (EMAIL)
Dixon, John (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY (FFD) REPORT - NON-LICENSED SUPERVISOR VIOLATED FFD POLICY
The following information was provided by the licensee via email:
"On August 23, 2023 at 2100 CDT, Grand Gulf Nuclear Station was notified that a non-licensed supervisor violated the station's Fitness for Duty policy. The employee's unescorted access at Grand Gulf Nuclear Station has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"On August 23, 2023 at 2100 CDT, Grand Gulf Nuclear Station was notified that a non-licensed supervisor violated the station's Fitness for Duty policy. The employee's unescorted access at Grand Gulf Nuclear Station has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).
"The NRC Resident Inspector has been notified."