Event Notification Report for November 15, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/14/2023 - 11/15/2023
Agreement State
Event Number: 56860
Rep Org: California Radiation Control Prgm
Licensee: CITY OF HOPE
Region: 4
City: Duarte State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Ian Howard
Licensee: CITY OF HOPE
Region: 4
City: Duarte State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Ian Howard
Notification Date: 11/16/2023
Notification Time: 20:05 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [PST]
Last Update Date: 11/16/2023
Notification Time: 20:05 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [PST]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
Clark, Theresa (NMSS)
NMSS_Events_Notification, (EMAIL)
Vossmar, Patricia (R4DO)
Clark, Theresa (NMSS)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - IODINE-131 OVERDOSE
The following information was provided by the California Department of Public Health (CDPH) via email:
"On November 15, 2023, at 2107 PST, [DELETED], the radiation safety officer (RSO) at City of Hope, reported by email that a patient scheduled to receive an oral administration of 100 mCi (millicuries) of iodine-131 (I-131) was instead orally administered 160 mCi of I-131, an excess of 60 mCi. On November 16, 2023, the RSO calculated that the difference in the prescribed dose to the thyroid (target organ) was 488 rem, and that the difference in the prescribed dose to the whole body effective-dose-equivalent was 62 rem. The licensee will be submitting a 15-day written report with additional details."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
No patient intervention was reported immediately but may be reported in the 15-day report. The excess activity of 60 mCi and dose of 488 rem will result in a dose to the patient that exceeds the original prescribed dose by more than 50 percent.
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 California Department of Public Health (CDPH) via email:
"On November 15, 2023, at 2107 PST, [DELETED], the radiation safety officer (RSO) at City of Hope, reported by email that a patient scheduled to receive an oral administration of 100 mCi (millicuries) of iodine-131 (I-131) was instead orally administered 160 mCi of I-131, an excess of 60 mCi. On November 16, 2023, the RSO calculated that the difference in the prescribed dose to the thyroid (target organ) was 488 rem, and that the difference in the prescribed dose to the whole body effective-dose-equivalent was 62 rem. The licensee will be submitting a 15-day written report with additional details."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
No patient intervention was reported immediately but may be reported in the 15-day report. The excess activity of 60 mCi and dose of 488 rem will result in a dose to the patient that exceeds the original prescribed dose by more than 50 percent.
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.
Non-Agreement State
Event Number: 56857
Rep Org: Patriot Engineering
Licensee: Patriot Engineering
Region: 3
City: Evansville State: IN
County:
License #: 13-32725-01
Agreement: N
Docket:
NRC Notified By: Kyle Bauer
HQ OPS Officer: Eric Simpson
Licensee: Patriot Engineering
Region: 3
City: Evansville State: IN
County:
License #: 13-32725-01
Agreement: N
Docket:
NRC Notified By: Kyle Bauer
HQ OPS Officer: Eric Simpson
Notification Date: 11/16/2023
Notification Time: 08:11 [ET]
Event Date: 11/15/2023
Event Time: 17:35 [CST]
Last Update Date: 10/23/2024
Notification Time: 08:11 [ET]
Event Date: 11/15/2023
Event Time: 17:35 [CST]
Last Update Date: 10/23/2024
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 10/31/2024
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST TROXLER GAUGE
The following information was provided by the licensee via phone conservation:
An NRC licensee lost a portable moisture density gauge while in transit to a testing site. The licensee inadvertently drove to the work location with a Troxler gauge on the work vehicle tailgate. The gauge was last known to be in possession by the licensee at the intersection of Kentucky and Diamond Avenues in Evansville, Indiana. The Troxler Model 3400, SN 20494, contained 9 mCi, Cs-137 and 1320 mCi, Am-241/Be.
* * * UPDATE ON 12/11/23 AT 1104 EST FROM KYLE BAUER TO ERIC SIMPSON * * *
The following is a synopsis of information that was provided by the licensee via email:
The site radiation safety officer received a call on Friday, November 17, 2023, from the job site informing them that the gauge was returned. The licensee returned to the job site, retrieved the gauge, performed leak tests, and notified the NRC Region III Office (Jason Draper).
Notified R3DO (McCraw), NMSS Events, and ILTAB via email.
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
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST TROXLER GAUGE
The following information was provided by the licensee via phone conservation:
An NRC licensee lost a portable moisture density gauge while in transit to a testing site. The licensee inadvertently drove to the work location with a Troxler gauge on the work vehicle tailgate. The gauge was last known to be in possession by the licensee at the intersection of Kentucky and Diamond Avenues in Evansville, Indiana. The Troxler Model 3400, SN 20494, contained 9 mCi, Cs-137 and 1320 mCi, Am-241/Be.
* * * UPDATE ON 12/11/23 AT 1104 EST FROM KYLE BAUER TO ERIC SIMPSON * * *
The following is a synopsis of information that was provided by the licensee via email:
The site radiation safety officer received a call on Friday, November 17, 2023, from the job site informing them that the gauge was returned. The licensee returned to the job site, retrieved the gauge, performed leak tests, and notified the NRC Region III Office (Jason Draper).
Notified R3DO (McCraw), NMSS Events, and ILTAB via email.
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
Part 21
Event Number: 56882
Rep Org: Tioga Pipe Inc.
Licensee:
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Kerby Scales
Licensee:
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Kerby Scales
Notification Date: 12/08/2023
Notification Time: 16:47 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [EST]
Last Update Date: 02/02/2024
Notification Time: 16:47 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [EST]
Last Update Date: 02/02/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 2/5/2024
EN Revision Text: PART 21 - INTERIM REPORT FOR BUTTWELD 90 DEGREE ELBOWS
The following is a synopsis of information that was provided by Tioga Pipe Incorporated via fax:
On November 15, 2023, nine pieces of one-inch buttweld long radius 90 degree elbows were determined not to meet correct thickness requirements. Three of the nine fittings were installed in the plant. The supplier requested that the uninstalled material be quarantined and tagged as nonconforming. The supplier doesn't know where the fittings were installed in the plant.
Brunswick Nuclear Generating Station is the only plant affected.
For questions concerning this 10 CFR 21 issue, please contact:
Bryan Nichols
Director of Quality Assurance
Tioga Pipe Incorporated
(484) 546-5613
bnichols@tiogapipe.com
* * * UPDATE ON 12/11/23 AT 0959 EST FROM SHANNON ECHOLS TO ERIC SIMPSON * * *
Duplicate Part 21 notification made by Mackson Nuclear, LLC. This notification is identical to the Part 21 notification made by Tioga Pipe Incorporated via fax to NRC on Friday, December 8, 2023. No additional information was provided.
Brunswick Nuclear Generating Station is the only plant affected.
Notified R2RDO (Miller) and Part 21 Group via email.
* * * UPDATE ON 02/02/24 AT 1001 EST FROM WILLIAM KOTCHER TO ERIC SIMPSON * * *
The following is information that was provided by Tioga Pipe Incorporated via fax:
"The licensee, Duke Energy - Brunswick Nuclear Plant, evaluated the installed elbows for acceptability in accordance with their corrective action program. Brunswick inspectors performed UT thickness evaluations of the installed nonconforming elbows (Fitting IDs: 16836-1-3, -14, and -20) and the results were used to confirm that the subject system remained operable. The remaining six nonconforming elbows (Fitting IDs: 16836-1-1, -6, -7, -11, -15, and -21) have been returned to the manufacturer, Flowline, and are being processed and controlled under Flowline's nonconforming items program."
The faxed information includes an attached E-mail chain of seven E-mails related to the Tioga Part-21 notification.
Questions are directed to William Kotcher, (713) 512-35699, or Bryan Nichols, (484) 546-5613.
Notified R2RDO (Miller) and Part 21 Group via email.
EN Revision Text: PART 21 - INTERIM REPORT FOR BUTTWELD 90 DEGREE ELBOWS
The following is a synopsis of information that was provided by Tioga Pipe Incorporated via fax:
On November 15, 2023, nine pieces of one-inch buttweld long radius 90 degree elbows were determined not to meet correct thickness requirements. Three of the nine fittings were installed in the plant. The supplier requested that the uninstalled material be quarantined and tagged as nonconforming. The supplier doesn't know where the fittings were installed in the plant.
Brunswick Nuclear Generating Station is the only plant affected.
For questions concerning this 10 CFR 21 issue, please contact:
Bryan Nichols
Director of Quality Assurance
Tioga Pipe Incorporated
(484) 546-5613
bnichols@tiogapipe.com
* * * UPDATE ON 12/11/23 AT 0959 EST FROM SHANNON ECHOLS TO ERIC SIMPSON * * *
Duplicate Part 21 notification made by Mackson Nuclear, LLC. This notification is identical to the Part 21 notification made by Tioga Pipe Incorporated via fax to NRC on Friday, December 8, 2023. No additional information was provided.
Brunswick Nuclear Generating Station is the only plant affected.
Notified R2RDO (Miller) and Part 21 Group via email.
* * * UPDATE ON 02/02/24 AT 1001 EST FROM WILLIAM KOTCHER TO ERIC SIMPSON * * *
The following is information that was provided by Tioga Pipe Incorporated via fax:
"The licensee, Duke Energy - Brunswick Nuclear Plant, evaluated the installed elbows for acceptability in accordance with their corrective action program. Brunswick inspectors performed UT thickness evaluations of the installed nonconforming elbows (Fitting IDs: 16836-1-3, -14, and -20) and the results were used to confirm that the subject system remained operable. The remaining six nonconforming elbows (Fitting IDs: 16836-1-1, -6, -7, -11, -15, and -21) have been returned to the manufacturer, Flowline, and are being processed and controlled under Flowline's nonconforming items program."
The faxed information includes an attached E-mail chain of seven E-mails related to the Tioga Part-21 notification.
Questions are directed to William Kotcher, (713) 512-35699, or Bryan Nichols, (484) 546-5613.
Notified R2RDO (Miller) and Part 21 Group via email.
Agreement State
Event Number: 57255
Rep Org: WA Office of Radiation Protection
Licensee: Dermatology of Seattle and Bellevue
Region: 4
City: Burien State: WA
County:
License #: WN-M0327-1
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Adam Koziol
Licensee: Dermatology of Seattle and Bellevue
Region: 4
City: Burien State: WA
County:
License #: WN-M0327-1
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Adam Koziol
Notification Date: 07/31/2024
Notification Time: 20:30 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [PDT]
Last Update Date: 07/31/2024
Notification Time: 20:30 [ET]
Event Date: 11/15/2023
Event Time: 00:00 [PDT]
Last Update Date: 07/31/2024
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 - POTENTIAL LEAKAGE FROM MEDICAL SOURCE
The following is a summary of information received from the Washington State Department of Health via email:
An inspection was conducted on July 25, 2024 at the licensee facility for the use of Alpha DaRT. The inspection team noted that on November 15, 2023, records indicated that two of the applicators had alpha contamination inside of the sterile packaging with readings of 10,000 counts per minute (cpm) and 6000 cpm, with average background of 23 cpm using an alpha meter.
Washington Incident No.: WA-24-018
The following is a summary of information received from the Washington State Department of Health via email:
An inspection was conducted on July 25, 2024 at the licensee facility for the use of Alpha DaRT. The inspection team noted that on November 15, 2023, records indicated that two of the applicators had alpha contamination inside of the sterile packaging with readings of 10,000 counts per minute (cpm) and 6000 cpm, with average background of 23 cpm using an alpha meter.
Washington Incident No.: WA-24-018