Event Notification Report for October 22, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/21/2024 - 10/22/2024
Agreement State
Event Number: 57393
Rep Org: PA Bureau of Radiation Protection
Licensee: Geisinger Health System
Region: 1
City: Danville State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Karen Cotton-Gross
Licensee: Geisinger Health System
Region: 1
City: Danville State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/23/2024
Notification Time: 07:57 [ET]
Event Date: 10/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 10/23/2024
Notification Time: 07:57 [ET]
Event Date: 10/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 10/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Pennsylvania Department Bureau of Radiation Protection (the Department) via email:
"On October 23, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres. It is reportable per 10 CFR 35.3045.
"On October 22, 2024, a patient was receiving a SirSphere treatment. During the course of administration of the Y-90 spheres, the microcatheter became blocked, and the procedure was stopped. The remaining dose/waste was assessed, and it was calculated that the patient received approximately 30 mCi out of a prescribed 50 mCi. This represents an approximate 40 percent underdose. The authorized user (AU) was satisfied with that amount, believing it to be therapeutic and does not expect any harmful effects to the patient. Both the patient and AU were notified.
"The Department will perform a reactive inspection. More information will be provided as received."
Event Report ID No: PA240020
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 Pennsylvania Department Bureau of Radiation Protection (the Department) via email:
"On October 23, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres. It is reportable per 10 CFR 35.3045.
"On October 22, 2024, a patient was receiving a SirSphere treatment. During the course of administration of the Y-90 spheres, the microcatheter became blocked, and the procedure was stopped. The remaining dose/waste was assessed, and it was calculated that the patient received approximately 30 mCi out of a prescribed 50 mCi. This represents an approximate 40 percent underdose. The authorized user (AU) was satisfied with that amount, believing it to be therapeutic and does not expect any harmful effects to the patient. Both the patient and AU were notified.
"The Department will perform a reactive inspection. More information will be provided as received."
Event Report ID No: PA240020
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.
Fuel Cycle Facility
Event Number: 57394
Facility: Global Laser Enrichment
Region: 2 State: NC
Unit: [] [] []
RX Type: Uranium Enrichment
NRC Notified By: Tim Knowles
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: NC
Unit: [] [] []
RX Type: Uranium Enrichment
NRC Notified By: Tim Knowles
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/23/2024
Notification Time: 11:06 [ET]
Event Date: 10/22/2024
Event Time: 13:30 [EDT]
Last Update Date: 02/27/2025
Notification Time: 11:06 [ET]
Event Date: 10/22/2024
Event Time: 13:30 [EDT]
Last Update Date: 02/27/2025
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (b)(2) - Loss Or Degraded Safety Items
10 CFR Section:
PART 70 APP A (b)(2) - Loss Or Degraded Safety Items
Person (Organization):
Suber, Gregory (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Suber, Gregory (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 2/28/2025
EN Revision Text: LOSS OF ITEM RELIED ON FOR SAFETY
The following information was provided by the licensee via phone and email:
"Loss or degradation of items relied on for safety that results in failure to meet the performance requirement of 10 CFR 70.61.
"A temperature interlock, designated as item relied on for safety (IROFS), failed to actuate at setpoint.
"NRC Region II has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee is troubleshooting the cause, and the system was placed in safe shutdown.
* * * RETRACTION ON 2/27/2025 AT 1526 EST FROM PAT JENNEY TO TROY JOHNSON * * *
"During further investigation, it was determined that the operators stopped the evolution prior to the applicability of the item relied on for safety (IROFS) in question, and the IROFS was never called upon to take action. Based on this investigation Global Laser Enrichment is retracting the event notification."
Notified R2DO (Penmetsa) and NMSS Events Notification (email).
EN Revision Text: LOSS OF ITEM RELIED ON FOR SAFETY
The following information was provided by the licensee via phone and email:
"Loss or degradation of items relied on for safety that results in failure to meet the performance requirement of 10 CFR 70.61.
"A temperature interlock, designated as item relied on for safety (IROFS), failed to actuate at setpoint.
"NRC Region II has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee is troubleshooting the cause, and the system was placed in safe shutdown.
* * * RETRACTION ON 2/27/2025 AT 1526 EST FROM PAT JENNEY TO TROY JOHNSON * * *
"During further investigation, it was determined that the operators stopped the evolution prior to the applicability of the item relied on for safety (IROFS) in question, and the IROFS was never called upon to take action. Based on this investigation Global Laser Enrichment is retracting the event notification."
Notified R2DO (Penmetsa) and NMSS Events Notification (email).
Agreement State
Event Number: 57395
Rep Org: Tennessee Div of Rad Health
Licensee: Eastman Chemical Company
Region: 1
City: Kingsport State: TN
County:
License #: R-82007-K28
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Robert A. Thompson
Licensee: Eastman Chemical Company
Region: 1
City: Kingsport State: TN
County:
License #: R-82007-K28
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Robert A. Thompson
Notification Date: 10/23/2024
Notification Time: 15:50 [ET]
Event Date: 10/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 10/23/2024
Notification Time: 15:50 [ET]
Event Date: 10/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 10/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER
The following information was provided by the Tennessee Division of Radiological Health via email:
"During a scheduled six-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. The open position is the normal operating position. No abnormal levels of radiation were detected. A VEGA field technician has been contacted to service the gauge.
"Corrective actions or reports, as well as additional information, will be updated with a NMED report within 30 days."
Manufacturer: Ohmart/Vega
Source Holder Model: SHF2
Source Holder SN: 99949B
Isotope: Cs-137, 24.4 mCi
Tennessee Event Report ID Number: TN-24-081
The following information was provided by the Tennessee Division of Radiological Health via email:
"During a scheduled six-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. The open position is the normal operating position. No abnormal levels of radiation were detected. A VEGA field technician has been contacted to service the gauge.
"Corrective actions or reports, as well as additional information, will be updated with a NMED report within 30 days."
Manufacturer: Ohmart/Vega
Source Holder Model: SHF2
Source Holder SN: 99949B
Isotope: Cs-137, 24.4 mCi
Tennessee Event Report ID Number: TN-24-081