Event Notification Report for June 15, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/14/2021 - 06/15/2021
Agreement State
Event Number: 55294
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Advent Health Orlando
Region: 1
City: Orlando State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Farrar Stewart
HQ OPS Officer: Thomas Herrity
Licensee: Advent Health Orlando
Region: 1
City: Orlando State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Farrar Stewart
HQ OPS Officer: Thomas Herrity
Notification Date: 06/07/2021
Notification Time: 17:14 [ET]
Event Date: 06/03/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2021
Notification Time: 17:14 [ET]
Event Date: 06/03/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FERDAS, MARC (R1)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
FERDAS, MARC (R1)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/15/2021
EN Revision Text: The following was received from the Florida Department of Health via email:
"Center for Diagnostic Pathology discovered a lost source on June 3. It was a seed that was implanted in breast tissue on May 24 and removed on May 25. Two specimens with seeds were removed and one was processed in the Operating Room. The pathologist thought the seed was removed but it was discovered that a biopsy clip was mistaken for the seed. The clip was sent to the lab instead and when the lab manager did the inventory on June 2, they could not find the seed. On June 3 a survey could not locate the seed. They believe the seed was left in the specimen that was frozen to be sliced by histology. They could see in the slices where the seed was, but they could not find the seed and believe it was dislodged during the slicing and collected with the rest of the waste to be incinerated by Daniels. That waste was picked up June 1. It was stated that due to the source being low energy, the exposure risk was low.
"A follow up investigation is pending."
Florida incident number: Not yet assigned.
* * * UPDATE ON 6/08/21 AT 0800 EDT FROM MATTHEW SENSION TO LLOYD DESOTELL * * *
Florida Department of Health re-sent the incident report and provided the incident number.
Florida Event Number: FL21-075
Notified R1DO (Ferdas)(email), ILTAB (email) and NMSS Event Notifications (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: The following was received from the Florida Department of Health via email:
"Center for Diagnostic Pathology discovered a lost source on June 3. It was a seed that was implanted in breast tissue on May 24 and removed on May 25. Two specimens with seeds were removed and one was processed in the Operating Room. The pathologist thought the seed was removed but it was discovered that a biopsy clip was mistaken for the seed. The clip was sent to the lab instead and when the lab manager did the inventory on June 2, they could not find the seed. On June 3 a survey could not locate the seed. They believe the seed was left in the specimen that was frozen to be sliced by histology. They could see in the slices where the seed was, but they could not find the seed and believe it was dislodged during the slicing and collected with the rest of the waste to be incinerated by Daniels. That waste was picked up June 1. It was stated that due to the source being low energy, the exposure risk was low.
"A follow up investigation is pending."
Florida incident number: Not yet assigned.
* * * UPDATE ON 6/08/21 AT 0800 EDT FROM MATTHEW SENSION TO LLOYD DESOTELL * * *
Florida Department of Health re-sent the incident report and provided the incident number.
Florida Event Number: FL21-075
Notified R1DO (Ferdas)(email), ILTAB (email) and NMSS Event Notifications (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
Agreement State
Event Number: 55296
Rep Org: South Carolina Department of Health
Licensee: Prisma Health Greenville Memorial Hospital
Region: 1
City: Greenville State: SC
County:
License #: L275
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Brian P. Smith
Licensee: Prisma Health Greenville Memorial Hospital
Region: 1
City: Greenville State: SC
County:
License #: L275
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Brian P. Smith
Notification Date: 06/08/2021
Notification Time: 06:34 [ET]
Event Date: 06/04/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/08/2021
Notification Time: 06:34 [ET]
Event Date: 06/04/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/16/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT UNDERDOSE
The following event was received from the South Carolina Department of Health [the Department] via email:
"The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete."
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT UNDERDOSE
The following event was received from the South Carolina Department of Health [the Department] via email:
"The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete."
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: 55298
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: GS2 Engineering, Inc.
Region: 1
City: Columbia State: SC
County:
License #: 638
Agreement: Y
Docket:
NRC Notified By: Adam L. Gause
HQ OPS Officer: Lloyd Desotell
Licensee: GS2 Engineering, Inc.
Region: 1
City: Columbia State: SC
County:
License #: 638
Agreement: Y
Docket:
NRC Notified By: Adam L. Gause
HQ OPS Officer: Lloyd Desotell
Notification Date: 06/08/2021
Notification Time: 15:31 [ET]
Event Date: 06/02/2016
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2021
Notification Time: 15:31 [ET]
Event Date: 06/02/2016
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
FERDAS, MARC (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 6/16/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE
The following was received from the South Carolina Department of Health and Environmental Control via email:
"The South Carolina Department of Health and Environmental Control discovered a potential reportable event during a routine inspection of GS2 Engineering, Inc. on 06/08/2021. During the inspection it was discovered that a Troxler Model 3430 portable gauge (serial number 25345) [nominally 8 mCi Cs-137, 40 mCi Am-241:Be source] had been damaged and hit by a vehicle while on a temporary jobsite. The event appears to have occurred on 06/02/16 according to past utilization logs. The Troxler Model 3430 portable gauge has been stored at the licensee's facility within a locked cabinet. Survey results using a NDS ND-2000A survey instrument around the surface of the gauge indicated readings as high as 12 mR/hr. Survey results using a Ludlum 14-C survey instrument around the surface of the gauge indicated readings as high as 25 mR/hr. The gauge is secure within the licensee's storage area. This event is still under investigation by the South Carolina Department of Health and Environmental Control. "
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE
The following was received from the South Carolina Department of Health and Environmental Control via email:
"The South Carolina Department of Health and Environmental Control discovered a potential reportable event during a routine inspection of GS2 Engineering, Inc. on 06/08/2021. During the inspection it was discovered that a Troxler Model 3430 portable gauge (serial number 25345) [nominally 8 mCi Cs-137, 40 mCi Am-241:Be source] had been damaged and hit by a vehicle while on a temporary jobsite. The event appears to have occurred on 06/02/16 according to past utilization logs. The Troxler Model 3430 portable gauge has been stored at the licensee's facility within a locked cabinet. Survey results using a NDS ND-2000A survey instrument around the surface of the gauge indicated readings as high as 12 mR/hr. Survey results using a Ludlum 14-C survey instrument around the surface of the gauge indicated readings as high as 25 mR/hr. The gauge is secure within the licensee's storage area. This event is still under investigation by the South Carolina Department of Health and Environmental Control. "
Power Reactor
Event Number: 55305
Facility: Comanche Peak
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian Mitchell
HQ OPS Officer: Bethany Cecere
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian Mitchell
HQ OPS Officer: Bethany Cecere
Notification Date: 06/12/2021
Notification Time: 23:57 [ET]
Event Date: 06/12/2021
Event Time: 22:27 [CDT]
Last Update Date: 06/13/2021
Notification Time: 23:57 [ET]
Event Date: 06/12/2021
Event Time: 22:27 [CDT]
Last Update Date: 06/13/2021
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):
JOSEY, JEFFREY (R4)
JOSEY, JEFFREY (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Standby | 0 | Hot Standby |
EN Revision Imported Date: 6/15/2021
EN Revision Text: MAIN STEAM LINE (MSL) RADIATION MONITOR NON-FUNCTIONAL
"At time 2227 CDT on 06/12/21, Main Steam Line 2-01 Radiation Monitor 2-RE-2325 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-01 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-01. Corrective actions are being pursued to restore 2-RE-2325 to functional status.
"The NRC Resident Inspector has been notified."
EN Revision Text: MAIN STEAM LINE (MSL) RADIATION MONITOR NON-FUNCTIONAL
"At time 2227 CDT on 06/12/21, Main Steam Line 2-01 Radiation Monitor 2-RE-2325 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-01 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-01. Corrective actions are being pursued to restore 2-RE-2325 to functional status.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55306
Facility: Fort Calhoun
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: Bill Rice
HQ OPS Officer: Jeffrey Whited
Region: 4 State: NE
Unit: [1] [] []
RX Type: (1) CE
NRC Notified By: Bill Rice
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/15/2021
Notification Time: 15:38 [ET]
Event Date: 06/15/2021
Event Time: 12:30 [CDT]
Last Update Date: 06/15/2021
Notification Time: 15:38 [ET]
Event Date: 06/15/2021
Event Time: 12:30 [CDT]
Last Update Date: 06/15/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
JOSEY, JEFFREY (R4)
JOSEY, JEFFREY (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
OFFSITE NOTIFICATION
"At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4).
"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."
The licensee notified the NRC Region IV Office.
"At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4).
"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."
The licensee notified the NRC Region IV Office.