Event Notification Report for July 27, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/26/2021 - 07/27/2021
Agreement State
Event Number: 55360
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MaineHealth Maine Medical Center
Region: 1
City: Scarborough State: ME
County:
License #: ME 05611
Agreement: Y
Docket:
NRC Notified By: Catherine Perham
HQ OPS Officer: Donald Norwood
Licensee: MaineHealth Maine Medical Center
Region: 1
City: Scarborough State: ME
County:
License #: ME 05611
Agreement: Y
Docket:
NRC Notified By: Catherine Perham
HQ OPS Officer: Donald Norwood
Notification Date: 07/19/2021
Notification Time: 15:38 [ET]
Event Date: 10/19/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/19/2021
Notification Time: 15:38 [ET]
Event Date: 10/19/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/19/2021
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: 7/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was received via E-mail:
"MaineHealth Maine Medical Center reported a leaking Cs-137 source (Eckert & Ziegler Model RV-137-200U, Serial No.: 1490-24-6) that contained an estimated activity of 5.84 MBq (157.8 microCi). The incident was discovered during a semi-annual leak test performed on 10/19/2020. Leak test results revealed 950.9 Bq (0.0257 microCi). The Cs-137 contamination was contained in the drawer the source was stored in. The assumption was made that the source was still leaking and MaineHealth sealed it in its storage lead pig. The outer surface of the lead pig was cleaned and wiped, resulting in removable contamination of less than 200 dpm. The pig was placed in a plastic bag as an extra means of containment and the bag was sealed and labeled. All other items that were contaminated or potentially contaminated in the clean-up process were also placed in a plastic bag, sealed, and labeled. The drawer was cleaned and a final wipe test confirmed that removable contamination was below 200 dpm. The staff who used the source were notified that it was considered out of service and should not be handled or used. The source remained stored in the hot laboratory pending finalization of plans for repair or disposal."
Maine Event Report ID No.: ME 20-004
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was received via E-mail:
"MaineHealth Maine Medical Center reported a leaking Cs-137 source (Eckert & Ziegler Model RV-137-200U, Serial No.: 1490-24-6) that contained an estimated activity of 5.84 MBq (157.8 microCi). The incident was discovered during a semi-annual leak test performed on 10/19/2020. Leak test results revealed 950.9 Bq (0.0257 microCi). The Cs-137 contamination was contained in the drawer the source was stored in. The assumption was made that the source was still leaking and MaineHealth sealed it in its storage lead pig. The outer surface of the lead pig was cleaned and wiped, resulting in removable contamination of less than 200 dpm. The pig was placed in a plastic bag as an extra means of containment and the bag was sealed and labeled. All other items that were contaminated or potentially contaminated in the clean-up process were also placed in a plastic bag, sealed, and labeled. The drawer was cleaned and a final wipe test confirmed that removable contamination was below 200 dpm. The staff who used the source were notified that it was considered out of service and should not be handled or used. The source remained stored in the hot laboratory pending finalization of plans for repair or disposal."
Maine Event Report ID No.: ME 20-004
Agreement State
Event Number: 55361
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Versa Integrity Group, Inc.
Region: 4
City: Houston State: TX
County:
License #: L 06669
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Donald Norwood
Licensee: Versa Integrity Group, Inc.
Region: 4
City: Houston State: TX
County:
License #: L 06669
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Donald Norwood
Notification Date: 07/19/2021
Notification Time: 16:02 [ET]
Event Date: 07/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/19/2021
Notification Time: 16:02 [ET]
Event Date: 07/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/19/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/27/2021
EN Revision Text: AGREEMENT STATE REPORT - POSSIBLE OVER-EXPOSURE TO RADIOGRAPHER
The following information was received via E-mail:
"On July 19, 2021, the licensee notified the Agency [Texas Department of State Health Services] that one of its radiographer's personal dosimetry badge results for the monitoring period of June 2021 indicated a deep dose equivalent (DDE) of 5,114 millirem. The radiographer had terminated his employment with the licensee on July 6, 2021. The licensee has contacted the radiographer by phone and the radiographer stated he did not know how it could have happened. The licensee is investigating to determine if the dose was to the radiographer or to the badge only. The licensee also reported that the radiographer had more than one day of work and that the dose to this badge did not occur all within a 24 hour period. An investigation into this event is ongoing."
Texas Incident No.: 9870
EN Revision Text: AGREEMENT STATE REPORT - POSSIBLE OVER-EXPOSURE TO RADIOGRAPHER
The following information was received via E-mail:
"On July 19, 2021, the licensee notified the Agency [Texas Department of State Health Services] that one of its radiographer's personal dosimetry badge results for the monitoring period of June 2021 indicated a deep dose equivalent (DDE) of 5,114 millirem. The radiographer had terminated his employment with the licensee on July 6, 2021. The licensee has contacted the radiographer by phone and the radiographer stated he did not know how it could have happened. The licensee is investigating to determine if the dose was to the radiographer or to the badge only. The licensee also reported that the radiographer had more than one day of work and that the dose to this badge did not occur all within a 24 hour period. An investigation into this event is ongoing."
Texas Incident No.: 9870
Non-Agreement State
Event Number: 55362
Rep Org: Mistras Group, Inc.
Licensee: Mistras Group, Inc.
Region: 3
City: Heath State: OH
County:
License #: 12-16559-02
Agreement: N
Docket:
NRC Notified By: Matt Kim
HQ OPS Officer: Donald Norwood
Licensee: Mistras Group, Inc.
Region: 3
City: Heath State: OH
County:
License #: 12-16559-02
Agreement: N
Docket:
NRC Notified By: Matt Kim
HQ OPS Officer: Donald Norwood
Notification Date: 07/19/2021
Notification Time: 16:10 [ET]
Event Date: 07/19/2021
Event Time: 02:00 [AST]
Last Update Date: 07/19/2021
Notification Time: 16:10 [ET]
Event Date: 07/19/2021
Event Time: 02:00 [AST]
Last Update Date: 07/19/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2202(b)(2) - Excessive Release 1xali
10 CFR Section:
20.2202(b)(2) - Excessive Release 1xali
Person (Organization):
PELKE, PATRICIA (R3)
O'KEEFE, NEIL (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PELKE, PATRICIA (R3)
O'KEEFE, NEIL (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/27/2021
EN Revision Text: TEMPORARY LOSS OF CONTROL OF RADIOGRAPHY EXPOSURE DEVICE
The following is a synopsis of information received via e-mail:
The Mistras Director of Radiation Safety was notified by a Mistras radiographer (working in Prudhoe Bay, Alaska) that an exposure device had been left unsecured in a truck in an ammo can with no lock and without the alarm set. The truck had then been turned in to the Tarmac shop for maintenance.
The Tarmac shop discovered the device in the truck around 0200 AST. Upon discovery of the device, they immediately closed the truck and notified security. They did not handle the device.
The device was retrieved by approved Mistras personnel and placed into the vault at MCC Camp. After being notified of the event, the Director personally verified that the exposure device was secured in the vault. The exposure device involved is Serial Number: D10742, containing 81 Curies of Ir-192.
The location of the event in Prudhoe Bay is a secured location with no access to or from the camp without proper security clearance. The Tarmac shop services all vehicles on the North Slope as they are owned by a Mistras customer.
EN Revision Text: TEMPORARY LOSS OF CONTROL OF RADIOGRAPHY EXPOSURE DEVICE
The following is a synopsis of information received via e-mail:
The Mistras Director of Radiation Safety was notified by a Mistras radiographer (working in Prudhoe Bay, Alaska) that an exposure device had been left unsecured in a truck in an ammo can with no lock and without the alarm set. The truck had then been turned in to the Tarmac shop for maintenance.
The Tarmac shop discovered the device in the truck around 0200 AST. Upon discovery of the device, they immediately closed the truck and notified security. They did not handle the device.
The device was retrieved by approved Mistras personnel and placed into the vault at MCC Camp. After being notified of the event, the Director personally verified that the exposure device was secured in the vault. The exposure device involved is Serial Number: D10742, containing 81 Curies of Ir-192.
The location of the event in Prudhoe Bay is a secured location with no access to or from the camp without proper security clearance. The Tarmac shop services all vehicles on the North Slope as they are owned by a Mistras customer.
Agreement State
Event Number: 55366
Rep Org: LOUISIANA DEQ
Licensee: Acuren Inspection, Inc.
Region: 4
City: Laporte State: LA
County:
License #: LA-7072-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Ossy Font
Licensee: Acuren Inspection, Inc.
Region: 4
City: Laporte State: LA
County:
License #: LA-7072-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Ossy Font
Notification Date: 07/20/2021
Notification Time: 19:44 [ET]
Event Date: 07/20/2021
Event Time: 15:30 [CDT]
Last Update Date: 07/20/2021
Notification Time: 19:44 [ET]
Event Date: 07/20/2021
Event Time: 15:30 [CDT]
Last Update Date: 07/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/28/2021
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT
The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone:
The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs.
The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT
The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone:
The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs.
The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.
Power Reactor
Event Number: 55379
Facility: Sequoyah
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ben Hammargren
HQ OPS Officer: Brian P. Smith
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ben Hammargren
HQ OPS Officer: Brian P. Smith
Notification Date: 07/25/2021
Notification Time: 16:00 [ET]
Event Date: 07/25/2021
Event Time: 12:38 [EDT]
Last Update Date: 07/25/2021
Notification Time: 16:00 [ET]
Event Date: 07/25/2021
Event Time: 12:38 [EDT]
Last Update Date: 07/25/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
MILLER, MARK (R2)
MILLER, MARK (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 7/27/2021
EN Revision Text: SURVEILLENCE FREQUENCY EXCEEDED FOR ICE CONDENSER TEMPERATURE
"At 1238 EDT on July 25, 2021, the Unit 2 Ice Bed became INOPERABLE due to SR [Surveillance Requirement] 3.6.12.1 exceeding its surveillance interval. LCO [Limiting Condition for Operation] 3.6.12 was declared not met as required by SR 3.0.1.
"SR 3.6.12.1 to verify maximum ice bed temperature is less than or equal to 27 degrees F could not be completed due to a failed temperature recorder. The results of the backup method of temperature verification were verified satisfactory at 1258 EDT and the LCO condition was then exited.
"The ice bed is a single train system which functions to control radiation release and mitigate the consequences of an accident by scrubbing radioactive iodine and providing a heat sink to limit containment pressure within design limits, therefore the requirements of 10 CFR 50.72 (b) (3) (v) (C) and (D) were met.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
EN Revision Text: SURVEILLENCE FREQUENCY EXCEEDED FOR ICE CONDENSER TEMPERATURE
"At 1238 EDT on July 25, 2021, the Unit 2 Ice Bed became INOPERABLE due to SR [Surveillance Requirement] 3.6.12.1 exceeding its surveillance interval. LCO [Limiting Condition for Operation] 3.6.12 was declared not met as required by SR 3.0.1.
"SR 3.6.12.1 to verify maximum ice bed temperature is less than or equal to 27 degrees F could not be completed due to a failed temperature recorder. The results of the backup method of temperature verification were verified satisfactory at 1258 EDT and the LCO condition was then exited.
"The ice bed is a single train system which functions to control radiation release and mitigate the consequences of an accident by scrubbing radioactive iodine and providing a heat sink to limit containment pressure within design limits, therefore the requirements of 10 CFR 50.72 (b) (3) (v) (C) and (D) were met.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55367
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Prime NDT Services, Inc.
Region: 3
City: Strasburg State: OH
County:
License #: 03320990003
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Jeffrey Whited
Licensee: Prime NDT Services, Inc.
Region: 3
City: Strasburg State: OH
County:
License #: 03320990003
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/21/2021
Notification Time: 10:00 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/21/2021
Notification Time: 10:00 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
KENNEDY, SILAS (IR)
DESIREE DAVIS (ILTAB) (ILTAB)
MILLIGAN, PATRICIA (INES)
PELKE, PATRICIA (R3)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
KENNEDY, SILAS (IR)
DESIREE DAVIS (ILTAB) (ILTAB)
MILLIGAN, PATRICIA (INES)
EN Revision Imported Date: 7/28/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following was received from the Ohio Bureau of Radiation Protection via email:
"Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via [the common carrier] on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by [the common carrier]. [The common carrier] is aware of the situation and believes that the package was delayed at their facility. On July 20, [the common carrier] informed Prime NDT Services, Inc. that the package could not be located.
"The State of Tennessee has been informed."
Ohio Item Number: OH210007
Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following was received from the Ohio Bureau of Radiation Protection via email:
"Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via [the common carrier] on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by [the common carrier]. [The common carrier] is aware of the situation and believes that the package was delayed at their facility. On July 20, [the common carrier] informed Prime NDT Services, Inc. that the package could not be located.
"The State of Tennessee has been informed."
Ohio Item Number: OH210007
Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 55368
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: University of California, San Diego
Region: 4
City: La Jolla State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ossy Font
Licensee: University of California, San Diego
Region: 4
City: La Jolla State: CA
County:
License #: 1339-37
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ossy Font
Notification Date: 07/21/2021
Notification Time: 17:21 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/21/2021
Notification Time: 17:21 [ET]
Event Date: 07/20/2021
Event Time: 00:00 [PDT]
Last Update Date: 07/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/28/2021
EN Revision Text: AGREEMENT STATE REPORT - Y-90 BRACHYTHERAPY UNDERDOSE
The following was received from the California Department of Public Health via email:
"A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000.
"Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent).
"Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure.
"Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021."
5010 Number: 072121
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 - Y-90 BRACHYTHERAPY UNDERDOSE
The following was received from the California Department of Public Health via email:
"A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000.
"Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent).
"Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure.
"Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021."
5010 Number: 072121
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: 55369
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: University of Illinois - Chicago
Region: 3
City: Chicago State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Ossy Font
Licensee: University of Illinois - Chicago
Region: 3
City: Chicago State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Ossy Font
Notification Date: 07/21/2021
Notification Time: 17:36 [ET]
Event Date: 04/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2021
Notification Time: 17:36 [ET]
Event Date: 04/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/28/2021
EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The RSO [Radiation Safety Officer] called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned.
"The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021.
"Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending.
"A reactionary inspection will be performed."
Item Number: IL210020
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 - Y-90 MICROSPHERE UNDERDOSE
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The RSO [Radiation Safety Officer] called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned.
"The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021.
"Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending.
"A reactionary inspection will be performed."
Item Number: IL210020
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-Power Reactor
Event Number: 55380
Rep Org: Univ Of Missouri-Columbia
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Bruce Meffert
HQ OPS Officer: Thomas Herrity
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Bruce Meffert
HQ OPS Officer: Thomas Herrity
Notification Date: 07/27/2021
Notification Time: 13:56 [ET]
Event Date: 07/26/2021
Event Time: 17:31 [CDT]
Last Update Date: 07/27/2021
Notification Time: 13:56 [ET]
Event Date: 07/26/2021
Event Time: 17:31 [CDT]
Last Update Date: 07/27/2021
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Wertz, Geoffrey (HQ PM )
Helvenston, Edward Edward (HQ PM )
Takacs, Michael (NPR Even)
Schuster, William (NPR Even)
Wertz, Geoffrey (HQ PM )
Helvenston, Edward Edward (HQ PM )
Takacs, Michael (NPR Even)
Schuster, William (NPR Even)
REACTOR SHUTDOWN DUE TO CONTROL ROD DRIVE FAILURE
"On July 26, 2021 at 1731 CDT, while the reactor was subcritical during a reactor startup, the University of Missouri-Columbia Research Reactor (MURR) was manually shut down due to the failure of the control rod drive mechanism for shim control blade B. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'
"A spare control rod drive mechanism was installed for control blade B, post-installation operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on July 26, 2021. Currently, MURR is operating at 10 MW [full power]. A detailed event report will follow within 14 days."
"On July 26, 2021 at 1731 CDT, while the reactor was subcritical during a reactor startup, the University of Missouri-Columbia Research Reactor (MURR) was manually shut down due to the failure of the control rod drive mechanism for shim control blade B. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'
"A spare control rod drive mechanism was installed for control blade B, post-installation operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on July 26, 2021. Currently, MURR is operating at 10 MW [full power]. A detailed event report will follow within 14 days."