Event Notification Report for September 25, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/24/2023 - 09/25/2023
Agreement State
Event Number: 56739
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: PETNET
Region: 1
City: Hackensack State: NJ
County:
License #: 459066
Agreement: Y
Docket:
NRC Notified By: Sarah Sanderlin
HQ OPS Officer: Kerby Scales
Licensee: PETNET
Region: 1
City: Hackensack State: NJ
County:
License #: 459066
Agreement: Y
Docket:
NRC Notified By: Sarah Sanderlin
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 11:50 [ET]
Event Date: 09/15/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/15/2023
Notification Time: 11:50 [ET]
Event Date: 09/15/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was received from the New Jersey Department of Environmental Protection (NJDEP) via email:
"On 9/15/2023, NJDEP staff was notified of a potential overexposure of an authorized user (AU) at a radiopharmacy. This licensee states that a whole body badge from June was submitted late and results were just received. This AU's June badge results were 4632 mrem. The badge was processed twice to ensure the reading was correct. This brings the AU's annual readings to 5351 mrem. As a result, the licensee has been put on work restrictions while an investigation is done. The licensee has also requested Landauer reprocess the badge. Staff was also told that the ring badges had the exact same reading as the whole body badge. Records of instant read out dosimeters are kept by this licensee and all recorded readings were no higher than 2 mR per day for June and July. More information to follow as the licensee's investigation is completed."
New Jersey Event Number: To Be Determined
The following information was received from the New Jersey Department of Environmental Protection (NJDEP) via email:
"On 9/15/2023, NJDEP staff was notified of a potential overexposure of an authorized user (AU) at a radiopharmacy. This licensee states that a whole body badge from June was submitted late and results were just received. This AU's June badge results were 4632 mrem. The badge was processed twice to ensure the reading was correct. This brings the AU's annual readings to 5351 mrem. As a result, the licensee has been put on work restrictions while an investigation is done. The licensee has also requested Landauer reprocess the badge. Staff was also told that the ring badges had the exact same reading as the whole body badge. Records of instant read out dosimeters are kept by this licensee and all recorded readings were no higher than 2 mR per day for June and July. More information to follow as the licensee's investigation is completed."
New Jersey Event Number: To Be Determined
Agreement State
Event Number: 56741
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Advocate Christ Hospital and Medical Center
Region: 3
City: Oak Lawn State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Kerby Scales
Licensee: Advocate Christ Hospital and Medical Center
Region: 3
City: Oak Lawn State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 14:38 [ET]
Event Date: 04/14/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2023
Notification Time: 14:38 [ET]
Event Date: 04/14/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - PATIENT UNDERDOSE
The following information was received from the state of Illinois via email:
"During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event.
"On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending."
Illinois Item Number: IL230026
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 from the state of Illinois via email:
"During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event.
"On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending."
Illinois Item Number: IL230026
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: 56742
Rep Org: Alabama Radiation Control
Licensee: Applied Technical Services
Region: 1
City: East Mobile State: AL
County:
License #: RML 1454
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Kerby Scales
Licensee: Applied Technical Services
Region: 1
City: East Mobile State: AL
County:
License #: RML 1454
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 18:00 [ET]
Event Date: 09/14/2023
Event Time: 17:00 [CDT]
Last Update Date: 09/15/2023
Notification Time: 18:00 [ET]
Event Date: 09/14/2023
Event Time: 17:00 [CDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by Alabama Radiation Control via email:
"The licensee's representative called an Alabama Radiation Control staff member to report that an RT [radiographic testing] crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS [Applied Technical Services] office in Marietta, Georgia to respond.
"Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident Number: To Be Determined
The following information was provided by Alabama Radiation Control via email:
"The licensee's representative called an Alabama Radiation Control staff member to report that an RT [radiographic testing] crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS [Applied Technical Services] office in Marietta, Georgia to respond.
"Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Incident Number: To Be Determined
Agreement State
Event Number: 56744
Rep Org: California Radiation Control Prgm
Licensee: Tesla (Non-Licensee), San Rafael
Region: 4
City: Santa Anna State: CA
County:
License #: GL - N/A
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Kerby Scales
Licensee: Tesla (Non-Licensee), San Rafael
Region: 4
City: Santa Anna State: CA
County:
License #: GL - N/A
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Kerby Scales
Notification Date: 09/18/2023
Notification Time: 17:53 [ET]
Event Date: 09/13/2023
Event Time: 00:00 [PDT]
Last Update Date: 09/18/2023
Notification Time: 17:53 [ET]
Event Date: 09/13/2023
Event Time: 00:00 [PDT]
Last Update Date: 09/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST GENERALLY LICENSED SOURCE
The following information was received from the California Department of Public Health via email:
"On 09/13/23, Tesla Corporation contacted [Radiation Health Branch] RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source."
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
The following information was received from the California Department of Public Health via email:
"On 09/13/23, Tesla Corporation contacted [Radiation Health Branch] RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source."
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
Power Reactor
Event Number: 56753
Facility: Peach Bottom
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Mike Hoffmaster
HQ OPS Officer: Michael Bloodgood
Region: 1 State: PA
Unit: [2] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Mike Hoffmaster
HQ OPS Officer: Michael Bloodgood
Notification Date: 09/21/2023
Notification Time: 10:31 [ET]
Event Date: 09/20/2023
Event Time: 15:15 [EDT]
Last Update Date: 09/21/2023
Notification Time: 10:31 [ET]
Event Date: 09/20/2023
Event Time: 15:15 [EDT]
Last Update Date: 09/21/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | -1 | Power Operation | -1 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via phone and email:
"A licensed operator had a confirmed positive test for alcohol during another entity's pre-access fitness-for-duty screening for unescorted access authorization. The individual's unescorted access at Peach Bottom Atomic Power Station has been denied.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"A licensed operator had a confirmed positive test for alcohol during another entity's pre-access fitness-for-duty screening for unescorted access authorization. The individual's unescorted access at Peach Bottom Atomic Power Station has been denied.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56755
Facility: Turkey Point
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ron Foster
HQ OPS Officer: Lawrence Criscione
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ron Foster
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/22/2023
Notification Time: 22:09 [ET]
Event Date: 09/22/2023
Event Time: 18:19 [EDT]
Last Update Date: 09/22/2023
Notification Time: 22:09 [ET]
Event Date: 09/22/2023
Event Time: 18:19 [EDT]
Last Update Date: 09/22/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 1819 EDT on 9/22/2023, with Unit 3 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main generator lockout. The probable cause of the main generator lockout was from a lightning strike. The trip was uncomplicated with all systems responding normally post-trip. Operations stabilized the plant in Mode 3. Decay heat is being removed by the steam dump system. Unit 4 is not affected. Auxiliary feed water was actuated as expected as a result of the reactor trip.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 1819 EDT on 9/22/2023, with Unit 3 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main generator lockout. The probable cause of the main generator lockout was from a lightning strike. The trip was uncomplicated with all systems responding normally post-trip. Operations stabilized the plant in Mode 3. Decay heat is being removed by the steam dump system. Unit 4 is not affected. Auxiliary feed water was actuated as expected as a result of the reactor trip.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified."
Agreement State
Event Number: 56682
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Licensee: G.E. Healthcare DBA
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian P. Smith
Notification Date: 08/17/2023
Notification Time: 12:15 [ET]
Event Date: 08/12/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Notification Time: 12:15 [ET]
Event Date: 08/12/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/26/2023
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT
The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:
"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:
"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
"The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed."
Illinois Event Number: IL230018
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: AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT
The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:
"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:
"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.
"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
"The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed."
Illinois Event Number: IL230018
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: 56697
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Licensee: G.E.Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: John Russell
Notification Date: 08/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Notification Time: 15:50 [ET]
Event Date: 08/24/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/26/2023
EN Revision Text: AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE
The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed.
Illinois Item Number: IL230021
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: AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE
The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):
"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.
"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.
"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."
* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *
The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed.
Illinois Item Number: IL230021
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: 56746
Rep Org: Colorado Dept of Health
Licensee: North Colorado Medical Center
Region: 4
City: Greeley State: CO
County:
License #: CO 263-01
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: John Russell
Licensee: North Colorado Medical Center
Region: 4
City: Greeley State: CO
County:
License #: CO 263-01
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: John Russell
Notification Date: 09/19/2023
Notification Time: 13:03 [ET]
Event Date: 09/18/2023
Event Time: 10:00 [MDT]
Last Update Date: 09/19/2023
Notification Time: 13:03 [ET]
Event Date: 09/18/2023
Event Time: 10:00 [MDT]
Last Update Date: 09/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE
The following information was received from the Colorado Department of Public Health and Environment via email:
"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."
Colorado Event Report ID: CO 230032
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 from the Colorado Department of Public Health and Environment via email:
"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."
Colorado Event Report ID: CO 230032
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: 56748
Rep Org: Texas Dept of State Health Services
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Licensee: Black Mountain Sand
Region: 4
City: Fort Worth State: TX
County:
License #: General
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: John Russell
Notification Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
Notification Time: 18:20 [ET]
Event Date: 05/09/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
Groom, Jeremy (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE - LOST SOURCE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.
"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.
"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."
Texas Incident Number: 10021
Texas NMED Number: TX230028
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