| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
9/24/2018 - 9/25/2018 ** EVENT NUMBERS ** |
| Agreement State | Event Number: 53564 | Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: STERICYCLE
Region: 4
City: STOUD State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID LAWRENZ
HQ OPS Officer: DONG HWA PARK | Notification Date: 08/24/2018
Notification Time: 16:35 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL
The following information was received via E-mail:
"Oklahoma DEQ [Department of Environmental Quality] notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr on surface of the waste package."
See EN 53561.
* * * UPDATE ON 8/25/2018 AT 1737 EDT FROM DAVID LAWRENZ TO OSSY FONT * * *
The following update was provided via E-mail:
"The originator of the waste has a radioactive material license, however the package containing the contaminated waste was not from the radiology department where licensed activity occurs. Furthermore the licensee does not use I-131 or any isotope with a half-life nearly as long. [Kansas Radiation Control] will visit the site next week to determine what the dose estimates are for those in the waiting room, lab staff (both blood draw and blood testing), waste transporter and waste handlers. [Kansas Radiation Control] also intend to identify where the blood vial and associated potentially contaminated waste is stored/disposed.
"It will likely prove impossible to discover the licensee who administered the I-131 to the patient as the individual did not report they were recently treated, there was no surveys in their unrestricted portion of their facility that is unaffiliated with their RAM [radioactive material] work, and the waste is mixed in with several other patients over the course of several days."
* * * UPDATE FROM DAVID LAWRENZ TO VINCE KLCO ON 9/24/2018 AT 1509 EDT * * *
The following update was provided via E-mail:
"Oklahoma DEQ notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas on 8/24/2018. This was reported to the HOO by David Lawrenz on the same day.
"The Cancer Center of Kansas (CCK) was contacted by Stericycle, the company that handles sharps disposal, August 23, 2018. Stericycle stated they had received a radioactive sharps container from CCK. During a phone call with Stericycle, David Lawrenz learned the sharps container had been picked up last week and delivered to the incinerator facility on Monday August 20th.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn, and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr. on surface of the waste package on 8/24/18 when [redacted] picked up the container from Stericycle.
"After [redacted] picked up the sharps container on 8/24/18, it was determined the sharps container came from the CCK lab. [redacted] took surveys on the exterior of the container and found 500 microR/hr for the highest reading prior to returning to CCK. The CCK lab is separate from the CCK radiology department and the sharps containers are used separately as well. The CCK lab is not a restricted area and no radioactive material is used there. Consequently, the sharps from the lab were not monitored for radioactive contamination.
"With the knowledge that the sharps came from a department that does not handle radioactive material and the fact that so much time had passed we determined the radioactive contamination must have originated from outside CCK. CCK only uses Tc99m. CCK is authorized for 35.100 and 35.200 use only. CCK is a cancer specialty clinic so the most likely scenario is that a patient had very recently undergone I-131 therapy at another facility and then came to CCK for lab work. The discarded lab detritus from that patient was then placed in the sharps container that Stericycle collected.
"On August 27, 2018 [two individuals from the Kansas Department of Health and Environment] arrived at CCK and met with [the Lab Supervisor]. [redacted] took surveys of the sharps container and lab area. This area is separate from the radiology department. No areas were above background.
"[The Lab Supervisor took Kansas personnel] to the hot lab used under the Adams Diagnostics 12-B880. The rejected waste is now stored for decay in the regulated area. [The Lab Supervisor] surveyed the container at 259 microR/hr on contact.
"New procedures are being written to include surveys of the labs sharps container to prevent the issue from happening in the future. The licensee was found to not be in violation of any requirements and there will be no enforcement action as a result of this investigation unless new information comes to light.
"Root cause analysis is a patient failed to follow instructions after the medical procedure."
Notified the R4DO (Alexander) and NMSS Events via email. |
| Agreement State | Event Number: 53607 | Rep Org: NV DIV OF RAD HEALTH
Licensee: AZTECH MATERIALS AND TESTING, LLC
Region: 4
City: LAS VEGAS State: NV
County:
License #: RML 00-11-0482-01
Agreement: Y
Docket:
NRC Notified By: JOHN FOLLETTE
HQ OPS Officer: THOMAS KENDZIA | Notification Date: 09/14/2018
Notification Time: 18:25 [ET]
Event Date: 09/14/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/14/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LANCE ENGLISH (ILTAB) | | This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - STOLEN MOSITURE DENSITY GAUGE
The following information was received from the State of Nevada via email:
"Around 0900 PDT on September 14, 2018 the State of Nevada Radiation Control Program was informed by Aztech Inspection & Testing, LLC, RML 00-11-0482-01, that a Humboldt, Model 5001EZ, Serial Number 1142, containing 10 millicuries (mCi) of cesium-137 and 40 mCi americium-241: beryllium, was stolen from the licensee's vehicle parked in the parking lot of the gauge user's residence. The gauge was secured to the steering wheel using a chain and lock inside of the cab of a locked pickup truck. The State is following the incident and working with local authorities to develop a press release. Local Law enforcement and the FBI have been notified. Follow-up information will be provided to NRC on the recovery of the stolen gauge and entered into NMED [Nuclear Material Event Database]."
Nevada NMED report number NV180004
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: 53619 | Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JOHN SCHWERTFEGER
HQ OPS Officer: VINCE KLCO | Notification Date: 09/24/2018
Notification Time: 14:06 [ET]
Event Date: 09/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
LAURA KOZAK (R3DO)
FFD GROUP (EMAIL) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 73 | Power Operation | 73 | Power Operation | Event Text CONTROLLED SUBSTANCE DISCOVERED WITHIN THE PROTECTED AREA
"On September 22, 2018, at approximately 0050 [CDT], Duane Arnold Energy Center (DAEC) Security was contacted by a site assigned contractor that they had located what appeared to be drug paraphernalia inside the Protected Area. Local Law Enforcement was contacted and responded to DAEC. The Linn County Sheriff's office took the items into evidence for testing to determine if there was any presence of a controlled substance. On September 24, 2018, at 1013, the Linn County Sheriff's office notified DAEC that the items tested positive for the presence of a controlled substance. Therefore, this is being reported in accordance with 10 CFR 26.719. DAEC Site security is working with NextEra Corporate security regarding the investigation into this incident.
"The Resident Inspector has been notified." |
| Power Reactor | Event Number: 53622 | Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JASON BUSH
HQ OPS Officer: OSSY FONT | Notification Date: 09/25/2018
Notification Time: 20:25 [ET]
Event Date: 09/25/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/25/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
RYAN ALEXANDER (R4DO) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 90 | Power Operation | 90 | Power Operation | Event Text CONTROL BUILDING CHILLERS IN UNANALYZED CONDITION
"At 1200 CDT on September 25, 2018, while the plant was in MODE 1 at 90 percent power, it was identified that an additional condition existed which had not previously been considered in developing the compensatory measures implemented for design flaws and single point vulnerabilities associated with the Control Building Chilled Water System. Specifically, a 20 minute 'quick restart timer' on Control Building Chillers that have analog control systems (HVK-CHL1A & 1B) would prevent the chillers from starting in specific scenarios.
"The recommended compensatory actions to address the new condition were implemented at 1235 CDT on September 25, 2018.
"Currently the Chilled Water System is otherwise operating as designed. Operator actions are in place to ensure the plant meets all required design safety system functions. Work is currently underway to identify and correct all design vulnerabilities.
"The [NRC] Senior Resident Inspector has been notified."
This was identified by engineering during an extended condition search. | |