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Event Notification Report for February 21, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/20/2019 - 2/21/2019

** EVENT NUMBERS **

Fuel Cycle Facility	Event Number: 53869
Facility: LOUISIANA ENERGY SERVICES RX Type: Comments: URANIUM ENRICHMENT FACILITY GAS CENTRIFUGE FACILITY Region: 2 City: EUNICE State: NM County: LEA License #: SNM-2010 Docket: 70-3103 NRC Notified By: RICARDO MEDINA HQ OPS Officer: RICHARD SMITH	Notification Date: 02/12/2019 Notification Time: 13:55 [ET] Event Date: 02/11/2019 Event Time: 15:19 [MST] Last Update Date: 02/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS	Person (Organization): ERIC MICHEL (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

LOSS OR DEGRADATION OF SAFETY ITEMS

"[On February 11, 2019 at 1519 MST,] it was discovered that the calibration certificates for Measuring and Testing Equipment (M&TE) used to perform temperature trip IROFS [Items Relied On For Safety] surveillances, only had 1 set of calibration data. The instruments have an internal temperature sensor and an external input for temperature. Previously, the IROFS surveillances for IROFS 1, 2, 4, 5, 11, 43, C15, and C16 were performed using the external input.

"An external vendor, that performs the calibration for this M&TE, confirmed that the calibration had only been performed on the internal temperature sensor. This issue of how ATC-1 and ATC-2 (Jofra brand dry-block temperature calibrators) were calibrated is not currently an issue, as UUSA [URENCO USA] now only uses the Jofras as a heat source and uses a separately calibrated resistance temperature detector (RTD) and display for IROFS surveillances.

"Further investigation findings showed that a number of UF6 stations had not had their scheduled surveillance with the new method using a separately calibrated RTD. In total, 25 stations had their required annual IROFS surveillances performed with M&TE equipment which used an input that was not properly calibrated.

"The plant is in a safe condition."

The licensee will be contacting Region II.

Agreement State	Event Number: 53871
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: NORTH AMERICAN STAINLESS Region: 1 City: GHENT State: KY County: License #: 201-499-57 Agreement: Y Docket: NRC Notified By: ANJAN (AJ) BHATTACHARYYA HQ OPS Officer: BRIAN P. SMITH	Notification Date: 02/13/2019 Notification Time: 12:00 [ET] Event Date: 02/10/2019 Event Time: 00:00 [EST] Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE DEVICE DAMAGED BY MOLTEN STEEL

The following report was received from the Commonwealth of Kentucky via fax:

"KY RHB [Kentucky Radiation Health Branch] was notified by telephone on 2/12/2019 at 1315 EST by a representative from a specifically licensed facility, North American Stainless, that on Sunday, 2/10/2019, North American Stainless encountered a 'breakout' when molten steel escaped and poured onto billet caster molds located below a 'tundish' filled with molten steel. One of the molds attached to a Berthold Model No. LB300ML Mold Level Control fixed gauging device, serial number 9415, containing 1 mCi (37 MBq) Co-60 (source serial number 1819-11-15) was covered with the liquid steel encapsulating the source holder. After the steel and mold had cooled, it was freed on 2/12/2019 and segregated. The encapsulating steel rendered the device on-off mechanism (shutter) inoperable. Initial readings taken with a Ludlum 2241-3 survey instrument measured 6.25 mR/hr measured 12 inches directly in front of the window, and 1.25 mR/hr measured 90 degrees from the line of the window measured at a distance of 12 inches. Readings at the back of the source holder were 132 microR/hr measured at a distance of 12 inches. No overexposures have been reported. On 2/12/2019, Radiametric Technologies, a service provider located in Lorain, Ohio, requested reciprocal approval and was granted reciprocity on 2/13/2019 in order to assess and remediate the situation.

"The fixed gauging device involved in the incident was recently leak tested (test conducted on 7/31/2018) by Suntrac Services, League City TX. Radiametric Technologies, Lorain OH, recently tested the source holder on-off mechanism (1/31/2019) and it was found to be in good working order. North American Stainless is reviewing the incident to avoid future incidents involving 'tundish' failures. A full report will be provided once the remediation is complete.

"Reporting criteria in 10 CFR 30.50(b)(2)."

KY Report #KY190001

Non-Agreement State	Event Number: 53872
Rep Org: US ARMY AVIATION MISSILE COMMAND Licensee: US ARMY Region: 1 City: REDSTONE ARSENAL State: AL County: License #: 01-00126-21 Agreement: Y Docket: NRC Notified By: HAROLD DEASON HQ OPS Officer: JEFFREY WHITED	Notification Date: 02/13/2019 Notification Time: 12:12 [ET] Event Date: 01/31/2019 Event Time: 00:00 [CST] Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

REPORT OF LOSS OF AM-241 SOURCES CONTAINED IN HELICOPTER LASERS

The following is a summary of a call with the US Army Aviation Missile Command.

While taking inventory of sources located in decommissioned helicopter lasers, the US Army Aviation Missile Command identified that they were missing 88 Am-241 sources located in 44 helicopter lasers. It can not be determined exactly where the sources were lost, though the licensee is going to provide possible options, including that the lasers could have been lost during combat. It is assumed that the sources are not in public areas. It can not be determined when the sources were lost.

The licensee noted that it is unlikely anyone would receive a dose as a result of this loss of material because it is difficult to retrieve the sources.

The US Army continues to attempt to find the sources during routine house keeping activities. They have a similar license for a new aircraft and will perform inventory checks more frequently to ensure that any losses are more promptly reported.

The licensee has notified the NRC Regional Office.

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: 53873
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: BARD BRACHYTHERAPY Region: 3 City: CAROL STREAM State: IL County: License #: IL-02062-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: JEFFREY WHITED	Notification Date: 02/13/2019 Notification Time: 13:20 [ET] Event Date: 02/13/2019 Event Time: 00:00 [CST] Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ERIC DUNCAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - REPORT OF LOSS OF BRACHYTHERAPY SEEDS

The following was received from the State of Illinois via e-mail:

"The agency [Illinois Emergency Management Agency] was notified the morning of 2/13/19 by Bard Brachytherapy, IL-02062-01, in Carol Stream to advise that a package of (34) I-125 brachytherapy seeds arrived with no obvious damage, but (5) of the (34) seeds were unaccounted for. Facility staff were immediately alerted of the issue when [the common carrier] opened the dock door and meters alerted to elevated radiation readings. (2) seeds were identified by the licensee staff outside of the package on the floor. Package wipes were taken and there is no indication of removable contamination. Each of the seeds has a current activity of 0.346 mCi and would have an exposure rate of approximately 0.6 mR/h at one foot. There is currently no reason to suspect any malicious intent or deliberate diversion of package contents. The five unaccounted for seeds contain an aggregate activity of 1.73 microCuries as of 2/13/19.

"The [common carrier] driver's vehicle was surveyed by licensee staff. Additionally, it was determined that the driver picked the package up at O'Hare airport, went to the [common carrier's] hub and then directly to Bard. Licensee staff are coordinating with [the common carrier] and are currently en route to the hub to perform surveys. Additional details will be provided as they become available. This matter remains open."

Illinois Item Number: IL190008

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: 53874
Rep Org: NJ RAD PROT AND REL PREVENTION PGM Licensee: COOPER HEALTH SYSTEMS Region: 1 City: CAMDEN State: NJ County: License #: 438814 Agreement: Y Docket: NRC Notified By: RICHARD PEROS HQ OPS Officer: JEFFREY WHITED	Notification Date: 02/13/2019 Notification Time: 13:29 [ET] Event Date: 02/12/2019 Event Time: 00:00 [EST] Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POTENTIAL GAMMA KNIFE TREATMENT UNDERDOSE RECEIVED

The following was received from the state of New Jersey via e-mail:

"While receiving treatment with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, the patient's head may have slipped forward in the stereotactic frame by two millimeters. This was not noticed until after the treatment was completed. The licensee is not sure when the slippage occurred. If the movement occurred during treatment, the dose received would have been 50 percent of the prescribed dose. The authorized user and authorized medical physicist are in discussions with the Radiation Safety Officer concerning the matter. The licensee will follow-up with a full report."

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: 53875
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH Licensee: DESERT NDT, LLC DBA SHAWCOR Region: 4 City: ABILENE State: TX County: License #: 42-35224-01 Agreement: Y Docket: NRC Notified By: DAVID STRADINGER HQ OPS Officer: RODNEY CLAGG	Notification Date: 02/13/2019 Notification Time: 14:35 [ET] Event Date: 02/12/2019 Event Time: 16:45 [CST] Last Update Date: 02/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following information was received via email from the state of North Dakota:

"Desert NDT, LLC dba Shawcor reported a 3.256 TBq (88 Ci) Iridium-192 sealed source (Industrial Nuclear Model 32, serial #022E) had disconnected from a drive cable connected to an Industrial Nuclear Model IR-100 radiography exposure device (serial #4321) at a temporary job site in Williston, ND on 2/12/2019. The event occurred at 1645 [MST] while the radiography crew, consisting of a radiographer and assistant radiographer, was performing industrial radiography under extreme cold weather conditions on a pipe section. Upon retracting the source after the third exposure, the crew noticed the radiography device's safety latch did not pop up indicating the source in the safe/locked position. Upon performing a radiation survey while approaching the device, the crew noticed an increased exposure rate indicating a source disconnect. The crew immediately retreated from the device and reset an actual 2 mR/hr public dose boundary and contacted their radiation safety officer who made arrangements for authorized retrieval personnel to dispatch to the site. The crew maintained constant surveillance of the site while awaiting the source retrieval personnel. The source was successfully retrieved at 2020 [MST]. At the time of the event, the radiographer had received 50 mR and the assistant radiographer 55 mR on their direct reading dosimeters. The retrieval individual received a total of 357 mR to the direct reading dosimeter located on his arm and 243 mR to the direct reading dosimeter located on his chest. Shawcor will provide a detailed report to the North Dakota Department of Health upon establishing the root cause and corrective actions."

NMED Item #ND190001

Page Last Reviewed/Updated Wednesday, March 24, 2021