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Event Notification Report for March 20, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/19/2020 - 3/20/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54581
Rep Org: SC DEPT OF HEALTH & ENV CONTROL Licensee: ECS SOUTHEAST, LLP Region: 1 City: LITTLE RIVER State: SC County: License #: 958 Agreement: Y Docket: NRC Notified By: JIM PETERSON HQ OPS Officer: BRIAN LIN	Notification Date: 03/11/2020 Notification Time: 11:48 [ET] Event Date: 03/11/2020 Event Time: 08:15 [EDT] Last Update Date: 03/11/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PATRICK FINNEY (R1DO) ILTAB (EMAIL) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - STOLEN GAUGE

The following information was received from the state of South Carolina via email:

"On March 11, 2020, the Department [South Carolina Department of Health and Environmental Control (SCDHEC)] was notified by the licensee at approximately 0815 [EDT] that a portable gauging device had been stolen from the licensee's storage location at 19 Highway 90 East, Little River. The gauging device is an Instrotek Model 3500 [moisture density gauge], serial number 722. This device contains 10 milliCuries of Cs-137 and 40 milliCuries of Am-241:Be. The licensee stated that the theft has been reported to local law enforcement. SCDHEC has notified the South Carolina Law Enforcement Division's Fusion Center."

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: 54582
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: ROSWELL PARK CANCER INSTITUTE CORP Region: 1 City: BUFFALO State: NY County: License #: 2923 Agreement: Y Docket: NRC Notified By: DANIEL SAMSON HQ OPS Officer: SILAS KENNEDY	Notification Date: 03/11/2020 Notification Time: 16:38 [ET] Event Date: 01/27/2020 Event Time: 00:00 [EDT] Last Update Date: 03/11/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PATRICK FINNEY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - MISSING IODINE-125 SEED

The following information was received from the state of New York via email:

"On February 13, 2020, the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Activity: approximately 252 microCuries) at Roswell Park Cancer Institute in Buffalo, New York."

"An l-125 localization seed was removed from a patient, along with a specimen, in a procedure that took place on January 27, 2020. The seed and specimen are believed to have been delivered to the facility's Pathology Department. The RSO [Radiation Safety Officer] was informed of the missing seed on February 10, 2020. Currently, the facility is trying to locate the missing seed. Updates will be provided as they become available."

New York Event Report ID No. NYDOH-20-01

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: 54583
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: ST. JOSEPH'S DIAGNOSTIC CENTER, LLC Region: 1 City: TAMPA State: FL County: License #: 1889-1 Agreement: Y Docket: NRC Notified By: MATTHEW G. SENISON HQ OPS Officer: SILAS KENNEDY	Notification Date: 03/11/2020 Notification Time: 18:48 [ET] Event Date: 02/03/2020 Event Time: 00:00 [EDT] Last Update Date: 03/11/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PATRICK FINNEY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF CONTROL OF A Cs-137 SOURCE

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

"St. Joseph's called the BRC [Bureau of Radiation Control] to notify that a source was unintentionally removed from their facility. They had contracted with North American Philips to trade in an old PET/CT Scanner and replace it with a new one. The licensee had cleared and reserved the room for the contractor to work in for a week. The old scanner had a sealed Cs-137 calibration source inside [16.57 milliCuries], and when the contractor removed it, they did not remove the source and leave it with the licensee as was agreed. The contractor notified the licensee when they realized they had possession of the source. The source is now at the North American Philips site in Nashville, TN. The new PET/CT will not have the referenced source; North American Philips has offered to dispose of it through Bionomics. The licensee has expressed willingness to proceed with that option rather than have the source returned. Since the contractor, rather than the licensee, misappropriated the source, an on-site visit from an inspector is not requested at this time."

Florida Incident Number: FL20-034

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

Part 21	Event Number: 54588
Rep Org: ENGINE SYSTEMS, INC. Licensee: ENGINE SYSTEMS, INC. Region: 1 City: ROCKY MOUNT State: NC County: License #: Agreement: Y Docket: NRC Notified By: DAN ROBERTS HQ OPS Officer: ANDREW WAUGH	Notification Date: 03/19/2020 Notification Time: 16:38 [ET] Event Date: 03/19/2020 Event Time: 00:00 [EDT] Last Update Date: 03/19/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): CHRISTOPHER CAHILL (R1DO) MARK MILLER (R2DO) JOHN HANNA (R3DO) NEIL O'KEEFE (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - TEST STAND DEFICIENCY

The following is a summary of information obtained from Engine Systems, INC. (ESI) via fax:

On February 14, 2019, ESI determined that all new P/N H40084720 EMD fuel injectors they supplied are considered suspect. The endurance test stand utilized for new EMD fuel injectors was found to contain a deficiency that may damage injectors during the testing process. There is a potential for the actuating stem of the endurance test stand to strike the injector follower off center, creating side loading that results in inadvertent rubbing between the follower and body. The condition is exacerbated by a lack of continuous lubrication from the test stand. Over the 2-hour test duration, the running surface of the follower scores and metal particles are introduced into the top end of the injector. The migration of these particles through the injector could initiate a seizure.

An improperly functioning fuel injector could affect the load carrying capability of the diesel engine and adversely affect the diesel's ability to perform its safety-related function.

The licensees affected are Columbia, St. Lucie, Dresden, Fitzpatrick, Point Beach, Turkey Point, Quad Cities, and Grand Gulf.

Points of Contact: John Kriesel, Engineering Manager and Dan Roberts, Quality Manager at Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804. Office number: 252-977-2720

Page Last Reviewed/Updated Wednesday, March 24, 2021