Event Notification Report for January 18, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/17/2016 - 01/18/2016
Agreement State
Event Number: 51689
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: NORTON HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 201-031-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: JOHN SHOEMAKER
Licensee: NORTON HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 201-031-26
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/27/2016
Notification Time: 12:36 [ET]
Event Date: 01/18/2016
Event Time: 00:00 [CST]
Last Update Date: 01/27/2016
Notification Time: 12:36 [ET]
Event Date: 01/18/2016
Event Time: 00:00 [CST]
Last Update Date: 01/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - LOST I-125 MEDICAL SEED
The following report was received from the Commonwealth of Kentucky via email:
"[The licensee] reported the loss of a I-125 localization seed (lsoAid Advantage, Model IAI-125A). On 1/19/16, the licensee discovered the number of seeds in storage did not match the number recorded. After the licensee conducted an investigation, they believe the seed was lost when it was transferred from the vial, pathology puts them in, to the Cidex storage/decontamination vial. The seeds in the vial had been placed there between 12/21/15 and 1/18/16. As part of the investigation the licensee verified that all seeds were removed from patients during that time and the hot lab was thoroughly searched.
"They [the licensee] believe the I-125 seed was most likely disposed of in the trash and taken to landfill with other waste from the hospital. The licensee reported the missing seed came from one of the three orders, lot #39858, 0.147 mCi as of 1/19/16, lot #39809, 0.128 mCi as of 1/19/16, or lot #39111, 0.075 mCi as of 1/19/16. Corrective actions include retraining Nuclear Medicine Techs in the handling of radioactive breast seeds, including stressing the importance of surveying all material to verify that the seed was placed in the Cidex vial and not lost in the surrounding area.
Kentucky Event Report ID No.: KY160001
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 report was received from the Commonwealth of Kentucky via email:
"[The licensee] reported the loss of a I-125 localization seed (lsoAid Advantage, Model IAI-125A). On 1/19/16, the licensee discovered the number of seeds in storage did not match the number recorded. After the licensee conducted an investigation, they believe the seed was lost when it was transferred from the vial, pathology puts them in, to the Cidex storage/decontamination vial. The seeds in the vial had been placed there between 12/21/15 and 1/18/16. As part of the investigation the licensee verified that all seeds were removed from patients during that time and the hot lab was thoroughly searched.
"They [the licensee] believe the I-125 seed was most likely disposed of in the trash and taken to landfill with other waste from the hospital. The licensee reported the missing seed came from one of the three orders, lot #39858, 0.147 mCi as of 1/19/16, lot #39809, 0.128 mCi as of 1/19/16, or lot #39111, 0.075 mCi as of 1/19/16. Corrective actions include retraining Nuclear Medicine Techs in the handling of radioactive breast seeds, including stressing the importance of surveying all material to verify that the seed was placed in the Cidex vial and not lost in the surrounding area.
Kentucky Event Report ID No.: KY160001
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: 51667
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-1280
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: STEVE SANDIN
Licensee: US STEEL
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-1280
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2016
Notification Time: 13:34 [ET]
Event Date: 01/18/2016
Event Time: 00:00 [EST]
Last Update Date: 01/20/2016
Notification Time: 13:34 [ET]
Event Date: 01/18/2016
Event Time: 00:00 [EST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - FAILED SHUTTER ASSEMBLY ON LEVEL CONTROL GAUGE
The following information was received from the Commonwealth of Pennsylvania via E-mail:
"The Department [Pennsylvania Department of Environmental Protection] was notified on January 19, 2016, that during routine activities on January 18, 2016, the weld on the collimator block, which is part of the shutter assembly to the gauge, failed. This event is reportable per 10 CFR 30.50(b)(2).
"The weld on the collimator block failed on a Thermo Measure Tech level control gauge. The shutter was closed at the time of the event and no workers received any dose. The licensee notified a service provider who responded and installed a new collimator assembly.
Device Information:
Manufacturer: Thermo Measure Tech
Model: 5204
Device Serial Number: B497
Isotope: Cesium-137
Activity: 4 curies
"[The cause is attributed to] equipment failure.
"A new shutter assembly was installed and tested. The Department plans a reactive inspection. More information will be provided upon receipt.
"Pennsylvania Event Report ID No.: PA160004"
The following information was received from the Commonwealth of Pennsylvania via E-mail:
"The Department [Pennsylvania Department of Environmental Protection] was notified on January 19, 2016, that during routine activities on January 18, 2016, the weld on the collimator block, which is part of the shutter assembly to the gauge, failed. This event is reportable per 10 CFR 30.50(b)(2).
"The weld on the collimator block failed on a Thermo Measure Tech level control gauge. The shutter was closed at the time of the event and no workers received any dose. The licensee notified a service provider who responded and installed a new collimator assembly.
Device Information:
Manufacturer: Thermo Measure Tech
Model: 5204
Device Serial Number: B497
Isotope: Cesium-137
Activity: 4 curies
"[The cause is attributed to] equipment failure.
"A new shutter assembly was installed and tested. The Department plans a reactive inspection. More information will be provided upon receipt.
"Pennsylvania Event Report ID No.: PA160004"
Fuel Cycle Facility
Event Number: 51662
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
Region: 2 State: NC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: STEVE SANDIN
Region: 2 State: NC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/19/2016
Notification Time: 15:56 [ET]
Event Date: 01/18/2016
Event Time: 21:00 [EST]
Last Update Date: 01/19/2016
Notification Time: 15:56 [ET]
Event Date: 01/18/2016
Event Time: 21:00 [EST]
Last Update Date: 01/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
GERALD MCCOY (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GERALD MCCOY (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ACCUMULATION OF URANIUM OXIDE POWDER IN THE DRY SCRAP RECYCLE FURNACE OFF-GAS SYSTEM
"It was discovered on 1/18/16, that an accumulation of uranium oxide existed that indicated a degradation of an IROFS [Item Relied On For Safety] in the dry scrap recycle furnace off-gas system. Approximately 42 kg of uranium oxide powder was removed from the favorable geometry off-gas dropout. The degraded IROFS resulted in a failure to meet performance requirements in the event of a fire. The dry scrap recycle operation had been shut down on 1/14/16 and was not in operation at the time.
"Additional controls on combustibles, geometry and moderation remained intact and at no time was an unsafe condition present.
"Additional corrective actions, extent of condition, and extent of cause are being investigated.
"This event is being communicated to meet the reporting requirements of 10CFR70, Appendix A(b)(2)."
The licensee will inform State and local agencies and NRC Region II.
"It was discovered on 1/18/16, that an accumulation of uranium oxide existed that indicated a degradation of an IROFS [Item Relied On For Safety] in the dry scrap recycle furnace off-gas system. Approximately 42 kg of uranium oxide powder was removed from the favorable geometry off-gas dropout. The degraded IROFS resulted in a failure to meet performance requirements in the event of a fire. The dry scrap recycle operation had been shut down on 1/14/16 and was not in operation at the time.
"Additional controls on combustibles, geometry and moderation remained intact and at no time was an unsafe condition present.
"Additional corrective actions, extent of condition, and extent of cause are being investigated.
"This event is being communicated to meet the reporting requirements of 10CFR70, Appendix A(b)(2)."
The licensee will inform State and local agencies and NRC Region II.