Event Notification Report for March 22, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/21/2017 - 03/22/2017
EVENT NUMBERS
52634526535265952660
Agreement State
Event Number: 52634
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT State: TX
County:
License #: 06443
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT State: TX
County:
License #: 06443
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/23/2017
Notification Time: 17:30 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/21/2017
Notification Time: 17:30 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - FOUR STUCK SHUTTERS IDENTIFIED DURING A SIX MONTH INSPECTION
The following report was received from the Texas Department of State Health Services via email:
"On March 23, 2017, [at 1545 CDT] a consulting company called the Agency [Texas Department of State Health Services] to report that on March 22, 2017, during [a] six month inspection of devices, four devices were found with stuck shutters. Two Ohmart Vega devices contained cesium-137, models SHLG with source serial numbers SM-6918 (120 milliCuries) and 5811GK (5000 milliCuries). The other two were [the] same manufacturer, same isotope, but model SHF2 with source serial numbers M-0076 and M-0077 at 200 milliCuries each. The consulting service is in contact with the licensee's radiation safety officer who is submitting a request to amend the license maintaining the devices in the open position until repaired. No exposures are anticipated and the repairs should be performed within the next 90 days. Updates will be provided as received."
Texas Incident #: I 9473
* * * UPDATE ON 4/12/17 AT 1416 EDT FROM ART TUCKER TO DONG PARK * * *
The following information was provided by the State of Texas via email:
"On April 12, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that part of its corrective actions in response to this event was to inspect all the gauge shutters again to insure proper operation. The inspection was done on April 11, 2017. During this inspection, two additional gauge shutters were found stuck in the open position.
"Both gauges are Ohmart model SH-F2 gauges one with a 30 millicurie cesium-137 source, and the second one contains a 100 millicurie [cesium-137] source. No member of the general public or employees at the facility will receive any additional exposure from this event. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Kramer) and NMSS Events Notification via email.
* * * UPDATE ON 4/21/17 AT 1628 EDT FROM ART TUCKER TO DONG PARK * * *
The following information was provided by the State of Texas via email:
"The Agency [Texas Department of State Health Services] received inspection reports from the licensee and has identified two additional gauges, one SHGL-1 and one SHGL-2, that were found to have shutters that would not close. This inspection occurred in October, 2015. The gauges were reported as functional on the next inspection in April of 2016. The Agency has requested additional information on the gauges. The Agency will be performing an on-site inspection on May 4, 2017. The licensee has replaced the radiation safety officer. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Azua) and NMSS Events Notification via email.
The following report was received from the Texas Department of State Health Services via email:
"On March 23, 2017, [at 1545 CDT] a consulting company called the Agency [Texas Department of State Health Services] to report that on March 22, 2017, during [a] six month inspection of devices, four devices were found with stuck shutters. Two Ohmart Vega devices contained cesium-137, models SHLG with source serial numbers SM-6918 (120 milliCuries) and 5811GK (5000 milliCuries). The other two were [the] same manufacturer, same isotope, but model SHF2 with source serial numbers M-0076 and M-0077 at 200 milliCuries each. The consulting service is in contact with the licensee's radiation safety officer who is submitting a request to amend the license maintaining the devices in the open position until repaired. No exposures are anticipated and the repairs should be performed within the next 90 days. Updates will be provided as received."
Texas Incident #: I 9473
* * * UPDATE ON 4/12/17 AT 1416 EDT FROM ART TUCKER TO DONG PARK * * *
The following information was provided by the State of Texas via email:
"On April 12, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that part of its corrective actions in response to this event was to inspect all the gauge shutters again to insure proper operation. The inspection was done on April 11, 2017. During this inspection, two additional gauge shutters were found stuck in the open position.
"Both gauges are Ohmart model SH-F2 gauges one with a 30 millicurie cesium-137 source, and the second one contains a 100 millicurie [cesium-137] source. No member of the general public or employees at the facility will receive any additional exposure from this event. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Kramer) and NMSS Events Notification via email.
* * * UPDATE ON 4/21/17 AT 1628 EDT FROM ART TUCKER TO DONG PARK * * *
The following information was provided by the State of Texas via email:
"The Agency [Texas Department of State Health Services] received inspection reports from the licensee and has identified two additional gauges, one SHGL-1 and one SHGL-2, that were found to have shutters that would not close. This inspection occurred in October, 2015. The gauges were reported as functional on the next inspection in April of 2016. The Agency has requested additional information on the gauges. The Agency will be performing an on-site inspection on May 4, 2017. The licensee has replaced the radiation safety officer. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Azua) and NMSS Events Notification via email.
Agreement State
Event Number: 52653
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: INTERNATIONAL PAPER
Region: 1
City: GEORGETOWN State: SC
County:
License #: 060
Agreement: Y
Docket:
NRC Notified By: LELAND R. CAVE
HQ OPS Officer: DONG HWA PARK
Licensee: INTERNATIONAL PAPER
Region: 1
City: GEORGETOWN State: SC
County:
License #: 060
Agreement: Y
Docket:
NRC Notified By: LELAND R. CAVE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/31/2017
Notification Time: 11:21 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 03/31/2017
Notification Time: 11:21 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 03/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILL COOK (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BILL COOK (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER
The following report was received from the South Carolina Department of Health and Environmental Control via email:
"The licensee provided notification of a stuck shutter on a Berthold Model LB7440 fixed gauging device. The shutter was stuck in the open position. The gauging device contains 100 mCi of Cs-137. A licensed contractor found the shutter stuck in the open position on March 22, 2017, and the licensee notified the State [of South Carolina] on March 30, 2017. The contractor proceeded with corrective maintenance on the shutter mechanism. The licensee stated that a written report will be sent within 30 days of the event. Updates to this event will be made through the NMED system."
The following report was received from the South Carolina Department of Health and Environmental Control via email:
"The licensee provided notification of a stuck shutter on a Berthold Model LB7440 fixed gauging device. The shutter was stuck in the open position. The gauging device contains 100 mCi of Cs-137. A licensed contractor found the shutter stuck in the open position on March 22, 2017, and the licensee notified the State [of South Carolina] on March 30, 2017. The contractor proceeded with corrective maintenance on the shutter mechanism. The licensee stated that a written report will be sent within 30 days of the event. Updates to this event will be made through the NMED system."
Agreement State
Event Number: 52659
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: 02500250000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: STEVE SANDIN
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: 02500250000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 14:33 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2017
Notification Time: 14:33 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RICHARD SKOKOWSKI (R3DO)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - PACKAGE LOST DURING SHIPMENT
The following information was provided by the State of Ohio via email:
"On 3/31/17 the licensee (Cardinal Health) notified ODH [Ohio Department of Health] that a package containing a Ge [Germanium] Generator was being returned to the manufacturer (IRE Elit) in Belgium.
"The package was sent on 3/7/17 and on 3/22/17 Cardinal was notified by IRE that the package had not arrived. Cardinal immediately contacted the shipper [common carrier] concerning the package and at that time they had indication that it was stuck in customs in Paris, France.
"On 3/31/17 Cardinal was told by [common carrier] that the package has not been located in customs and they are continually searching for the package.
"On 4/3/17 licensee told by [common carrier] that there was no record that the package had ever left the [common carrier] hub in . . . and still have not located the package.
"Package is labeled as a Yellow II DOT Type A container with 1371 MBq (37 mCi) of Germanium 68. Solid/self-shielded container with a TI at shipment of 0.3.
"Item No.: OH170002
"Reference Number: OH 2017-017"
* * *UPDATE FROM STEPHEN JAMES TO VINCE KLCO ON 4/11/17 AT 1618 EDT * * *
The following information was received from the State of Ohio via email:
"Package was located by common carrier and returned to the licensee (Cardinal Health) in Dublin, Ohio. Package had one of two security seals still intact; however, licensee stated that there was no indication that package had been opened during time in transit. Package will be wipe tested and repacked for return to manufacturer."
Notified the R1DO (Jackson), R3DO (Jeffers) and NMSS Events via email.
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 State of Ohio via email:
"On 3/31/17 the licensee (Cardinal Health) notified ODH [Ohio Department of Health] that a package containing a Ge [Germanium] Generator was being returned to the manufacturer (IRE Elit) in Belgium.
"The package was sent on 3/7/17 and on 3/22/17 Cardinal was notified by IRE that the package had not arrived. Cardinal immediately contacted the shipper [common carrier] concerning the package and at that time they had indication that it was stuck in customs in Paris, France.
"On 3/31/17 Cardinal was told by [common carrier] that the package has not been located in customs and they are continually searching for the package.
"On 4/3/17 licensee told by [common carrier] that there was no record that the package had ever left the [common carrier] hub in . . . and still have not located the package.
"Package is labeled as a Yellow II DOT Type A container with 1371 MBq (37 mCi) of Germanium 68. Solid/self-shielded container with a TI at shipment of 0.3.
"Item No.: OH170002
"Reference Number: OH 2017-017"
* * *UPDATE FROM STEPHEN JAMES TO VINCE KLCO ON 4/11/17 AT 1618 EDT * * *
The following information was received from the State of Ohio via email:
"Package was located by common carrier and returned to the licensee (Cardinal Health) in Dublin, Ohio. Package had one of two security seals still intact; however, licensee stated that there was no indication that package had been opened during time in transit. Package will be wipe tested and repacked for return to manufacturer."
Notified the R1DO (Jackson), R3DO (Jeffers) and NMSS Events via email.
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: 52660
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNIVERSITY OF VIRGINIA OFFICE OF ENVIRONMENTAL HEALTH AND SA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF VIRGINIA OFFICE OF ENVIRONMENTAL HEALTH AND SA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 16:07 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2017
Notification Time: 16:07 [ET]
Event Date: 03/22/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - WRITTEN DIRECTIVE INCORRECTLY IDENTIFIED THE TARGET ORGAN
The following information was received from the Commonwealth of Virginia via fax:
"On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive.
"The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated.
"ORH will review the licensee's written report and determine additional actions to be taken.
"Event Report ID No.: VA-17-004"
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 Commonwealth of Virginia via fax:
"On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive.
"The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated.
"ORH will review the licensee's written report and determine additional actions to be taken.
"Event Report ID No.: VA-17-004"
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.