Event Notification Report for April 05, 2018

LOST RADIOACTIVE MATERIAL

"A Marine Corps CH-53 helicopter crashed around 1453 PDT on 5 April 2018 at the outlying landing field of Naval Air Facility El Centro, California. This helicopter carries seven in-blade-inspection-systems (IBIS), one per blade, and each one carries a strontium-90 source with an activity of 0.5 milliCuries. The U.S. Navy was able to retrieve five of the IBIS, but two of them were not located after several surveys of the aircraft and the surrounding area. The U.S. Navy is reporting those two sources as lost for a total 1 milliCurie of strontium-90."

The Licensee has notified NRC Region 1 (Seeley) and (Elliott).


* * * UPDATE FROM L.L. FRAGOSO (VIA EMAIL) TO HOWIE CROUCH AT 1242 EDT ON 4/12/18 * * *

"The sixth strontium-90 source has been found buried under the fuselage wreckage. That leaves only one strontium-90 source missing for a total of 0.5 mCi lost."

Notified R1DO (Jackson) and NMSS Events Notification (email).


* * * UPDATE FROM L.L. FRAGOSO (VIA EMAIL) TO ANDREW WAUGH AT 0902 EDT ON 4/18/18 * * *

"The last report was made in error. Upon evaluation of the sixth IBIS (buried underneath a gear box), they found no source pin, hence we still have two missing IBIS sources. Personnel will be surveying the area in the next couple of days in the hope of finding the two missing sources."

Notified R1DO (Lilliendahl) and NMSS Events Notification (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

SECONDARY CONTAINMENT HATCH LEFT OPEN

"On Thursday, April 5, 2018, at approximately 1117 hours Central Daylight Time, Entergy contract personnel opened the personnel hatch allowing access to the roof of the Secondary Containment Building for the purposes of performing an inspection of various items located on the roof.

"During the time period the individuals were on the roof, the hatch was left open. An individual was adjacent to the door with a radio and had constant communication link with the control room operator.

"Pursuant 10 CFR 50.72(b)(3)(v)(C), and 10 CFR 50.72(b)(3)(v)(D) this event is being reported as an event or condition that could have prevented the fulfillment of a safety function.

"Because the site had an individual briefed and at the door in constant communications with the control room to close the hatch if condition required such an action, this event is not viewed as an actual loss of safety function."

The NRC Resident Inspector was notified.

AGREEMENT STATE REPORT - STUCK SOURCE

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

"American Crystal Sugar Company experienced a stuck sealed source (Berthold Technologies U.S.A., LLC Model SSC-100, 60 milliCuries [Co-60] at calibration) in a source tube located inside a vessel during a routine shutter check at their Hillsboro, ND location. The sealed source is fixed to a cable which allows the source to be lowered through a source tube which is located inside a vessel. Upon attempting to retract the source into the shielded gauge housing (Berthold Technologies U.S.A., LLC Model LB 8120-01) to perform the shutter check, the source did not budge. The licensee contacted Berthold Technologies U.S.A., LLC (manufacturer) regarding the stuck source. Berthold personnel instructed the licensee to apply a penetrating oil to the source tube in an attempt to break it loose. As of the notification time, the source remained lodged in the source tube in its normal operating position. The five detectors associated with this source continue to read radiation levels as expected. The licensee will continue to apply the penetrating oil and attempt to pull it back into the shielded gauge housing and provide an update in the morning. More information will be provided as received."

ND Incident Report # ND180001

AGREEMENT STATE REPORT - ABANDONED SOURCE

The following was received from the State of Illinois via email:

"At approximately 0904 [CDT] on 4/5/18, the Agency [Illinois Emergency Management Agency (IEMA)] received a call reporting a radioactive source abandoned near a dumpster in residential Carpentersville, IL. Carpentersville Fire and Hazmat was managing the scene. A patrol with the Carpentersville police department reported finding the source at approximately 0806 [CDT] this morning and utilized the manufacturer label and emergency contact information on the package to notify Siemens Medical Solutions. Police had secured the scene until the fire department had arrived. Siemens' RSO [Radiation Safety Officer] had arrived on scene by 0930 [CDT] and contacted the IEMA radioactive materials section. The RSO confirmed the source to be an improperly abandoned Ge-68 phantom source (model CS-20-1, S/N 11054). Review of the Siemens license confirmed they were authorized for possession of the material and qualified to perform an assessment/transport. After discussion with Fire/Hazmat and IEMA, the RSO took possession of the phantom and the scene was cleared. At 1026 [CDT], the Agency received confirmation of the source being safely placed in Siemens' licensed storage area. Additional leak tests confirmed no contamination and Siemens is tracking down the owner of the source. Preliminary checks show the source was originally shipped to California. Additional details will be provided as they become available.

"The radioactive material recovered was a Ge/Ga-68 epoxy-based reference source utilized in the calibration of PET/CT scanners. The Ge-68 source was contained within its storage packaging and exhibited exposure rates of 0.8 mR/h at one foot and 0.090 mR/h at one meter. Although it originally contained 1.39 mCi of Ge/Ga-68 (assay date of March 31, 2016), the source had decayed to approximately 212 microCuries. However, unshielded contact exposure rate could still be as high as 1100 mR/h on contact. The police officer and fire department personnel established a fifty foot perimeter and never got closer than seven feet to the package. There are no exposure concerns resulting from this incident. The package markings were clearly displayed and no effort was apparent to cover or deface."

Illinois Report Number: IL180026


* * * UPDATE ON 04/10/18 AT 1347 EDT FROM GARY FORSEE TO ANDREW WAUGH * * *

The following update was received from the State of Illinois via email regarding two additional missing sources:

"At approximately 0904 [CDT] on 4/5/18, the Agency received a call reporting a radioactive source abandoned near a dumpster in residential Carpentersville, IL. A patrol with the Carpentersville police department reported finding the source at approximately 0806 [CDT] that morning and utilized the manufacturer label and emergency contact information on the package to notify Siemens Medical Solutions. Police had secured the scene until the fire department had arrived. Siemens' RSO had arrived on scene by 0930 [CDT] and contacted the IEMA radioactive materials section. The RSO confirmed the source to be an improperly abandoned Ge-68 phantom source (model CS-20-1, S/N 11054). Review of the Siemens license confirmed they were authorized for possession of the material and qualified to perform an assessment/transport. After discussion with Fire/Hazmat and IEMA, the RSO took possession of the phantom and the scene was cleared. At 1026 [CDT], the Agency received confirmation of the source being safely placed in Siemens' licensed storage area. Additional leak tests confirmed no contamination and the phantom source is pending proper disposal at the manufacturer's Knoxville, TN location. In coordination with Siemens and State of California officials, it was determined the source was originally supplied to Huntington Memorial Hospital in Pasadena, CA. On the evening of 4/5/18, officials with the State of California confirmed Huntington Memorial Hospital's PET/CT unit was serviced and (3) sources shipped for disposal by Zetta Medical (a non-licensed company based out of Lake Zurich, IL). This 11/27/17 servicing by Zetta Medical resulted in the removal and replacement of the following sources: Ge-68 1.14 mCi rod source (S/N 19626), Ge-68 1.14 mCi rod source (S/N 19625), and a Ge-68 1.39 mCi phantom source (S/N 11054). IEMA staff contacted Eckert and Ziegler and confirmed that neither package was received at their company. At this point, IEMA notified first responders and other state and federal partners of the two additional missing sources. IEMA staff dispatched two responders to conduct gamma scintillator surveys of the area where the phantom was found. Extensive searches of the area on the afternoon of 4/6/18, did not result in locating the two missing Ge-68 rod sources.

"IEMA performed an investigation at Zetta Medical on 4/9/18. According to provided FedEx manifests and shipping receipts, Zetta Medical's on site technician, packaged the three sources and transported them to a local FedEx drop off location on 12/7/17. The location of the sources from the time of removal on 11/27/17 until 12/7/17 remains under investigation as well. The shipping manifest was obtained that identifies Zetta Medical as the shipper. The intended recipient was Eckert and Ziegler in California. The shipper/recipient information was inadvertently reversed; resulting in the sources being shipped to Zetta Medical in Lake Zurich. The two packages arrived in Lake Zurich, IL on 12/12/17. On 12/13/17, Zetta Medical attempted to ship the sources back to Eckert and Zeigler in Burbank, CA via Pilot Freight Services. The two packages were consigned as UN2915 for return via air out of O'Hare airport to LAX. The two packages were returned to Zetta Medical on 12/19/17. At this point, the sources were stored in Zetta Medical's warehouse for several months.

"The Zetta Medical employee claims to have packaged and shipped the two packages (containing three Ge-68 sources total) back to Eckert and Zeigler via FedEx on or around 3/12/18. Although electronic shipping records are retained for outgoing shipments, Zetta Medical representatives said this shipment did not have an electronic record. Video surveillance is present in the company. However, the equipment was not recording for the time period of concern. After speaking with FedEx's corporate Radiation Safety Officer and their review of dispatch records over the last four months, FedEx has determined they have no records of a hazmat (radioactive) package being picked up from Zetta Medical. Police found the abandoned phantom source at the dumpster adjacent to the home of the Zetta Medical employee who claims to have shipped the packages.

"It was identified that Zetta Medical has performed unauthorized work with licensed radioactive material. It was also confirmed that representatives of Zetta Medical took possession of at least three Ge-68 sources before losing control of the same. This investigation remains open pending enforcement proceedings and pending paperwork from those entities involved.

"The radioactive material recovered was a Ge/Ga-68 epoxy-based reference source utilized in the calibration of PET/CT scanners. Ge-68 has a 271 day half-life, with gamma exposure from the Ga-68 daughter in equilibrium. The recovered Ge-68 source exhibited exposure rates of 0.8 mR/h at one foot and 0.090 mR/h at one meter. Although it originally contained 1.39 mCi of Ge/Ga-68 (assay date of 3/31/16), the source had decayed to approximately 212 microCi. Leak tests were taken on scene and confirmed to not have removable contamination. The police officer and fire department personnel established a fifty foot perimeter and never got closer than seven feet to the package. There are no exposure concerns resulting from this portion of the incident. The package markings were clearly displayed and no effort was apparent to cover or deface.

"The two remaining, missing Ge-68 rod sources were originally assayed with 1.14 mCi of activity each. They now each contain approximately 0.2 mCi of Ge-68 and are sealed in a 0.25" x 11" steel rod. There should be no airborne hazard due to the internal matrix unless immersed in fire. Data made available from the manufacturer states if the sources are removed from their shielding, the exposure rate would be approximately 1 mR/h at one foot and 100 microR/h at one meter. There are no exposure concerns reported from this incident; however, efforts to recover the remaining two sources are still ongoing."

Notified R3DO (Stone), ILTAB DO (Ahern), and NMSS Events Notification (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