Event Notification Report for January 24, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/23/2019 - 01/24/2019
EVENT NUMBERS
53845538475384454647
Non-Agreement State
Event Number: 53845
Rep Org: NUCOR STEEL
Licensee: NUCOR STEEL
Region: 3
City: Crawfordsville State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: SHAWN AKER
HQ OPS Officer: JEFFREY WHITED
Licensee: NUCOR STEEL
Region: 3
City: Crawfordsville State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: SHAWN AKER
HQ OPS Officer: JEFFREY WHITED
Notification Date: 01/24/2019
Notification Time: 15:36 [ET]
Event Date: 01/24/2019
Event Time: 07:00 [EST]
Last Update Date: 01/24/2019
Notification Time: 15:36 [ET]
Event Date: 01/24/2019
Event Time: 07:00 [EST]
Last Update Date: 01/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GAUGE NOT OPERATING DUE TO POWER LOSS TO UNIT
The following was received via e-mail:
"[The Nucor Steel] Electrician received a call this morning at approximately 0700 EST by the slitter line operator notifying him that the slitter line gauge was not operating and had no power to the entire unit. The electrician did a survey to ensure the shutter was closed on the device. He measured 12 microR/hr on contact, at 1 foot and at 3 feet. At that time he trouble shot the electrical and determined that it was something that was not going to be resolved quickly so he locked out the device and did another survey to confirm that the shutter was closed. He used a Fluke 451 meter serial# 2194 Calibration date 5/30/2018.
"[The Nucor Engineer] went over this afternoon to confirm the survey with another meter and got 18 microR/hr on contact, 8 microR/hr at 1 foot with a background of 5 microR/hr, [using] a fluke 451P serial #6064 meter with calibration date 5/30/2018.
"[Nucor] maintenance personnel are planning on continuing to troubleshoot the electrical issue and determine whether they can fix it or they will need to call in an outside vendor tomorrow. Only electrical work on power to the system will be performed by Nucor personnel.
"[The Nucor] radioactive materials registration is XF7000385, expires 12/9/19. The gauge is a DMC AM-5A Serial# BS957911 with a Am-241 source 1 Curie activity Serial# 5135LV."
No personnel radiation exposure occurred due to this event.
No additional notifications were performed by the licensee.
The following was received via e-mail:
"[The Nucor Steel] Electrician received a call this morning at approximately 0700 EST by the slitter line operator notifying him that the slitter line gauge was not operating and had no power to the entire unit. The electrician did a survey to ensure the shutter was closed on the device. He measured 12 microR/hr on contact, at 1 foot and at 3 feet. At that time he trouble shot the electrical and determined that it was something that was not going to be resolved quickly so he locked out the device and did another survey to confirm that the shutter was closed. He used a Fluke 451 meter serial# 2194 Calibration date 5/30/2018.
"[The Nucor Engineer] went over this afternoon to confirm the survey with another meter and got 18 microR/hr on contact, 8 microR/hr at 1 foot with a background of 5 microR/hr, [using] a fluke 451P serial #6064 meter with calibration date 5/30/2018.
"[Nucor] maintenance personnel are planning on continuing to troubleshoot the electrical issue and determine whether they can fix it or they will need to call in an outside vendor tomorrow. Only electrical work on power to the system will be performed by Nucor personnel.
"[The Nucor] radioactive materials registration is XF7000385, expires 12/9/19. The gauge is a DMC AM-5A Serial# BS957911 with a Am-241 source 1 Curie activity Serial# 5135LV."
No personnel radiation exposure occurred due to this event.
No additional notifications were performed by the licensee.
Agreement State
Event Number: 53847
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: INSPIRA MEDICAL CENTERS, INC.
Region: 1
City: VINELAND State: NJ
County:
License #: 450632
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: THOMAS KENDZIA
Licensee: INSPIRA MEDICAL CENTERS, INC.
Region: 1
City: VINELAND State: NJ
County:
License #: 450632
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/25/2019
Notification Time: 10:37 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [EST]
Last Update Date: 01/25/2019
Notification Time: 10:37 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [EST]
Last Update Date: 01/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSED BY GREATER THAN 20 PERCENT
The following was received from the State of New Jersey via email:
"While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. 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.
The following was received from the State of New Jersey via email:
"While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. 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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 53844
Rep Org: TILDEN MINING COMPANY L.C.
Licensee: TILDEN MINING COMPANY L.C.
Region: 3
City: ISHPEMING State: MI
County:
License #: 21-26748-01
Agreement: N
Docket:
NRC Notified By: LAWRENCE GRAY
HQ OPS Officer: DONALD NORWOOD
Licensee: TILDEN MINING COMPANY L.C.
Region: 3
City: ISHPEMING State: MI
County:
License #: 21-26748-01
Agreement: N
Docket:
NRC Notified By: LAWRENCE GRAY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/24/2019
Notification Time: 11:14 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [EST]
Last Update Date: 02/18/2019
Notification Time: 11:14 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [EST]
Last Update Date: 02/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FAILURE TO CLOSE AND LOCK NUCLEAR GAUGE SHUTTER
The following was received via e-mail:
"Between 2200 EST on January 23, 2019 and 0000 EST on January 24, 2019 a Ronan RLL1 [Density Scale Source] was unbolted from the frame on which it was mounted and placed on the floor. (Source was a Cs-137 0.54 milliCurie decayed to 0.45 milliCurie, Serial #212785A)
"No permit was pulled to remove the scale source, and the shutter wasn't closed and locked out.
"After it was unbolted, and was placed on the floor with the beam pointed towards a conveyor belt and the ceiling.
"Balling line 10, Conveyor 21 was approximately 6 feet above the placed source, and the ceiling is at 60 feet.
"No employees worked in front of the beam once placed on the floor.
"No one noticed the scale sitting on the floor unlocked until January 24, 2019 around 1500 EST.
"Once the source was found, trained personnel put the shutter block in place and locked out the source.
"The RSO then authorized a permit.
"Once the source was secured, and permit posted, the RSO did a full investigation.
"Basic cause - The maintenance employee that unbolted the source entered the area from a direction that could only be accessed during a maintenance down. There was a radiation label on the scale itself, but no sign from his access point."
* * * RETRACTION ON 2/18/19 AT 1311 EST FROM LAWRENCE GRAY TO THOMAS KENDZIA * * *
Based on the findings of an NRC inspector, this event was determined to not be reportable since the shutter was fully functional and no exposure to personal occurred.
Notified R3DO (Duncan), NMSS Events Notification Group by email.
The following was received via e-mail:
"Between 2200 EST on January 23, 2019 and 0000 EST on January 24, 2019 a Ronan RLL1 [Density Scale Source] was unbolted from the frame on which it was mounted and placed on the floor. (Source was a Cs-137 0.54 milliCurie decayed to 0.45 milliCurie, Serial #212785A)
"No permit was pulled to remove the scale source, and the shutter wasn't closed and locked out.
"After it was unbolted, and was placed on the floor with the beam pointed towards a conveyor belt and the ceiling.
"Balling line 10, Conveyor 21 was approximately 6 feet above the placed source, and the ceiling is at 60 feet.
"No employees worked in front of the beam once placed on the floor.
"No one noticed the scale sitting on the floor unlocked until January 24, 2019 around 1500 EST.
"Once the source was found, trained personnel put the shutter block in place and locked out the source.
"The RSO then authorized a permit.
"Once the source was secured, and permit posted, the RSO did a full investigation.
"Basic cause - The maintenance employee that unbolted the source entered the area from a direction that could only be accessed during a maintenance down. There was a radiation label on the scale itself, but no sign from his access point."
* * * RETRACTION ON 2/18/19 AT 1311 EST FROM LAWRENCE GRAY TO THOMAS KENDZIA * * *
Based on the findings of an NRC inspector, this event was determined to not be reportable since the shutter was fully functional and no exposure to personal occurred.
Notified R3DO (Duncan), NMSS Events Notification Group by email.
Agreement State
Event Number: 54647
Rep Org: COLORADO DEPT OF HEALTH
Licensee: GARDEN COMMERCIAL PROPERTIES
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: GL001607
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Licensee: GARDEN COMMERCIAL PROPERTIES
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: GL001607
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/07/2020
Notification Time: 17:55 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Notification Time: 17:55 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [MDT]
Last Update Date: 04/07/2020
Emergency Class: Non Emergency
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following summary was received from the State of Colorado via E-mail:
The licensee is unable to locate two tritium exit signs with an activity of 11.5 Ci each. The site is a rental property. After the occupants moved out the property owner could not account for the exit signs.
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 summary was received from the State of Colorado via E-mail:
The licensee is unable to locate two tritium exit signs with an activity of 11.5 Ci each. The site is a rental property. After the occupants moved out the property owner could not account for the exit signs.
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