Event Notification Report for March 21, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/20/2019 - 03/21/2019
Agreement State
Event Number: 53957
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HOLLY ENERGY PARTNERS LLC
Region: 4
City: EL PASO State: TX
County:
License #: GLA02278
Agreement: Y
Docket:
NRC Notified By: MATTHEW KENNINGTON
HQ OPS Officer: JOANNA BRIDGE
Licensee: HOLLY ENERGY PARTNERS LLC
Region: 4
City: EL PASO State: TX
County:
License #: GLA02278
Agreement: Y
Docket:
NRC Notified By: MATTHEW KENNINGTON
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/25/2019
Notification Time: 17:53 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [CDT]
Last Update Date: 03/25/2019
Notification Time: 17:53 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [CDT]
Last Update Date: 03/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - STUCK OPEN GAUGE SHUTTER
The following was received via e-mail:
"On March 25, 2019, the agency [Texas Department of State Health Services] reviewed a voicemail left on an investigator's office phone line in which a licensee reported a stuck shutter on a gauge. The gauge is a Thermo Fisher Scientific model 7062BP, with serial number S99G0101, containing a 100 millicurie Cesium-137 source with serial number 6551GQ. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located on a 6" line and no exposures are anticipated as a result of this malfunction. The manufacturer has been contacted and service will be scheduled. Updates will be sent in accordance with SA-300."
Texas Incident: I-9668
The following was received via e-mail:
"On March 25, 2019, the agency [Texas Department of State Health Services] reviewed a voicemail left on an investigator's office phone line in which a licensee reported a stuck shutter on a gauge. The gauge is a Thermo Fisher Scientific model 7062BP, with serial number S99G0101, containing a 100 millicurie Cesium-137 source with serial number 6551GQ. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located on a 6" line and no exposures are anticipated as a result of this malfunction. The manufacturer has been contacted and service will be scheduled. Updates will be sent in accordance with SA-300."
Texas Incident: I-9668
Agreement State
Event Number: 53972
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: BAPTIST HEALTH LEXINGTON
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-004-27
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: JIM DRAKE
Licensee: BAPTIST HEALTH LEXINGTON
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-004-27
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: JIM DRAKE
Notification Date: 04/03/2019
Notification Time: 13:40 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2019
Notification Time: 13:40 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT- ELUATE EXCEEDED BREAKTHROUGH LIMITS ON RUBIDIUM - 82 GENERATOR
The following was received from the State of Kentucky via fax.
"On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO [Radiation Safety Officer] was notified and the hospital was instructed to discontinue use."
Kentucky Event Report ID No.: KY190003
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 Kentucky via fax.
"On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO [Radiation Safety Officer] was notified and the hospital was instructed to discontinue use."
Kentucky Event Report ID No.: KY190003
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 !!!!!
Agreement State
Event Number: 53952
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL CORPORATION
Region: 1
City: BRADDOCK State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Licensee: US STEEL CORPORATION
Region: 1
City: BRADDOCK State: PA
County:
License #: PA-G0310
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/22/2019
Notification Time: 14:22 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2019
Notification Time: 14:22 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FAILED MOISTURE GAUGE SHUTTER
The following was received from the Commonwealth of Pennsylvania via e-mail:
"The licensee reported that on March 21, 2019, the Berthold Technologies Model LB-7 410 moisture gauge containing 300 milliCuries of americium-241 was not able to operate as designed; the shutter locking mechanism cylinder was able to be pulled out of the gauge. The gauge was being removed from the east side of #3 Blast Furnace to the storage area at the Blast Furnace spares building. A service provider was already scheduled on site to observe removal and transport of the gauge. A contract employee working with the service provider stated that the cylinder was able to be pulled out of the gauge. The cylinder was never fully removed, but if it was, this would allow the shutter to be manually opened or closed. The cylinder locking device was depressed by the service provider employee and it is currently in that condition. The shutter can't be moved with the cylinder depressed. The gauge is currently locked in the storage area at the Blast Furnace spares building.
All work was performed using ALARA principles and at no point were employees exposed to excess levels of radiation. Survey results indicated no abnormal amounts of radiation in the area before, during, or after the removal of the device. Berthold has been contact for repair or replacement."
PA Event Report ID No: PA19001
* * * RETRACTION FROM THE JOHN CHIPPO TO CATY NOLAN ON 4/24/19 AT 1059 EDT * * *
The following was received via fax:
"A follow-up interview and review of the operation of the locking mechanism was conducted with the contract employee. It was determined that the contract employee was unfamiliar with the operation of the locking mechanism at the time of the removal and that the cylinder never was able to be pulled out of the gauge. Based on this investigation, it has been determined that there was not a failure of the locking mechanism or shutter during the removal of the gauge on March 21, 2019. Therefore, this event should be retracted from NMED."
Notified R1DO (Lilliendahl) and NMSS Events (via email).
The following was received from the Commonwealth of Pennsylvania via e-mail:
"The licensee reported that on March 21, 2019, the Berthold Technologies Model LB-7 410 moisture gauge containing 300 milliCuries of americium-241 was not able to operate as designed; the shutter locking mechanism cylinder was able to be pulled out of the gauge. The gauge was being removed from the east side of #3 Blast Furnace to the storage area at the Blast Furnace spares building. A service provider was already scheduled on site to observe removal and transport of the gauge. A contract employee working with the service provider stated that the cylinder was able to be pulled out of the gauge. The cylinder was never fully removed, but if it was, this would allow the shutter to be manually opened or closed. The cylinder locking device was depressed by the service provider employee and it is currently in that condition. The shutter can't be moved with the cylinder depressed. The gauge is currently locked in the storage area at the Blast Furnace spares building.
All work was performed using ALARA principles and at no point were employees exposed to excess levels of radiation. Survey results indicated no abnormal amounts of radiation in the area before, during, or after the removal of the device. Berthold has been contact for repair or replacement."
PA Event Report ID No: PA19001
* * * RETRACTION FROM THE JOHN CHIPPO TO CATY NOLAN ON 4/24/19 AT 1059 EDT * * *
The following was received via fax:
"A follow-up interview and review of the operation of the locking mechanism was conducted with the contract employee. It was determined that the contract employee was unfamiliar with the operation of the locking mechanism at the time of the removal and that the cylinder never was able to be pulled out of the gauge. Based on this investigation, it has been determined that there was not a failure of the locking mechanism or shutter during the removal of the gauge on March 21, 2019. Therefore, this event should be retracted from NMED."
Notified R1DO (Lilliendahl) and NMSS Events (via email).