Event Notification Report for October 16, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/15/2020 - 10/16/2020
EVENT NUMBERS
54955549525495355013
Agreement State
Event Number: 54955
Rep Org: NV DIV OF RAD HEALTH
Licensee: Aztech Materials and Testing, LLC
Region: 4
City: Las Vegas State: NV
County:
License #: 00-11-0482-01
Agreement: Y
Docket:
NRC Notified By: Haley Brown
HQ OPS Officer: Thomas Herrity
Licensee: Aztech Materials and Testing, LLC
Region: 4
City: Las Vegas State: NV
County:
License #: 00-11-0482-01
Agreement: Y
Docket:
NRC Notified By: Haley Brown
HQ OPS Officer: Thomas Herrity
Notification Date: 10/19/2020
Notification Time: 17:24 [ET]
Event Date: 10/16/2020
Event Time: 08:06 [PDT]
Last Update Date: 10/23/2020
Notification Time: 17:24 [ET]
Event Date: 10/16/2020
Event Time: 08:06 [PDT]
Last Update Date: 10/23/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 10/26/2020
EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED ON CONSTRUCTION SITE
The following was received from the state of Nevada via email:
"A front-end loader ran over and crushed a Humboldt 5001EZ, S/N 3246, Portable Nuclear Gauge while the Authorized User was performing the standard count. The source was still in the shielded position during the incident, but the source rod was broken off and the gauge can no longer be used. No injuries or exposures occurred, but the device was damaged beyond repair and will be returned to the manufacturer for disposal."
State Event Report ID: NV-20-0010
* * * UPDATE VIA EMAIL FROM HALEY BROWN TO HOWIE CROUCH AT 1458 EST ON 10/23/2020 * * *
Leak Test results confirm that the Humboldt Portable Nuclear Gauge SN 3246 (11 mCi Cs-137/ 44 mCi Am-241) is not leaking. The licensee will be shipping this device to the manufacturer on Monday, October 26th for disposal.
Notified R4DO (Pick) and NMSS Events notification (email).
EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED ON CONSTRUCTION SITE
The following was received from the state of Nevada via email:
"A front-end loader ran over and crushed a Humboldt 5001EZ, S/N 3246, Portable Nuclear Gauge while the Authorized User was performing the standard count. The source was still in the shielded position during the incident, but the source rod was broken off and the gauge can no longer be used. No injuries or exposures occurred, but the device was damaged beyond repair and will be returned to the manufacturer for disposal."
State Event Report ID: NV-20-0010
* * * UPDATE VIA EMAIL FROM HALEY BROWN TO HOWIE CROUCH AT 1458 EST ON 10/23/2020 * * *
Leak Test results confirm that the Humboldt Portable Nuclear Gauge SN 3246 (11 mCi Cs-137/ 44 mCi Am-241) is not leaking. The licensee will be shipping this device to the manufacturer on Monday, October 26th for disposal.
Notified R4DO (Pick) and NMSS Events notification (email).
Agreement State
Event Number: 54952
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: GSH Material Testing and Inspection, Inc.
Region: 4
City: South Jordan State: UT
County:
License #: UT1800537
Agreement: Y
Docket:
NRC Notified By: Philip Griffin
HQ OPS Officer: Brian P. Smith
Licensee: GSH Material Testing and Inspection, Inc.
Region: 4
City: South Jordan State: UT
County:
License #: UT1800537
Agreement: Y
Docket:
NRC Notified By: Philip Griffin
HQ OPS Officer: Brian P. Smith
Notification Date: 10/16/2020
Notification Time: 17:39 [ET]
Event Date: 10/16/2020
Event Time: 14:22 [MDT]
Last Update Date: 10/16/2020
Notification Time: 17:39 [ET]
Event Date: 10/16/2020
Event Time: 14:22 [MDT]
Last Update Date: 10/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOST AND FOUND PORTABLE GAUGE
The following was received from the Utah Division of Radiation Control (the Division) via email:
"A portable gauge user failed to adequately secure the transportation case containing a Troxler 3430 gauge when leaving the jobsite. The user noticed the gauge was missing after travelling some distance from the jobsite. The user retraced his path back to the jobsite, but was unable to locate the gauge. The licensee then contacted the Division [at 1422 MDT] to report that the gauge was missing. During a subsequent telephone call [at 1503 MDT], the licensee informed the Division that the gauge had been located during an additional search by the user. The gauge was found just outside the jobsite entrance. The Troxler gauge contains a 40 mCi Am-241/Be sealed source and an 8 mCi Cs-137 sealed source."
Utah Event Number: UT 200006
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 was received from the Utah Division of Radiation Control (the Division) via email:
"A portable gauge user failed to adequately secure the transportation case containing a Troxler 3430 gauge when leaving the jobsite. The user noticed the gauge was missing after travelling some distance from the jobsite. The user retraced his path back to the jobsite, but was unable to locate the gauge. The licensee then contacted the Division [at 1422 MDT] to report that the gauge was missing. During a subsequent telephone call [at 1503 MDT], the licensee informed the Division that the gauge had been located during an additional search by the user. The gauge was found just outside the jobsite entrance. The Troxler gauge contains a 40 mCi Am-241/Be sealed source and an 8 mCi Cs-137 sealed source."
Utah Event Number: UT 200006
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: 54953
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: The Board of Trustees of the Leland Stanford, Jr. University
Region: 4
City: Stanford State: CA
County:
License #: 0676-43
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Brian P. Smith
Licensee: The Board of Trustees of the Leland Stanford, Jr. University
Region: 4
City: Stanford State: CA
County:
License #: 0676-43
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Brian P. Smith
Notification Date: 10/16/2020
Notification Time: 20:37 [ET]
Event Date: 10/16/2020
Event Time: 15:03 [PDT]
Last Update Date: 12/02/2020
Notification Time: 20:37 [ET]
Event Date: 10/16/2020
Event Time: 15:03 [PDT]
Last Update Date: 12/02/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KEVIN WILLIAMS (NMSS)
EN Revision Imported Date: 12/3/2020
EN Revision Text: AGREEMENT STATE REPORT - GREATER THAN INTENDED DOSE TO LIVER LOBE
The following was received via email from the California Radiation Control Program:
"On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation."
California 5010 Number: 101620
* * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1816 EST ON 12/2/2020 * * *
The following information was received via E-mail:
"The authorized user prescribed 31.57 mCi (1.17GBq) Y-90 to the right lobe of the liver and 13.22 mCi (0.49GBq) to the left lobe of the liver.
"The higher dosage, 31.57 mCi (1.17GBq) Y-90 was delivered to the left lobe of the liver.
"The prescribed dosage of 13.22 mCi (0.49GBq) would result in a dose to the left lobe of 7,000 rad (70Gy), however the delivered dose was 17,500 rad (175 Gy).
"This is 10,500 rad (105 Gy) above the prescribed dose."
Notified R4DO (Gepford) and via E-mail, NMSS (Williams) and the NMSS Events Notification E-mail Group.
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.
EN Revision Text: AGREEMENT STATE REPORT - GREATER THAN INTENDED DOSE TO LIVER LOBE
The following was received via email from the California Radiation Control Program:
"On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation."
California 5010 Number: 101620
* * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1816 EST ON 12/2/2020 * * *
The following information was received via E-mail:
"The authorized user prescribed 31.57 mCi (1.17GBq) Y-90 to the right lobe of the liver and 13.22 mCi (0.49GBq) to the left lobe of the liver.
"The higher dosage, 31.57 mCi (1.17GBq) Y-90 was delivered to the left lobe of the liver.
"The prescribed dosage of 13.22 mCi (0.49GBq) would result in a dose to the left lobe of 7,000 rad (70Gy), however the delivered dose was 17,500 rad (175 Gy).
"This is 10,500 rad (105 Gy) above the prescribed dose."
Notified R4DO (Gepford) and via E-mail, NMSS (Williams) and the NMSS Events Notification E-mail Group.
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.
Agreement State
Event Number: 55013
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: ELI Wireline Services LLC
Region: 4
City: Hays State: KS
County:
License #: 27-B1008
Agreement: Y
Docket:
NRC Notified By: Aaron Short
HQ OPS Officer: Solomon Sahle
Licensee: ELI Wireline Services LLC
Region: 4
City: Hays State: KS
County:
License #: 27-B1008
Agreement: Y
Docket:
NRC Notified By: Aaron Short
HQ OPS Officer: Solomon Sahle
Notification Date: 11/30/2020
Notification Time: 15:58 [ET]
Event Date: 10/16/2020
Event Time: 00:00 [CST]
Last Update Date: 11/30/2020
Notification Time: 15:58 [ET]
Event Date: 10/16/2020
Event Time: 00:00 [CST]
Last Update Date: 11/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - WELL LOGGING, STUCK SOURCE
The following information was received from the State of Kansas, Department of Health & Environment via email:
"On 10/16/2020 Kansas licensee #27-B1008 ELI Wireline Services LLC was logging a gas storage well when the tool became stuck in 2 3/8" tubing at approximately 2100 feet from surface. Attempts to free the tool while still attached to the wireline were unsuccessful and the wireline was pulled resulting in the rope socket leaving the cable head, two weight bars, gamma ray neutron tool, and a 3 Curie AmBe-241 sealed source lodged inside the tubing. The licensee's attempts to retrieve the source have so far been unsuccessful, partly due to windy weather conditions and 1500 pounds of gas pressure on the well. The licensee contacted the state of Kansas on 10/21/2020 to report a stuck radioactive source downhole. The licensee made the decision to wait until spring when the field had less pressure and the weather was better to clean out the tubing to enable the fishing tool to reach the stuck logging tool. Kansas agreed with the delay on source recovery for better weather and required that a sign matching the requirements of K.A.R. 28-35-362 [with the exception of (2)(C) and (2)(H)(i)] be placed at the wellhead no later than December 24, 2020. At this time this incident is not considered an abandoned source, however, The state of Kansas determined that it was appropriate to go ahead and report to the HOO out of an abundance of caution in the event that the source is unable to be retrieved in the spring of 2021."
The following information was received from the State of Kansas, Department of Health & Environment via email:
"On 10/16/2020 Kansas licensee #27-B1008 ELI Wireline Services LLC was logging a gas storage well when the tool became stuck in 2 3/8" tubing at approximately 2100 feet from surface. Attempts to free the tool while still attached to the wireline were unsuccessful and the wireline was pulled resulting in the rope socket leaving the cable head, two weight bars, gamma ray neutron tool, and a 3 Curie AmBe-241 sealed source lodged inside the tubing. The licensee's attempts to retrieve the source have so far been unsuccessful, partly due to windy weather conditions and 1500 pounds of gas pressure on the well. The licensee contacted the state of Kansas on 10/21/2020 to report a stuck radioactive source downhole. The licensee made the decision to wait until spring when the field had less pressure and the weather was better to clean out the tubing to enable the fishing tool to reach the stuck logging tool. Kansas agreed with the delay on source recovery for better weather and required that a sign matching the requirements of K.A.R. 28-35-362 [with the exception of (2)(C) and (2)(H)(i)] be placed at the wellhead no later than December 24, 2020. At this time this incident is not considered an abandoned source, however, The state of Kansas determined that it was appropriate to go ahead and report to the HOO out of an abundance of caution in the event that the source is unable to be retrieved in the spring of 2021."