| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/20/2013 - 08/21/2013 ** EVENT NUMBERS ** |
 | Power Reactor | Event Number: 49265 | Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: DONALD DETTMAN
HQ OPS Officer: PETE SNYDER | Notification Date: 08/12/2013
Notification Time: 09:23 [ET]
Event Date: 08/12/2013
Event Time: 08:59 [EDT]
Last Update Date: 08/20/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
MEL GRAY (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text TECHNICAL SUPPORT CENTER VENTILATION REMOVED FROM SERVICE FOR PLANNED MAINTENANCE
"This condition does not affect the health and safely of the public or the operation of the facility.
"At 0859 EDT on August 12, 2013, pre-planned maintenance commenced which affects the Technical Support Center (TSC) ventilation. The scope of the maintenance is to replace the TSC ventilation charcoal filters and sampling canisters. This maintenance is currently scheduled to be completed by August 20, 2013.
"TSC emergency functionality during a radiation release event requires TSC ventilation be maintained. The actual TSC ventilation emergency function for iodine removal will be lost for the duration of the pre-planned maintenance. If an emergency should occur and a radioactive release occurs, the ventilation system will not provide iodine removal capability.
"If an emergency is declared and the TSC facility activation is required, the TSC will be staffed and activated unless the TSC becomes uninhabitable due to ambient temperatures, radiological or other conditions. If relocation of the TSC staff becomes necessary, the staff will be directed to relocate to the alternate TSC location. The alternate TSC has been verified to have electrical power and communication capability. The Technical Support Center Directors have been notified.
"This event is being reported as a loss of emergency preparedness capabilities in accordance with 10 CFR 50.72(b)(3)(xiii). The NRC Resident Inspector has been notified."
* * * UPDATE FROM KEN CROW TO PETE SNYDER AT 1749 EDT ON 8/20/13 * * *
The TSC ventilation has been returned to service as of 1742 EDT on 8/20/13.
Notified R1DO (Schmidt). |
| Agreement State | Event Number: 49266 | Rep Org: NYC OFFICE OF RADIOLOGICAL HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: Not Provided
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 08/12/2013
Notification Time: 13:54 [ET]
Event Date: 09/20/2012
Event Time: [EDT]
Last Update Date: 08/12/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE - PATIENT BEING TREATED WITH Y-90 THERASPHERES RECEIVED ONLY 9.5% OF A TOTAL DOSE
The following report was received from New York City via email.
"Summary: Patient being treated with Y-90 Theraspheres received only 9.5% of a total dose of Y-90. The rest remained in the tubing.
"Details of the incident: A patient [at the NYC Mount Sinai Medical Center] was being treated with Y-90 Theraspheres. The target organ was the liver. Due to the need to access the liver via the radial artery in the arm, the angiocatheter was too short to connect to the delivery apparatus directly, thus requiring an extension tubing. The entire contents of the dose vial was emptied and flushed 4 times. It was discovered by the radiochemist [after the patient's treatment] that only 9.5% of the total dose was delivered. The rest remained in the extension tubing. [The prescribed dose was 120 Gy and the delivered dose was 11.4 Gy].
"Corrective action taken by the facility: More time will be taken to reposition the patient proximal to the delivery system. Also, the use of extension tubing will be avoided if possible. Policy and procedures will be updated to include when the use of extension tubing is allowed.
"Causes/Contributing Factors: Inadequate policy and procedures.
"RSO's review summarization: The failure to administer the correct dose to the patient was due to the addition of extension tubing. Because of the additional 40cm of IV tubing, which was used to bridge the distance between the Y-90 delivery system and the radial catheter, the intended dose remained lodged inside the extension. The additional flush used was not enough to push the dose through to the target."
The dose deviation was greater than 50%, and no additional patient testing or extended hospital stay was required. The patient and referring physician have been notified.
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: 49268 | Rep Org: NYC OFFICE OF RADIOLOGICAL HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 08/12/2013
Notification Time: 15:05 [ET]
Event Date: 01/31/2013
Event Time: 12:38 [EDT]
Last Update Date: 08/12/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE - EQUIPMENT FAILURE RESULTED IN NO PRESCRIBED DOSE DELIVERED TO PATIENT
The following report was received from New York City via email.
"Summary: Zero percent of prescribed dose delivered due to patient catheter occlusion.
"Details of the incident: On January 31, 2013 a male patient, 83 years of age, was scheduled to receive Theraspheres treatment in Interventional Radiology.
"The patient has a history of hepatitis C and hepatocellular carcinoma (HCC) with multiple HCC tumors in the liver, progressive in spite of previous chemoembolization and radiofrequency ablation therapy, was referred by oncology for Yttrium-90 microspheres therapy. At the time of a nuclear medicine consultation of December 21, 2012, it was determined that the patient is a candidate for Yttrium-90 (Y90) Therasphere therapy, the preferred radioembolization agent (device) for HCC. A lung shunt fraction of 3.3% (predetermined), and a desired dosimetry of 120 Gray, the Y90 Therasphere activity of 3.83 GBq was ordered for the patient.
"Interventional Radiology Physicians placed a 0.021 inch microcatheter, inside of a Sarah 5 Fr. Radial catheter, via the left radial artery, into the right hepatic artery, into the same position as during the January 11, 2013 diagnostic study. When the catheter was in place, a Y90 Therasphere administration kit was brought into position for dose delivery. The administration kit was prepared by the Authorized User according to standard operating procedure, using a manufacturer's checklist. The delivery line was connected to the angiocatheter in the patient's arm. Just prior to that, the catheter was first flushed with IV contrast to ensure position, followed by flushing with normal saline, and then connected to the Therasphere kit infusion line.
"The infusion was started at 12:18 PM [EST] by Interventional Radiology Physician and the Authorized User, according to standard protocol, with sufficient pressure applied to result in periodic drops of saline dripping into the pressure relief bottle. At the end of the first 20cc bolus of saline, the reading on the radiation meter outside of the container failed to drop to 0.0 as usual. This was an indication that most of the radioactivity was still present in the vial. There were 10 more attempts to infuse the activity. In spite of additional attempts, only some of the Theraspheres moved forward into the catheter. The infusion attempt was terminated at 12:38 PM. At that point, the catheter was disconnected, taking care not to spill any contents inside. Towels were positioned under the catheter opening, a syringe was connected directly to the catheter, and an attempt was made to flush the catheter, but it was not possible, as it was blocked.
"At this point the catheter was withdrawn from the patient, and was placed together with the connecting line, dose vial and infusion kit container into a plastic bag for containment. The Interventional Radiology Physicians and the Authorized User underwent the standard survey procedure for removal contamination, the outer gloves were surveyed. Indicating some activity. The gloves were removed and placed into the administration box. The booties were removed and the principles stepped away after testing negative for contamination. The absorbent lining, which was wet from the infusion saline over-flow and box platform supporting the infusion kit, was also placed into a plastic bag. The floor absorbent mat was rolled up and also placed in a plastic bag, and replaced with a new floor mat to allow patient transfer onto a stretcher. The patient sterile covering was also rolled up and placed in a plastic bag. Both the Nuclear Pharmacist and the Nuclear Medicine Technologist were surveyed and found free of contamination. Once the plastic bags with the infusion materials were removed from the immediate area and the patient taken for imaging in nuclear medicine, the procedure room (Number 1) was surveyed by the Radiation Safety Office staff and was declared free of removable contamination and cleared for routine clinical use.
"The patient underwent a whole body scan in Nuclear Medicine, but was found to have no radioactivity in his body. A survey of all the plastic bags with the materials involved in the procedure, revealed that all the activity was contained in one bag (containing the catheter, administration set and dose vial), independently documenting that the patient received no Y90 activity.
"Corrective action taken by the facility: Facility is working with the manufacturer to determine the cause of the incident. Corrective action will not be developed until the manufacturer determines what was the cause of the failure to deliver the prescribed dose.
"How was it discovered: The physician discovered the event when the reading on the radiation dosimeter outside of the delivery system failed to drop to 0.0 mR/hr as usual.
"Causes/Contributing Factors: Equipment malfunction.
"Equipment used: NORDION TheraSphere Administration Accessory Kit Part #: K125914-001
-RADOS Model: RAD 60R Personal Dosimeter
-Fluke Victoreen Ion Chamber Model: 451B-RYR-SS
-0.021" Microcatheter and a Sarah 5 Fr. Radial Catheter
"RSO's review summarization: The Radiation Safety Office was notified on January 31, 2013 at 12:40 PM that an incident had just occurred in the Interventional Radiology suite which may have resulted in contamination. The RSO staff immediately responded to the location and was informed of the details of the event by the Authorized User. The Authorized User had already collected all of the equipment associated with the Y-90 infusion kit in a large plastic bag which was on a cart. The RSO survey of this cart indicated that the entire dose activity was still within the infusion kit and associated delivery tubing. Thorough survey of the patient, floor, table, hands and feet of staff (who had remained in the room waiting for RSO arrival) did not find any contamination. The whole body scan of the patient confirmed that no radioactive material was injected into the patient. The RSO immediately informed the local regulatory authority by phone followed by a written report of the incident. The Authorized User contacted the manufacturer of the radiopharmaceutical and infusion kit and requested an engineer to come to the medical center to determine the cause of the incident. The referring physician also was informed. On February 6, 2013 an inspector from the local regulatory authority visited the medical center and reviewed the incident. At the conclusion of this meeting the inspector collected all the documentation including the Standard Operating Procedure and training materials to investigate further to see if this incident was a Medical Event since 0% of the prescribed dose had been administered. The inspector also requested that a date be scheduled where they could witness kit preparation as well as an actual patient procedure. The engineer from the manufacturer was in contact with the Authorized User and agreed to come to the medical center to examine the used equipment associated with the Y -90 infusion kit to reveal the cause of the incident."
The patient and referring physician have been notified.
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: 49269 | Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 08/12/2013
Notification Time: 17:11 [ET]
Event Date: 08/07/2013
Event Time: [EDT]
Last Update Date: 08/20/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE - PATIENT RECEIVED 20% LOWER THAN I-131 PRESCRIBED DOSE
The following Georgia Agreement State report was received via email.
"Event Description: Patient was scheduled for an I-131 prescribed dose of 100-150mCi for the treatment of Thyroid Carcinoma. The patient instead was administered a dose that deviated 20% lower than the prescribed dose. This incident was reported to the [Georgia] State per Rule 391-3-17.05(115)(a)1.(i):
'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin; and either (i) The total dose delivered differs from the prescribed dose by 20 percent or more.'"
The State will provide the corrective action information when provided by the licensee.
GA State Report ID: CTS 71850
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.
* * * UPDATE FROM TRAVIS CARTOSKI TO HOWIE CROUCH VIA EMAIL ON 8/20/13 AT 1240 EDT * * *
"A sodium iodine I-131 thyroid ablation treatment was ordered as a NaI I-131 whole body scan resulting in a patient receiving a diagnostic dose of 5 mCi of NaI (I-131) instead of the therapeutic dose of 50 mCi of NaI (I-131).
"Both the referring physician and the patient were also informed of the misadministration of the 5 mCi I-131 dose for the whole body scan on August 7, 2013 in light of the confirmed order for an I-131 thyroid ablation. The order verification process was reviewed with all involved staff members and an extensive review of the process was begun.
"Nuclear Medicine, like all diagnostic services, requires verification of the order for services. This verification must be in the form of a written order or an electronic authenticated order. On August 1, 2013 Piedmont Hospital Atlanta implemented EPIC, a new electronic medical record (EMR). The orders verification process changed a bit, because Piedmont Physician Groups could place an order within the EPIC environment (EPIC Physicians) and have them electronically authenticated, with e-signature and a time stamp. Physicians not in the EPIC environment (non-EPIC Physicians) could still schedule services through scheduling by providing a written order. Once scheduling had received a written order, the ancillary orders process would produce an order that looked just like the order produced by an EPIC physician, but the chart would have a paper clip to signify that it was a non-EPIC Physician order.
"During the first week of the EPIC implementation, many of the orders that were transcribed by the scheduling services department did not have the attachment of the original written order. This information came to light during the first few days of go-live but not all end users were informed on the issue. In this particular case, the patient's order was requested by a non-EPIC physician, as an I-131 whole body scan. The order was transcribed by scheduling , and as of August 7, 2013, the original order was not scanned into the chart. The order in the chart appeared to be an EPIC Physician order. Based on the information known at the time, the order for an I-131 whole body scan was verified and the patient was dosed and instructed to return on Friday August 9, 2013 for imaging.
"On August 8, 2013, a copy of the original order was scanned into the patient's record. The order contained more detailed information concerning the reason for the referral to nuclear medicine. This information would prove to be vital in determining the actual course of treatment requested by the referring physician.
"On Friday August 9, 2013, the patient returned for the whole body scan, but due to a downed system at the hospital the patient was referred to the Piedmont West Imaging Center to complete their test. While preparing the report template in PACs (Name removed), noticed that the patients chart had a paper clip icon but the documentation that she had received from the hospital Nuclear Medicine department only had an EPIC Physician order. (Name removed) opened the original scanned order for an I-131 whole body scan and discovered that within the comments section of the note that the Authorized User was referring the patient for an I-131 thyroid ablation. The office was contacted, and the order for an I-131 thyroid ablation was confirmed. (Name Removed), contacted the RSO to inform him of the events leading up to this misadministration.
"The actions taken to prevent a future reoccurrence of a similar event include:
-Training on the orders verification process in EPIC for all Nuclear Medicine staff members
-Defining the difference between an EPIC Physician order and a non-EPIC Physician order
-All non-EPIC Physician orders must have an attached copy of the original order or a call must be placed to the provider's office requesting a copy of the order if the patient does not have an original copy."
Notified R1DO (Schmidt) and FSME (via email). |
| Agreement State | Event Number: 49273 | Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: RUMFORD PAPER COMPANY
Region: 1
City: RUMFORD State: ME
County:
License #: ME-17203
Agreement: Y
Docket:
NRC Notified By: JEAN GESLIN
HQ OPS Officer: BILL HUFFMAN | Notification Date: 08/13/2013
Notification Time: 09:34 [ET]
Event Date: 03/25/2013
Event Time: [EDT]
Last Update Date: 08/13/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY POWELL (R1DO)
FSME EVENT RESOURCE (E-MA)
| Event Text AGREEMENT STATE REPORT - SHUTTER STUCK ON FIXED PROCESS GAUGE
The following event report was received from the State of Maine Radiation Control Program via e-mail:
"Rumford Paper Company reported that the shutter on a fixed nuclear gauge (Ohmart model SH-F1-A45, serial #13520085) was stuck in the open position on 3/25/2013. The gauge contained a 370 MBq (10 mCi) Cs-137 source (model A-2100, serial #3133CM). Restrictions were put into place so no personnel could enter the vessel until repairs could be completed. The manufacturer was contacted and performed the necessary repairs and the shutter now operates properly."
Maine Report Number: ME130002 |
| Agreement State | Event Number: 49274 | Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: ACS TESTING, INC.
Region: 4
City: SHERWOOD State: OR
County:
License #: ORE 90987
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: HOWIE CROUCH | Notification Date: 08/13/2013
Notification Time: 14:22 [ET]
Event Date: 08/02/2013
Event Time: 02:30 [PDT]
Last Update Date: 08/13/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - STOLEN AND RECOVERED TROXLER MOISTURE DENSITY GAUGE
The following information was obtained from the State of Oregon via email:
"A Troxler portable moisture density gauge was stolen out of the back of a worker's truck around 2:30 AM [PDT] on August 2nd, 2013. The gauge was recovered by the Sherwood police within the hour and returned to worker. The gauge handle and case remained locked. The only locks breached were the locks securing the device in the back of the truck. The licensee was just informed of the theft and reported it to Oregon RPS [Radiation Protection Services] at 10:00 AM on August 13th, 2013. The licensee will conduct further investigation and develop corrective actions. This information will be reported to Oregon RPS within 30 days.
"Device: Troxler 3430
SN: 38580
Sources: 9 mCi Cs-137 and 44 mCi Am-241/Be"
Oregon Incident #: 13-0029 |
| Non-Agreement State | Event Number: 49277 | Rep Org: R&M ENGINEERING - KETCHIKAN
Licensee: R&M ENGINEERING - KETCHIKAN
Region: 4
City: KETCHIKAN State: AK
County:
License #: 50-29259-01
Agreement: N
Docket:
NRC Notified By: GUY OWEN
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 08/13/2013
Notification Time: 20:03 [ET]
Event Date: 08/12/2013
Event Time: 08:15 [YDT]
Last Update Date: 08/13/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text TROXLER 3450 MOISTURE DENSITY GAUGE DAMAGED DURING ROAD CONSTRUCTION
The licensee reports that a Troxler 3450 moisture density gauge was damaged at a construction site on Prince Wales Island, Alaska. The gauge had been left at the side of a road and was run over by a pickup truck. The operating handle and source rod were bent, however the gauge sources were in the safe position. The gauge was surveyed by the licensee and there is no indication of leakage or personnel exposure. The licensee has stored the gauge in a secure location until the gauge can be returned to the manufacturer for repair.
The Troxler 3450 gauge is serial #540 and contains a 8 mCi Cs-137 and a 40 mCi Am-241/Be source. |
| Agreement State | Event Number: 49278 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STANFORD UNIVERSITY
Region: 4
City: STANFORD State: CA
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN SHOEMAKER | Notification Date: 08/13/2013
Notification Time: 21:56 [ET]
Event Date: 08/13/2013
Event Time: [PDT]
Last Update Date: 08/13/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY KELLAR (R4DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - CONTAMINATION LIMITS ON PACKAGE EXCEEDED
The following Agreement State report was received via email.
"[The California Department of Public Health / Radiation Health Branch was notified that Stanford University received a package containing Radium 223 from Cardinal Health in Denver, Colorado and the package indicated removable contamination of 400 DPM of technetium 99 on the package. The following information was provided:
"The caller stated, that a package was received at the Nuclear Medicine Department and the package had a reading of 400 DPM which exceeds the Dept. of Transportation limits. Caller stated the package has been isolated and secured in the appropriate area and the carrier notified. Caller stated that the package will be at normal readings tomorrow.
"Cardinal Health, in Denver, was notified and will investigate this issue. RHB California will report additional information." |
| Power Reactor | Event Number: 49291 | Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: COREY GRAY
HQ OPS Officer: HOWIE CROUCH | Notification Date: 08/20/2013
Notification Time: 11:49 [ET]
Event Date: 08/19/2013
Event Time: 14:24 [EDT]
Last Update Date: 08/20/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
RANDY MUSSER (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text NON-LICENSED CONTRACT SUPERVISOR HAD A CONFIRMED POSITIVE FITNESS FOR DUTY TEST
A non-licensed contract supervisor had a confirmed positive fitness for duty test. Plant access for the individual has been terminated.
The licensee has notified the NRC Resident Inspector. |
| Fuel Cycle Facility | Event Number: 49292 | Facility: WESTINGHOUSE HEMATITE
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
COMMERCIAL LWR FUEL
Region: 3
City: HEMATITE State: MO
County: JEFFERSON
License #: SNM-33
Agreement: N
Docket: 07000036
NRC Notified By: KEVIN DAVIS
HQ OPS Officer: HOWIE CROUCH | Notification Date: 08/20/2013
Notification Time: 17:56 [ET]
Event Date: 08/20/2013
Event Time: 11:15 [CDT]
Last Update Date: 08/20/2013 | Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
| Person (Organization):
LAURA KOZAK (R3DO)
ANTHONY HSIA (NMSS)
| Event Text 24 HOUR REPORT RELATED TO CRITICALITY CONTROL BULLETIN 91-01
"The Hematite Decommissioning Project (HDP) is excavating burial pits containing enriched uranium. HDP has established criticality safety controls to ensure the safe handling of the buried waste as it is excavated. These controls involve redundant surveys and visual inspections at the time of excavation. These controls failed to identify an item upon excavation that was 400,000 ncpm [net counts per minute] on contact and had dimensions of 6 inches or greater. Instead, the item was identified and placed in criticality safety controls (collared drum) after it had reached the Waste Holding Area.
"The item appeared to be a crushed container, estimated at 10 gal. in original size, and had contents primarily consisting of gloves and plastic. After the contents were removed, the empty container was confirmed to have only contamination that was below the threshold of criticality safety controls. The detailed assay of the contents was 22 g of U-235, which does require criticality safety controls.
"Work in the burial pit areas was stopped pending retraining of those workers on the requirements and criticality safety controls regarding survey and visual inspection during excavation. Excavated burial pit area waste that has not reached the Waste Holding Area will be resurveyed and inspected prior to proceeding to the Waste Holding Area."
The licensee notified NRC R3 (Tapp). | |