Event Notification Report for April 14, 2015

AGREEMENT STATE REPORT - SOURCE CAPSULE BREACHED RESULTING IN CONTAMINATED AREA AND INDIVIDUAL

"On April 15, 2015, the licensee notified the Agency that on April 14, 2015, one of its technicians was removing a cesium-137 source, with a current activity of 694 millicuries (original activity was 1200 millicuries in 06/1991), from an Ohmart SHLG-1 nuclear gauge. When he opened up the gauge, the source was ruptured. The cause of the rupture has not yet been determined. Areas of the workroom and the technician were contaminated. The technician was immediately [externally] decontaminated. The licensee swabbed the technician's nasal passages and found contamination. The licensee has sent the technician's dosimetry for immediate processing and is in the process of determining the internal dose estimate. Surveys confirmed that no contamination was carried outside the work room. Cleanup and surveys of the workroom are being performed. Access has been restricted since the incident. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.

Texas Incident I-9302

* * * UPDATE FROM ART TUCKER TO DAN LIVERMORE AT 1326 ON 04/21/15 * * *

"Currently 3 homes of employees have been found to have contamination, characterization has not been performed. Various articles of clothing have been confiscated by the company and residents have been moved to hotels, with all objects brought along cleared.

"The room in which the incident occurred has been sealed off. Additional licensee personnel have arrived to assist with surveys and cleanup. Assay of the source to determine what activity remains within the capsule has not yet been performed. Interviews of involved individuals are ongoing.

"Full body counts have been performed with initial readings of 4.86 mrem CEDE for one employee and 290 mrem CEDE for another."

Notified R4DO (Drake) and NMSS Events Notification via email.

Y-90 MICROSPHERE DOSE LESS THAN PRESCRIBED

A medical event involving Y-90 microspheres (TheraSpheres) occurred at approximately 1000 EDT on 4/14/15. The prescribed dosage was 34.6 mCi and the delivered dosage was 25.5 mCi. This equates to a 26.3 percent underdose. The patient was notified by the authorized user following treatment and before discharge on 4/13/15. The referring physician was notified by the authorized user via electronic mail at 1149 EDT on 4/13/15. The initial hypothesis on cause may have been related to difficult access to an anatomical region in the liver, resulting in the need to use lower than normal pressure on the syringe used for microsphere delivery. All established administration procedures were followed. A written report to the appropriate NRC offices will follow within 15 days.

* * * RETRACTION FROM MACK RICHARD TO VINCE KLCO ON 4/14/15 AT 1515 EDT * * *

The following information was excerpted from the licensee email:

"The reason for this retraction is based upon discussions with the Authorized User [AU] who performed the Y-90 treatment and additional questions raised and clarifications made by the NRC Region III Office. During that discussion, the AU indicated that he utilized a lower syringe pressure than normal to prevent reflux of the Y-90 microspheres which would have resulted in a less than optimal treatment. The AU acknowledged that the amount administered was acceptable, given the need to use the lower syringe pressure and that he will modify the written directive to appropriately reflect a change in the written directive based upon those circumstances."

Notified the R3DO (McCraw) and NMSS Events Notification via email.

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.

OFFSITE NOTIFICATION DUE TO SODIUM HYDROXIDE SPILL ONSITE EXCEEDING REPORTABLE QUANTITY

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"Arizona Public Service Co. made an offsite notification to the National Response Center regarding an approximately 3500 gallon caustic (8% sodium hydroxide) spill due to an improper valve lineup. The spill occurred at the Water Reclamation Facility (produces water for cooling towers and power plant and is located outside the Security Owner Controlled Area) in the area of the Fire Protection tanks (additional liquid was contained in a containment structure at the release location, and in a nearby concrete lined storm ditch on site). The release has been isolated, the immediate area has been barricaded. The quantity released exceeded the Reportable Quantity for sodium hydroxide (RQ of 1,000 pounds) and was therefore reported. Additionally, the state [Arizona] and county [Maricopa] have also been notified. There was no impact to the operation of the power units, aquifer or personnel onsite or offsite.

"The NRC Resident [Inspector] has been notified."

AGREEMENT STATE REPORT - CS-137 FOUND IN WASTE ENTERING A LANDFILL

The following report was received via e-mail:

"On April 13, 2015, the Agency [Texas Department of State Health Services] was notified by a landfill operator that material in a waste container set off their radiation alarms. The landfill provided a spectrum which showed the isotope as Cesium-137. An on-site investigation by this Agency confirmed the material to be dirt/mud contaminated with Cesium-137. The waste material at the landfill was isolated. The waste collection route sheet used to collect the waste was requested by the Agency. The Agency drove the route traveled by the collection vehicle using an RSI identifier in an attempt to locate the source of the contamination. The detector indicated the presence of radiation in a bar ditch along the intersection of two streets northeast of the City of Houston. Surveys conducted by the Agency identified a reading of 16 millirem on contact with the ground in one spot. Additional surveys indicated additional activity as far as 70 feet from the spot previously mentioned. The Agency received cost estimates from contractors to collect the material from both areas for proper disposal. The city of Houston had been contacted about the contamination and the steps that had been taken by the Agency. The City of Houston decided since the area of contamination was in their jurisdiction, they would be responsible for the remediation of the area. The Agency returned to the area on the evening of May 26, 2015, to inspect the area. The Agency discovered the road the bar ditch was running along had been closed by the city at both ends. There are no homes or businesses that require access to this section of road. The contractor was contacted on May 29, 2015. He stated they had begun work on remediating the area on May 21, 2015. He stated the road was blocked by the Houston City Works Department on that day. He stated they had dug down about 3 feet from the original surface of the ditch. He stated readings on contact at that location are 1 rem/hr. He stated they had come across a water line while they were digging and that it has restricted their use of tools. He stated that due to the dose rates they are seeing now (1 rem/hr) they are now using a low pressure water blaster to excavate the area. He stated they are sucking the water into barrels and monitoring the suction line for dose rates. He stated they would contact the state once the source has been located.

"On May 29, 2015, the Agency decided that due to the city closing the road to any access, the event should be reported to the Nuclear Regulatory Commission Headquarters Operations Officer (HOO.)"

Event location: Near the intersection of Sunbury and Bacher Streets.

Texas Event: I-9303

* * * UPDATE ON 10/23/2015 AT 1153 EDT FROM ARTHUR TUCKER TO DONG PARK * * *

The following report was received via e-mail:

"On April 13, 2015, the Agency was notified by a landfill operator that a load of waste had caused its radiation monitor to alarm. The operator provided a spectrum and the radioisotope was identified as cesium-137. An on-site investigation confirmed the material to be dirt/mud contaminated with cesium. Further investigation was initiated to find the source of the material. Using the waste collection vehicle's route sheets and the Agency's radiation detection equipment, the Agency identified the area where the mud had originated in a drainage ditch along the side of a street, which was within the city's easement. The waste material was isolated and a cost estimate was obtained for a contractor to remediate the area. The initial surface readings obtained in the ditch ranged from 430 microR/hr to 16 mR/hr. During remediation, the readings ranged up to 1Rem/hr and the depth of the material to be removed was within a few inches beneath the soil to a max depth of 14 feet in the most concentrated area. Site remediation was completed by the end of July 2015. The property was released for unrestricted use on September 1, 2015 after final soil samples were analyzed. The highest concentration of contamination, point of origin, was identified at a depth of approximately 14 feet below the ground surface. Ownership of the source of the radioactive material could not be determined. No violations were cited. File closed."

Notified R4DO (Werner) and NMSS EVENTS NOTIFICATION via email.