Event Notification Report for August 11, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/10/2015 - 08/11/2015
EVENT NUMBERS
513145131151317513085132251361
Agreement State
Event Number: 51314
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CLEARWATER PAPER CORPORATION
Region: 4
City: MCGEHEE State: AR
County:
License #: ARK-0530-0312
Agreement: Y
Docket:
NRC Notified By: SUSAN ELLIOT
HQ OPS Officer: JOHN SHOEMAKER
Licensee: CLEARWATER PAPER CORPORATION
Region: 4
City: MCGEHEE State: AR
County:
License #: ARK-0530-0312
Agreement: Y
Docket:
NRC Notified By: SUSAN ELLIOT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/12/2015
Notification Time: 16:30 [ET]
Event Date: 08/11/2015
Event Time: 13:00 [CDT]
Last Update Date: 03/08/2016
Notification Time: 16:30 [ET]
Event Date: 08/11/2015
Event Time: 13:00 [CDT]
Last Update Date: 03/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - DAMAGED KAY-RAY FIXED GAUGES REPAIRED WITH SHUTTER OPEN
The following report was received from the State of Arkansas via email:
"[The licensee] discovered two fixed gauges, manufactured by Kay-Ray, model #GRP-6082, serial #6124 (digester 2) and #6125 (digester 3) with a 5 Curie Cs-137 source were damaged sometime in May 2014.
"The Department [Arkansas Department of Health] became aware of the repair during a routine inspection of the plant. According to the field service report, repairs were performed on June 5, 2014. The repairs were to the lead shielding around source holders which was separated from the original fabrication and needed to be refastened. The field service report indicated the shutter was not closed during the repairs.
"Basic evaluations at the time of inspection, by [licensee] Radiation Control Health Physicists, indicated there were no public exposure levels above the regulatory requirement. The gauges are mounted on a steel metal box. The gauges are located on the 3rd floor 10 feet above the floor. Gauges are in cages inaccessible without a ladder. It is believed a small field of radiation was present but there were no significant exposures to the public.
"The State is awaiting a written report from the licensee and will continue to investigate this event. The State will update this event as more information becomes available.
"Louisiana Department of Environmental Quality office was notified."
Arkansas Event Number: ARK-2015-011
* * * UPDATE FROM SUSAN ELLIOTT TO STEVEN VITTO ON 03/08/2016 AT 0943 EST * * *
The following was received via email:
"The written report dated March 3, 2016, from Clearwater Paper Corporation, detailed corrective actions to ensure repairs to the lead shielding around source holders were sufficient to prevent radiation exposure. A licensed contractor inspected all sources for physical integrity and validated their findings. There was no radiation leakage from any of the fixed gauges to include the two in question. The licensee confirms no exposure to the public.
"The State considers this event closed."
Notified R4DO (Proulx) and NMSS_EVENTS_NOTIFICATION via email.
The following report was received from the State of Arkansas via email:
"[The licensee] discovered two fixed gauges, manufactured by Kay-Ray, model #GRP-6082, serial #6124 (digester 2) and #6125 (digester 3) with a 5 Curie Cs-137 source were damaged sometime in May 2014.
"The Department [Arkansas Department of Health] became aware of the repair during a routine inspection of the plant. According to the field service report, repairs were performed on June 5, 2014. The repairs were to the lead shielding around source holders which was separated from the original fabrication and needed to be refastened. The field service report indicated the shutter was not closed during the repairs.
"Basic evaluations at the time of inspection, by [licensee] Radiation Control Health Physicists, indicated there were no public exposure levels above the regulatory requirement. The gauges are mounted on a steel metal box. The gauges are located on the 3rd floor 10 feet above the floor. Gauges are in cages inaccessible without a ladder. It is believed a small field of radiation was present but there were no significant exposures to the public.
"The State is awaiting a written report from the licensee and will continue to investigate this event. The State will update this event as more information becomes available.
"Louisiana Department of Environmental Quality office was notified."
Arkansas Event Number: ARK-2015-011
* * * UPDATE FROM SUSAN ELLIOTT TO STEVEN VITTO ON 03/08/2016 AT 0943 EST * * *
The following was received via email:
"The written report dated March 3, 2016, from Clearwater Paper Corporation, detailed corrective actions to ensure repairs to the lead shielding around source holders were sufficient to prevent radiation exposure. A licensed contractor inspected all sources for physical integrity and validated their findings. There was no radiation leakage from any of the fixed gauges to include the two in question. The licensee confirms no exposure to the public.
"The State considers this event closed."
Notified R4DO (Proulx) and NMSS_EVENTS_NOTIFICATION via email.
Agreement State
Event Number: 51311
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CALFRAC WELL SERVICES CORP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 06710
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: CALFRAC WELL SERVICES CORP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 06710
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/12/2015
Notification Time: 08:43 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/12/2015
Notification Time: 08:43 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/12/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BOB HAGAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DAMAGED PORTABLE INLINE DENSITY GAUGE
The following report was received via e-mail:
"On August 11, 2015, the licensee notified the Agency [Texas Department of State Health Services] that during a routine inspection of one of its Berthold model 8010 portable inline density gauges (SN: 10182), that contained a 20 millicurie Cesium-137 source, it found that the shutter handle was bent and the shutter could not be fully operated. The shutter was in the closed position. The gauge was secured at the licensee's facility. The licensee's radiation safety officer (RSO) is investigating the cause of the damage. The RSO has contacted the gauge manufacturer and arrangements are being made for repairs. There have been no exposures to any individual as a result of this event. Further information will be provided as it is obtained in accordance with SA-300."
Texas Incident #I-9333
The following report was received via e-mail:
"On August 11, 2015, the licensee notified the Agency [Texas Department of State Health Services] that during a routine inspection of one of its Berthold model 8010 portable inline density gauges (SN: 10182), that contained a 20 millicurie Cesium-137 source, it found that the shutter handle was bent and the shutter could not be fully operated. The shutter was in the closed position. The gauge was secured at the licensee's facility. The licensee's radiation safety officer (RSO) is investigating the cause of the damage. The RSO has contacted the gauge manufacturer and arrangements are being made for repairs. There have been no exposures to any individual as a result of this event. Further information will be provided as it is obtained in accordance with SA-300."
Texas Incident #I-9333
Non-Agreement State
Event Number: 51317
Rep Org: MIDDLESEX HOSPITAL
Licensee: MIDDLESEX HOSPITAL
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 06-00649-03
Agreement: N
Docket:
NRC Notified By: JOAN MERTIN
HQ OPS Officer: JEFF HERRERA
Licensee: MIDDLESEX HOSPITAL
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 06-00649-03
Agreement: N
Docket:
NRC Notified By: JOAN MERTIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/13/2015
Notification Time: 12:03 [ET]
Event Date: 08/11/2015
Event Time: 12:00 [EDT]
Last Update Date: 08/25/2015
Notification Time: 12:03 [ET]
Event Date: 08/11/2015
Event Time: 12:00 [EDT]
Last Update Date: 08/25/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEDICAL EVENT - PATIENT RECEIVED UNDERDOSE OF YTTRIUM 90
During a treatment of the left lobe of the liver, the dose delivered to the patient was discovered to differ greater than 20 percent than the intended dose. 120 Gray was prescribed by the physician and 72 Gray was delivered. During the procedure the Rados meter did not appear to be operating properly. Subsequent investigation determined that there was some radioactivity that remained in the vial. The technologist called the manufacturer who advised to perform several flushes and the Rados meter still did not change. The procedure was ended at that point. After ending the procedure when the survey was performed on the waste jar, it was discovered that only 60% of the dose was delivered. The activity appeared to be concentrated in the plunger attached to the vial. A new Rados detector will be obtained prior to the next procedure.
The patient will be informed of the issue by the physician.
Source Material: Yttrium 90, 7.03 GBq.
* * * UPDATE AT 1718 EDT ON 08/25/15 FROM JOAN MERTON TO JEFF HERRERA * * *
"On 8/11/15, a left lobe liver Y-90 embolization was performed in the interventional radiology room at Middlesex Hospital. The Y-90 therasphere activity was 7.04 GBq on 8/2/15 at [12:00 EDT] and 0.696 GBq on 8/11/15 at 10:00 am. Prior to placing the vial containing the Y-90 into the dose calibrator, the nuclear medicine technologist turned and tapped the lead pot 90 [degrees] three times. The Y-90 was infused at 12:11 pm on 8/11/15. The prescribed dose to the target volume was 120 Gray. The device and assembly were set up according to the checklist provided by the manufacturer. The authorized user turned the lead pot containing the vial 90 degrees three times and then tapped it on the table twice. The Rados meter read 1.0 mR/hr when the seal was removed from the Y-90 vial and before the commencement of the embolization. After the first flush with saline (20 ml/min) the rados meter still displayed a reading of 1.0 mR/hr. Two further flushes failed to reduce the reading of 1.0 mR/hr. The authorized user requested that the company (BTG/Nordion) representative be contacted. The lead technologist was advised by phone by the BTG representative to have the physician repeat the massaging of the tubing where the Roberts clamp had been released and perform two (2) additional saline flushes. After performing the representative's suggestions the reading was still 1.0 mR/hr. Per the lead NM [Nuclear Medicine] technologist, the BTG representative had no further recommendations. The authorized user then lifted the plexiglass cover of the apparatus and tapped on the green plunger three times and replaced the cover and flushed one more time. The rados meter reading was still 1.0 mR/hr. The procedure was ended. Following post procedure measurements on the waste jar, the calculations showed that 60% (72 Gray) of the dose was delivered to the left lobe of the liver.
"Theraspheres may have been stuck in the vial and plunger. On 8/12/15, the Middlesex Hospital RSO/physicist measured the exposure levels from the separated out items in the waste jar. The highest reading was from the vial and plunger. The plunger was still attached to the vial.
"There is no anticipated adverse effect on the patient despite the fact that a lower dose (72 Gy) was delivered to the left lobe. Most of the patient's tumor burden is localized to the right lobe. Therefore, no additional Y-90 administration is necessary.
"Actions taken or planned: 1. BTG was notified. 2. The BTG RSO is working with the Middlesex Hospital RSO to determine the cause of the event. 3. In approximately 30 days, the Y-90 waste container will be sent to BTG for their investigation
"On 8/13/15, the patient and the referring physician were notified of the medical event."
Notified the R1DO (Krohn) and NMSS Events (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.
During a treatment of the left lobe of the liver, the dose delivered to the patient was discovered to differ greater than 20 percent than the intended dose. 120 Gray was prescribed by the physician and 72 Gray was delivered. During the procedure the Rados meter did not appear to be operating properly. Subsequent investigation determined that there was some radioactivity that remained in the vial. The technologist called the manufacturer who advised to perform several flushes and the Rados meter still did not change. The procedure was ended at that point. After ending the procedure when the survey was performed on the waste jar, it was discovered that only 60% of the dose was delivered. The activity appeared to be concentrated in the plunger attached to the vial. A new Rados detector will be obtained prior to the next procedure.
The patient will be informed of the issue by the physician.
Source Material: Yttrium 90, 7.03 GBq.
* * * UPDATE AT 1718 EDT ON 08/25/15 FROM JOAN MERTON TO JEFF HERRERA * * *
"On 8/11/15, a left lobe liver Y-90 embolization was performed in the interventional radiology room at Middlesex Hospital. The Y-90 therasphere activity was 7.04 GBq on 8/2/15 at [12:00 EDT] and 0.696 GBq on 8/11/15 at 10:00 am. Prior to placing the vial containing the Y-90 into the dose calibrator, the nuclear medicine technologist turned and tapped the lead pot 90 [degrees] three times. The Y-90 was infused at 12:11 pm on 8/11/15. The prescribed dose to the target volume was 120 Gray. The device and assembly were set up according to the checklist provided by the manufacturer. The authorized user turned the lead pot containing the vial 90 degrees three times and then tapped it on the table twice. The Rados meter read 1.0 mR/hr when the seal was removed from the Y-90 vial and before the commencement of the embolization. After the first flush with saline (20 ml/min) the rados meter still displayed a reading of 1.0 mR/hr. Two further flushes failed to reduce the reading of 1.0 mR/hr. The authorized user requested that the company (BTG/Nordion) representative be contacted. The lead technologist was advised by phone by the BTG representative to have the physician repeat the massaging of the tubing where the Roberts clamp had been released and perform two (2) additional saline flushes. After performing the representative's suggestions the reading was still 1.0 mR/hr. Per the lead NM [Nuclear Medicine] technologist, the BTG representative had no further recommendations. The authorized user then lifted the plexiglass cover of the apparatus and tapped on the green plunger three times and replaced the cover and flushed one more time. The rados meter reading was still 1.0 mR/hr. The procedure was ended. Following post procedure measurements on the waste jar, the calculations showed that 60% (72 Gray) of the dose was delivered to the left lobe of the liver.
"Theraspheres may have been stuck in the vial and plunger. On 8/12/15, the Middlesex Hospital RSO/physicist measured the exposure levels from the separated out items in the waste jar. The highest reading was from the vial and plunger. The plunger was still attached to the vial.
"There is no anticipated adverse effect on the patient despite the fact that a lower dose (72 Gy) was delivered to the left lobe. Most of the patient's tumor burden is localized to the right lobe. Therefore, no additional Y-90 administration is necessary.
"Actions taken or planned: 1. BTG was notified. 2. The BTG RSO is working with the Middlesex Hospital RSO to determine the cause of the event. 3. In approximately 30 days, the Y-90 waste container will be sent to BTG for their investigation
"On 8/13/15, the patient and the referring physician were notified of the medical event."
Notified the R1DO (Krohn) and NMSS Events (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.
Power Reactor
Event Number: 51308
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARK COVEY
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARK COVEY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/11/2015
Notification Time: 05:19 [ET]
Event Date: 08/11/2015
Event Time: 01:39 [CDT]
Last Update Date: 08/11/2015
Notification Time: 05:19 [ET]
Event Date: 08/11/2015
Event Time: 01:39 [CDT]
Last Update Date: 08/11/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BOB HAGAR (R4DO)
BOB HAGAR (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP AFTER AN OFFSITE ELECTRICAL FAULT
"Reactor trip caused by turbine trip. Turbine tripped immediately following the trip of one of four 345KV offsite lines. The reason for protective relaying not preventing the grid disturbance from tripping the turbine generator is not known at this time. All normal offsite and onsite power sources are available.
"Auxiliary Feedwater actuated as expected on low steam generator level following the trip from 100% power. All systems functioned as expected in response to the trip.
"The NRC Senior Resident Inspector has been notified."
An electrical fault on a 345 kV line 2 miles from the site caused the bus to strip and reclose, which cleared the fault. All control rods fully inserted and the plant is in its normal shutdown electrical lineup.
"Reactor trip caused by turbine trip. Turbine tripped immediately following the trip of one of four 345KV offsite lines. The reason for protective relaying not preventing the grid disturbance from tripping the turbine generator is not known at this time. All normal offsite and onsite power sources are available.
"Auxiliary Feedwater actuated as expected on low steam generator level following the trip from 100% power. All systems functioned as expected in response to the trip.
"The NRC Senior Resident Inspector has been notified."
An electrical fault on a 345 kV line 2 miles from the site caused the bus to strip and reclose, which cleared the fault. All control rods fully inserted and the plant is in its normal shutdown electrical lineup.
Agreement State
Event Number: 51322
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: UNKNOWN
Region: 4
City: ENID State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONALD NORWOOD
Licensee: UNKNOWN
Region: 4
City: ENID State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/17/2015
Notification Time: 11:10 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2015
Notification Time: 11:10 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BOB HAGAR (R4DO)
PAMELA HENDERSON (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
BOB HAGAR (R4DO)
PAMELA HENDERSON (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - ORPHANED SOURCE DISCOVERED / POSSIBLE OVEREXPOSURE INVOLVED
"[The Oklahoma Environmental Agency, Radiation Management Section] has been informed [on 8/17/2015] that a member of the public was cleaning out a warehouse belonging to Northern Oklahoma College in Enid, Oklahoma on August 15, 2015 when they came across an unusually heavy box. When opened, they found what was apparently a lead pig and about 10 glass vials. The pig was not secured and when tipped over a metal rod approximately 1.25 inches by 3 inches fell out. A piece of masking tape on the rod was labeled 'HOT' and '4 Radium tubes 1 broken.' One of the workers picked up the tube and handled it for a few minutes before they noticed the Radioactive label on the box. At this point, they returned the contents to the box and notified the University. The University does not possess a radioactive materials license. The person who handled the rod is now seeking medical attention complaining of nausea, dizziness, pain like arthritis in his hands, and blistering on his feet. [The Oklahoma Environmental Agency, Radiation Management Section] will be sending an inspector to the University, probably today. More information [will be provided] as it becomes available."
* * * UPDATE AT 1013 EDT ON 8/24/15 FROM KEVIN SAMPSON TO JEFF ROTTON * * *
The following update was received from the Oklahoma Department of Environmental Quality via email:
The original report documented that the material was discovered on 8/15/2015 while cleaning out a warehouse. This update revised this report to document that the discovery of the radioactive material occurred on 8/11/2015. The individual that handled the material with his hands was wearing leather work gloves when handling the radioactive material, but they were discarded with the other trash. On 8/14/15 the [member of the public] who handled the object reported feeling ill and on 8/17 went to a doctor complaining of nausea, dizziness, pain in his hands, and blisters on his feet.
"On 8/17/15 [The Oklahoma Department of Environmental Quality, Radiation Management Section] conducted a reactive inspection of the facility. Surveys of the facility using a microR meter and survey meter with GM detector did not find any contamination. Wipe tests of various objects and areas were collected and are being counted. The pig was as described in the original report and surveys of it produced readings from 1.5 to 3.5 mR/hr on the exterior and approx. 70 mR/hr directly above the open mouth. A variety of other sealed and unsealed sources were also found, many dating from the late 1950s. The college has secured these and will arrange for their disposal as soon as possible.
"On 8/18/15 [The Oklahoma Department of Environmental Quality, Radiation Management Section] again spoke with one of the workers who stated that the man who handled the source had been diagnosed with a reaction to mold exposure and given a cortisone injection. He was reportedly much better and had returned to work."
Notified the R4DO (Campbell), NMSS Events (via email) and NMSS Mgr. (Henderson).
"[The Oklahoma Environmental Agency, Radiation Management Section] has been informed [on 8/17/2015] that a member of the public was cleaning out a warehouse belonging to Northern Oklahoma College in Enid, Oklahoma on August 15, 2015 when they came across an unusually heavy box. When opened, they found what was apparently a lead pig and about 10 glass vials. The pig was not secured and when tipped over a metal rod approximately 1.25 inches by 3 inches fell out. A piece of masking tape on the rod was labeled 'HOT' and '4 Radium tubes 1 broken.' One of the workers picked up the tube and handled it for a few minutes before they noticed the Radioactive label on the box. At this point, they returned the contents to the box and notified the University. The University does not possess a radioactive materials license. The person who handled the rod is now seeking medical attention complaining of nausea, dizziness, pain like arthritis in his hands, and blistering on his feet. [The Oklahoma Environmental Agency, Radiation Management Section] will be sending an inspector to the University, probably today. More information [will be provided] as it becomes available."
* * * UPDATE AT 1013 EDT ON 8/24/15 FROM KEVIN SAMPSON TO JEFF ROTTON * * *
The following update was received from the Oklahoma Department of Environmental Quality via email:
The original report documented that the material was discovered on 8/15/2015 while cleaning out a warehouse. This update revised this report to document that the discovery of the radioactive material occurred on 8/11/2015. The individual that handled the material with his hands was wearing leather work gloves when handling the radioactive material, but they were discarded with the other trash. On 8/14/15 the [member of the public] who handled the object reported feeling ill and on 8/17 went to a doctor complaining of nausea, dizziness, pain in his hands, and blisters on his feet.
"On 8/17/15 [The Oklahoma Department of Environmental Quality, Radiation Management Section] conducted a reactive inspection of the facility. Surveys of the facility using a microR meter and survey meter with GM detector did not find any contamination. Wipe tests of various objects and areas were collected and are being counted. The pig was as described in the original report and surveys of it produced readings from 1.5 to 3.5 mR/hr on the exterior and approx. 70 mR/hr directly above the open mouth. A variety of other sealed and unsealed sources were also found, many dating from the late 1950s. The college has secured these and will arrange for their disposal as soon as possible.
"On 8/18/15 [The Oklahoma Department of Environmental Quality, Radiation Management Section] again spoke with one of the workers who stated that the man who handled the source had been diagnosed with a reaction to mold exposure and given a cortisone injection. He was reportedly much better and had returned to work."
Notified the R4DO (Campbell), NMSS Events (via email) and NMSS Mgr. (Henderson).
Agreement State
Event Number: 51361
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MITSUBISHI RAYON CARBON FIBER AND COMPOSITES
Region: 4
City: ANAHEIM State: CA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: DOANALD OESTERLE
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: MITSUBISHI RAYON CARBON FIBER AND COMPOSITES
Region: 4
City: ANAHEIM State: CA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: DOANALD OESTERLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/01/2015
Notification Time: 13:16 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [PDT]
Last Update Date: 09/01/2015
Notification Time: 13:16 [ET]
Event Date: 08/11/2015
Event Time: 00:00 [PDT]
Last Update Date: 09/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - RADIOACTIVE SOURCE SENT TO A WASTE RECYCLING FACILITY AND RETURNED
The following report was received via e-mail:
"On August 18, 2015, Mitsubishi Rayon Carbon Fiber and Composites (Mitsubishi) contacted the California Office of Emergency Services to report a missing source. The source, a Honeywell Measurex (now Vega Americas Corporation) BAL-55 source holder , S/N K0-003 with a Generally Licensed Kr-85 source (300 milliCuries as of 10/20/97). The source was determined to be missing on August 11, 2015. Upon learning that the machinery that the source holder was attached was sent to SA Recycling, Anaheim, [Mitsubishi] went to the facility and was informed that the unit had already been shredded and that there was no source found. [Mitsubishi] then contacted the manufacturer, who also provides services for their fixed gauges. When [Mitsubishi] finally was in contact with a service technician for Vega Americas, they were informed that the missing source was to be reported to RHB [California Radiologic Health Branch]. When [Mitsubishi] could not get in touch with RHB personnel after contacting the RHB Brea and Los Angeles County Radiation Management offices, he contacted the Office of Emergency Management.
"After the OES [Office of Emergency Services] report was forwarded to the ICE RAM [Inspection, Compliance, and Enforcement Radioactive Materials] South office, [Mitsubishi] was contacted by an RHB Inspector and informed that the source had been found by SA Recycling safety personnel and was currently being stored at their secure radioactive material storage area. [Mitsubishi] was informed that a written report was required to be submitted to RHB within 30 days.
"On August 19, 2015, an RHB Inspector arrived at SA Recycling to determine integrity of the device to ensure that the source was not damaged. Using a Ludlum 19, the dose rate was greater than 5 mR/hr on contact, 5 mR/hr at one inch, and 0.8 mR/hr at one foot (background was 7 microR/hr), which was consistent with the dose rate found by SA Recycling personnel (greater than 5 mR/hr on contact, 5mR/hr at 3.5 inches, 1.5 mR/hr at one foot and 0.21 mR/hr at three foot with a background of 9 microR/hr. The meter was a Ludlum 3 with a sodium iodide probe). Since the source is a noble gas, a significant amount would likely have released to the atmosphere within a weeks time if the source had been damaged. The consistent dose rate indicated that the source was most likely intact and not leaking. Since the source was most likely to be intact, the [RHB] inspector took possession of the source and returned it to Mitsubishi for storage in an isolated and secure area until disposal can be arranged with the manufacturer. Mitsubishi had been in the process of securing proper disposal when the source was improperly disposed as scrap metal. Upon arriving at the Mitsubishi facility, the [RHB] inspector was informed that the funds for the fees associated with the disposal were approved on August 19, 2015 and the disposal will be scheduled after the proper shipping package arrives at the Mitsubishi facility."
California Event: 081815
The following report was received via e-mail:
"On August 18, 2015, Mitsubishi Rayon Carbon Fiber and Composites (Mitsubishi) contacted the California Office of Emergency Services to report a missing source. The source, a Honeywell Measurex (now Vega Americas Corporation) BAL-55 source holder , S/N K0-003 with a Generally Licensed Kr-85 source (300 milliCuries as of 10/20/97). The source was determined to be missing on August 11, 2015. Upon learning that the machinery that the source holder was attached was sent to SA Recycling, Anaheim, [Mitsubishi] went to the facility and was informed that the unit had already been shredded and that there was no source found. [Mitsubishi] then contacted the manufacturer, who also provides services for their fixed gauges. When [Mitsubishi] finally was in contact with a service technician for Vega Americas, they were informed that the missing source was to be reported to RHB [California Radiologic Health Branch]. When [Mitsubishi] could not get in touch with RHB personnel after contacting the RHB Brea and Los Angeles County Radiation Management offices, he contacted the Office of Emergency Management.
"After the OES [Office of Emergency Services] report was forwarded to the ICE RAM [Inspection, Compliance, and Enforcement Radioactive Materials] South office, [Mitsubishi] was contacted by an RHB Inspector and informed that the source had been found by SA Recycling safety personnel and was currently being stored at their secure radioactive material storage area. [Mitsubishi] was informed that a written report was required to be submitted to RHB within 30 days.
"On August 19, 2015, an RHB Inspector arrived at SA Recycling to determine integrity of the device to ensure that the source was not damaged. Using a Ludlum 19, the dose rate was greater than 5 mR/hr on contact, 5 mR/hr at one inch, and 0.8 mR/hr at one foot (background was 7 microR/hr), which was consistent with the dose rate found by SA Recycling personnel (greater than 5 mR/hr on contact, 5mR/hr at 3.5 inches, 1.5 mR/hr at one foot and 0.21 mR/hr at three foot with a background of 9 microR/hr. The meter was a Ludlum 3 with a sodium iodide probe). Since the source is a noble gas, a significant amount would likely have released to the atmosphere within a weeks time if the source had been damaged. The consistent dose rate indicated that the source was most likely intact and not leaking. Since the source was most likely to be intact, the [RHB] inspector took possession of the source and returned it to Mitsubishi for storage in an isolated and secure area until disposal can be arranged with the manufacturer. Mitsubishi had been in the process of securing proper disposal when the source was improperly disposed as scrap metal. Upon arriving at the Mitsubishi facility, the [RHB] inspector was informed that the funds for the fees associated with the disposal were approved on August 19, 2015 and the disposal will be scheduled after the proper shipping package arrives at the Mitsubishi facility."
California Event: 081815