Event Notification Report for August 21, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/20/2015 - 08/21/2015
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 51359
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: ENERGY FUELS RESOURCES, INC.
Region: 4
City: BLANDING State: UT
County:
License #: UT 1900479
Agreement: Y
Docket:
NRC Notified By: RYAN JOHNSON
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ENERGY FUELS RESOURCES, INC.
Region: 4
City: BLANDING State: UT
County:
License #: UT 1900479
Agreement: Y
Docket:
NRC Notified By: RYAN JOHNSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/31/2015
Notification Time: 16:40 [ET]
Event Date: 08/21/2015
Event Time: 15:50 [MDT]
Last Update Date: 09/03/2015
Notification Time: 16:40 [ET]
Event Date: 08/21/2015
Event Time: 15:50 [MDT]
Last Update Date: 09/03/2015
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 - LOW LEVEL ALPHA RADIATION ON A SHIPPING CONTAINER
The following information was received via e-mail:
"On 8/21/2015 at 1550 [MDT] an incident involving radioactive material was reported to the Utah Department of Environmental Quality's 24 hr. hotline. The caller reported low level alpha radiation activity on an empty shipping container and roll-off box that exceeds DOT standards. The container arrived at their facility the morning of 8/21/2015 from a Utah (NRC Agreement State) regulated facility near Blanding. It was the belief of the caller that it is very unlikely there was any dosage to humans or the environment.
"The container was shipped from Blanding, Utah to Douglas, Wyoming through Grand Junction. The caller has notified the NRC [National Response Center], Incident #1126333. They have also contacted Colorado and Wyoming DOT."
Utah Event: UT15-0003
* * * UPDATE AT 1825 EDT ON 9/1/2015 FROM RYAN JOHNSON TO MARK ABRAMOVITZ * * *
The source of the alpha radiation was natural uranium. The container was decontaminated.
A radiation survey of the container was conducted before decontamination with the following results:
Direct alpha readings of 2437, 7616, and 6092 dpm per 100 square cm
Removable alpha readings of 191, 200, and 786 dpm per 100 square cm. These results are below the DOT 49CFR173.443(a) reporting requirements
Notified the R4DO (Warnick) and NMSS Events Resource (via e-mail).
* * * RETRACTION PROVIDED BY RYAN JOHNSON TO JEFF ROTTON VIA EMAIL AT 1514 EDT ON 09/03/2015 * * *
The following information was received from the State of Utah via email:
"After further investigation into this incident, the DWMRC [Division of Waste Management and Radiation Control] has concluded that the reported incident was in error and that DOT standards were not exceeded. The DOT alpha contamination limits found in 49 CFR 173.443(a) are for removable (non-fixed) contamination. The incident was reported on an incoming survey results for direct alpha measurements and not on removable alpha measurements. The removable alpha measurements from the same incoming survey were below the DOT alpha contamination limits. Therefore, the State of Utah is requesting to retract this incident (EN#51359)."
Notified R4DO (Warnick) and NMSS Events Notification group via email.
THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL
The following information was received via e-mail:
"On 8/21/2015 at 1550 [MDT] an incident involving radioactive material was reported to the Utah Department of Environmental Quality's 24 hr. hotline. The caller reported low level alpha radiation activity on an empty shipping container and roll-off box that exceeds DOT standards. The container arrived at their facility the morning of 8/21/2015 from a Utah (NRC Agreement State) regulated facility near Blanding. It was the belief of the caller that it is very unlikely there was any dosage to humans or the environment.
"The container was shipped from Blanding, Utah to Douglas, Wyoming through Grand Junction. The caller has notified the NRC [National Response Center], Incident #1126333. They have also contacted Colorado and Wyoming DOT."
Utah Event: UT15-0003
* * * UPDATE AT 1825 EDT ON 9/1/2015 FROM RYAN JOHNSON TO MARK ABRAMOVITZ * * *
The source of the alpha radiation was natural uranium. The container was decontaminated.
A radiation survey of the container was conducted before decontamination with the following results:
Direct alpha readings of 2437, 7616, and 6092 dpm per 100 square cm
Removable alpha readings of 191, 200, and 786 dpm per 100 square cm. These results are below the DOT 49CFR173.443(a) reporting requirements
Notified the R4DO (Warnick) and NMSS Events Resource (via e-mail).
* * * RETRACTION PROVIDED BY RYAN JOHNSON TO JEFF ROTTON VIA EMAIL AT 1514 EDT ON 09/03/2015 * * *
The following information was received from the State of Utah via email:
"After further investigation into this incident, the DWMRC [Division of Waste Management and Radiation Control] has concluded that the reported incident was in error and that DOT standards were not exceeded. The DOT alpha contamination limits found in 49 CFR 173.443(a) are for removable (non-fixed) contamination. The incident was reported on an incoming survey results for direct alpha measurements and not on removable alpha measurements. The removable alpha measurements from the same incoming survey were below the DOT alpha contamination limits. Therefore, the State of Utah is requesting to retract this incident (EN#51359)."
Notified R4DO (Warnick) and NMSS Events Notification group via email.
THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL
Agreement State
Event Number: 51452
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MOUNT CARMEL ST. ANN'S
Region: 3
City: WESTERVILLE State: OH
County:
License #: 02120250034
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: VINCE KLCO
Licensee: MOUNT CARMEL ST. ANN'S
Region: 3
City: WESTERVILLE State: OH
County:
License #: 02120250034
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: VINCE KLCO
Notification Date: 10/05/2015
Notification Time: 09:58 [ET]
Event Date: 08/21/2015
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2015
Notification Time: 09:58 [ET]
Event Date: 08/21/2015
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE
The following information was received by the State of Ohio via facsimile:
"A patient had a prostate volume study done on 7/24/15 at Mount Carmel St. Ann's (MCSA). The mass that was observed on the ultrasound is in the location of a typical prostate and takes the shape of a typical prostate. Implant (I-125) procedure was performed on 8/21/15. During the implant, ultrasound guidance was used when placing the seeds and the images that were seen matched what was taken at the time of the volume study on 7/24/15.
"A CT [Computerized Axial Tomography] scan was taken on 9/23/15 for post implant study to verify the seed placement and target coverage. The post implant study was performed on 10/1/15 and revealed that the prostate that is visible by CT is not adequately covered by the seeds, and that the seeds may be in the rectum. The images were reviewed further and there is a mass located between the rectum and the prostate. This is what is believed to have been visualized on the ultrasound, and what was treated in the OR [Operating Room].
"The licensee is still investigating to determine whether this tissue is part of the prostate, possibly rectum, or something else altogether. The patient has been scheduled for an MRI [Magnetic Resonance Imaging] to better visualize the tissues in this area. What is known at this time is that a large part of the prostate was not treated, the coverage to the intended target organ is below 80%, and this is being treated as a medical event. The licensee will submit a complete report when the analyses are finalized.
"ODH [Ohio Department of Health] intends to send an investigator to the licensee for follow-up. This NMED record will be updated as more information becomes available."
Ohio Incident: OH150010
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 information was received by the State of Ohio via facsimile:
"A patient had a prostate volume study done on 7/24/15 at Mount Carmel St. Ann's (MCSA). The mass that was observed on the ultrasound is in the location of a typical prostate and takes the shape of a typical prostate. Implant (I-125) procedure was performed on 8/21/15. During the implant, ultrasound guidance was used when placing the seeds and the images that were seen matched what was taken at the time of the volume study on 7/24/15.
"A CT [Computerized Axial Tomography] scan was taken on 9/23/15 for post implant study to verify the seed placement and target coverage. The post implant study was performed on 10/1/15 and revealed that the prostate that is visible by CT is not adequately covered by the seeds, and that the seeds may be in the rectum. The images were reviewed further and there is a mass located between the rectum and the prostate. This is what is believed to have been visualized on the ultrasound, and what was treated in the OR [Operating Room].
"The licensee is still investigating to determine whether this tissue is part of the prostate, possibly rectum, or something else altogether. The patient has been scheduled for an MRI [Magnetic Resonance Imaging] to better visualize the tissues in this area. What is known at this time is that a large part of the prostate was not treated, the coverage to the intended target organ is below 80%, and this is being treated as a medical event. The licensee will submit a complete report when the analyses are finalized.
"ODH [Ohio Department of Health] intends to send an investigator to the licensee for follow-up. This NMED record will be updated as more information becomes available."
Ohio Incident: OH150010
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.