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Event Notification Report for January 29, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/28/2016 - 01/29/2016

** EVENT NUMBERS **


51665 51666 51667 51668 51670 51671 51672

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Agreement State Event Number: 51665
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: WINPAK, INC.
Region: 3
City: SOUTH CHICAGO HEIGHTS State: IL
County:
License #: 9210998
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2016
Notification Time: 14:06 [ET]
Event Date: 01/20/2016
Event Time: [CST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF PROCESS AUTOMATION BETA GAUGE

The following information was received from the State of Illinois via email:

"The Plant Manager for WINPAK, Inc., in South Chicago Heights, IL, called to report the loss of an ABB Process Automation Model O-2 beta gauge (SN S-1379-T) containing 70 milliCuries of Sr-90. The recent annual general license self inspection revealed some discrepancies in serial numbers and the licensee could not locate this particular device. They believe it to have likely been removed by a local scrap vendor that was on-site. Another possibility is an equipment vendor that was doing some work on site. Both vendors are being contacted as part of the investigation. lEMA [Illinois Emergency Management Agency] staff are at the scrap yard today investigating as well.

"The licensee is continuing to pursue possible leads on the location of the source. lEMA has contacted the manufacturer and they have no records of return but have contacted NDC [does service work under contract to ABB] to see if they retrieved it under contract work. This item will remain open for the required time until the source is recovered or declared lost."

Illinois Item Number: IL15022

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

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Agreement State Event Number: 51666
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEOSTRUCTURES, INC
Region: 1
City: KING OF PRUSSIA State: PA
County:
License #: PA-1068
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2016
Notification Time: 13:05 [ET]
Event Date: 01/19/2016
Event Time: [EST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the Commonwealth of Pennsylvania via E-mail:

"On January 19, 2016, the Department [Pennsylvania Department of Environmental Protection] was notified that a moisture density gauge became disabled from damage in Berwyn, Pennsylvania. This event is reportable per 10 CFR 30.50(b)(2).

"The gauge was run over by a piece of heavy equipment. This damaged the gauge and it became unusable. The source rod was in the retracted position at the time of the incident and instrument readings confirmed no damage to the source occurred. The gauge was taken out of service and transported to the manufacturer for servicing. No exposures occurred.

"Manufacturer: lnstroTek
"Gauge Model: 3500 Xplorer
"Gauge S/N: 000856
"Radioactive Material: Cesium-137: 11 milliCuries, Americium-241: 44 milliCuries

"[The cause is attributed to] human error.

"The gauge was transported to the manufacturer for repair. A reactive inspection was performed by the Department and verified the validity of the licensee's instrument readings regarding exposure and leaking sources.

"Pennsylvania Event Report ID No.: PA160003"

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Agreement State Event Number: 51667
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: US STEEL
Region: 1
City: CLAIRTON State: PA
County:
License #: PA-1280
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/20/2016
Notification Time: 13:34 [ET]
Event Date: 01/18/2016
Event Time: [EST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILED SHUTTER ASSEMBLY ON LEVEL CONTROL GAUGE

The following information was received from the Commonwealth of Pennsylvania via E-mail:

"The Department [Pennsylvania Department of Environmental Protection] was notified on January 19, 2016, that during routine activities on January 18, 2016, the weld on the collimator block, which is part of the shutter assembly to the gauge, failed. This event is reportable per 10 CFR 30.50(b)(2).

"The weld on the collimator block failed on a Thermo Measure Tech level control gauge. The shutter was closed at the time of the event and no workers received any dose. The licensee notified a service provider who responded and installed a new collimator assembly.

Device Information:
Manufacturer: Thermo Measure Tech
Model: 5204
Device Serial Number: B497
Isotope: Cesium-137
Activity: 4 curies

"[The cause is attributed to] equipment failure.

"A new shutter assembly was installed and tested. The Department plans a reactive inspection. More information will be provided upon receipt.

"Pennsylvania Event Report ID No.: PA160004"

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Non-Agreement State Event Number: 51668
Rep Org: SSM HEALTH ST. CLARE HEALTH CENTER
Licensee: SSM HEALTH ST. CLARE HEALTH CENTER
Region: 3
City: FENTON State: MO
County:
License #: 24-11858-01
Agreement: N
Docket:
NRC Notified By: MARK POHLMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/20/2016
Notification Time: 14:59 [ET]
Event Date: 12/22/2015
Event Time: [CST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

MISSING I-125 CALIBRATION SEED

"Licensed material involved: The lost material was a single I-125 sealed source Model 6711 with an apparent activity of 0.359 mCi on 9/14/2015. The specific source missing was the calibration seed ordered along with the implant sources, which are preloaded into needles.

"Description of circumstances under which loss occurred: On 12/22/2015, during inventory and collection of seeds (from several prostate seed cases) for shipment back to the vendor for disposal, it was discovered that the calibration seed from one patient's pig was missing. This seed is distinctive due to the black marking on one half of the seed. This seed is only removed from its pig in the hot lab during calibration, so it is hypothesized that it inadvertently flipped out of forceps unnoticed during the calibration process.

"A statement of disposition, or probable disposition, of the licensed material involved: The calibrated seed is shipped in a separate pig along with the preloaded needle trays. The calibration seed is only removed from the pig in the hot lab. Therefore, our feeling is that the highest probability of loss was in the hot lab during calibration. While it is difficult to be completely sure of the location of the seed, it is felt that it is still in the hot lab in an inaccessible location.

"Exposures of individuals to radiation: Since the seed was not discovered on survey (at the lowest setting of the meter) in the hot lab nor the OR [Operating Room] suite, the best estimate of exposure to personnel is minimal. With the low energy of I-125 and the low activity of 0.359 mCi on the day of the implant (Sept. 24, 2015), it would not take much in the way of attenuating material to mitigate exposure to others.

"Actions that have been taken to recover the material: The L-Block shielding and supplies were all dismantled, moved and searched, however the seed was not found. Storage carts and stored supplies around the hot lab were also moved and surveyed, the seed however was still not recovered. Although the OR suite was surveyed at the time of the implant as a part of our policy, we returned to the same OR suite upon discovery of the missing source to survey again. The seed was still not recovered.

"Procedures or measures that have been, or will be, adopted to ensure against a recurrence: Several specific actions are warranted to reduce potential loss in the future. The highest likelihood of loss would seem to be when sources are being handled outside of their respective storage location. i.e. During movement of seeds from the pig to ion chamber and consolidation of unused seeds from the extra needles ordered for each implant. First, when the calibration seed is being removed and returned to the pig, use of reverse action forceps will be mandated. Secondly, when the seed is returned to the bottle and the cap replaced, the bottle will be inspected to verify it contains the calibration seed. Third, the practice of 'pushing out' seeds from unused needles into the pig following each case, in the OR suite, will no longer be allowed. Fourth and finally, the calibration source and the pig it is stored in, will remain in the hot lab. An extra pig with an empty bottle will be taken to the OR in the event a seed must be retrieved from a patient and must be stored."

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

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Agreement State Event Number: 51670
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: DENVER State: CO
County:
License #: CO 038-02
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/20/2016
Notification Time: 18:32 [ET]
Event Date: 11/09/2015
Event Time: [MST]
Last Update Date: 01/20/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
PAMELA HENDERSON (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING HIGH DOSE RATE THERAPY

"The Department [Colorado Department of Public Health and Environment (CDPHE)] received a phone report from the Radiation Safety Officer for Saint Joseph Hospital regarding a medical event involving the HDR [high dose rate therapy]. A patient was scheduled to receive three fractions of HDR treatment in November, 2015. It is believed the second fraction caused the medical event on November 9, 2015. In December, the patient reported to their primary care physician, burns to the leg. The authorized user was notified in December by the patient and/or primary care physician. The authorized medical physicist and radiation safety officer were notified of the event on January 19, 2016 and notified CDPHE on January 20, 2016. The intended dose to the treatment site was 6,000 cGy with all of the intended dose being delivered to the patient's leg. The preliminary cause was an error with the transfer tube-applicator interface, but the licensee is still conducting an internal investigation.

"The Department is expecting a full report from the licensee within 15 days and preparing for a visit to investigate the event."

Colorado Event Report ID No.: CO16-M16-01

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.

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Agreement State Event Number: 51671
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CLARION BOARDS, INC
Region: 1
City: SHIPPENVILLE State: PA
County:
License #: PA-G0084
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/21/2016
Notification Time: 13:06 [ET]
Event Date: 01/21/2016
Event Time: [EST]
Last Update Date: 01/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE GAUGE SHUTTER FAILURE

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"The roll pin on the shutter handle of a Ronan Engineering gauge broke, most likely due to environmental conditions. The shutter is in the closed position and the gauge is out of service. The licensee plans to contact the manufacturer for repair. No overexposures have occurred.

"Manufacturer: Ronan Engineering
Model: SA1-F37
Serial #: M7255
Isotope: Cs-137
Activity: 10 mCi

"Cause of the Event: The gauge is located in a harsh and dirty environment. In the past, they designed and installed a cover to shield the gauge. When inspecting the gauge after the event, it was noticed that this cover had fallen off.

"Actions: A reactive inspection is planned by the Department [Pennsylvania Department of Environmental Protection]. More information will be provided upon receipt."

PA Report No.: PA160005

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Agreement State Event Number: 51672
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: APPLIED TECHNICAL SERVICES, INC.
Region: 1
City: GREENVILLE State: TN
County:
License #: R-33172-C19
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/21/2016
Notification Time: 16:23 [ET]
Event Date: 12/06/2015
Event Time: [EST]
Last Update Date: 01/21/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE DUE TO DAMAGED GUIDE TUBE

The following information was obtained from the State of Tennessee via email:

"On December 6, 2015 at approximately 1300 EST, an exposure device D6032, (880 Delta) containing Source S/N SE4869, 50 Ci of Se-75, fell from its position on top of a flange assembly approximately six feet to the finished floor. Upon impact, the guide tube was crimped preventing the source from being able to return to the camera. The source was able to be returned to the collimator reducing the radiation present. Technicians secured a true two mR boundary and notified plant safety personnel and the RSO. The lead technician onsite was source retrieval certified and took charge of the retrieval process. The source was further shielded in a larger diameter pipe and covered with sand bags to reduce radiation levels. Using a pair of pliers, the technician was able to 're-round' the guide tube opening to allow the source to be returned to the camera. The guide tube, camera and control assembly was taken out of service pending inspection. The guide tube was damaged beyond use; the source 'pigtail' and control cable were inspected and tested using a no-go gauge. The guide tube was removed from service and the control assembly will be sent to the manufacturer for further evaluation (ball end connector). Source retrieval technician received a total dose of 150 mR during the event."

Tennessee Report No.: TN-16-012

Page Last Reviewed/Updated Friday, January 29, 2016
Friday, January 29, 2016