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Event Notification Report for July 25, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/22/2016 - 07/25/2016

** EVENT NUMBERS **


51767 52087 52088 52089 52091 52092 52093 52094 52095

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 51767
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: MICHAEL C. TESTER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/04/2016
Notification Time: 10:26 [ET]
Event Date: 03/03/2016
Event Time: 21:23 [EST]
Last Update Date: 07/25/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
MARVIN SYKES (R2DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

CONTAMINATED RADIOACTIVE MATERIAL SHIPMENT

"On March 3, 2016, at approximately 1745 [EST], a radioactive material shipment was received at NFS from the Westinghouse Electric Company in Hopkins, South Carolina. Receipt contamination and radiation surveys were completed at approximately 1905. Results indicated removable surface contamination on two of the nine radioactive material packages that exceeded the criteria of the cited regulations.

"The radioactive material shipment left the Westinghouse Electric Company facility at 1300 [EST] on March 3, 2016. It was received at the NFS receiving facility at approximately 1745 on March 3, 2016. Surface contamination and radiation surveys were initiated immediately upon receipt. Removable surface contamination in excess of 10 CFR 20.1906(d) limits was verified to be present on the external surface of two of the nine shipping containers in the shipment at 1905. Contamination was controlled at the receiving facility and successfully decontaminated below criteria of 10 CFR 20.1906(d) by approximately 2030 on March 3, 2016."

This was an exclusive shipment. The alpha contamination measured 4278 dpm/100 sq. cm. and 6345 dpm/100 sq. cm., respectively. The licensee informed Westinghouse who is conducting an investigation into this incident.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 07/15/16 AT 1243 EDT FROM RANDY SHACKELFORD TO DONG PARK * * *

"On 3/4/2016, NFS made an event report to the NRC Operations Center regarding receipt of containers with removable contamination that exceeded the criteria of the cited regulations. Based on a recent determination by NRC that the materials of concern are considered to be low toxicity alpha emitters, the contamination limits for low toxicity alpha emitters were not exceeded. Therefore, NFS is retracting the event report.

The licensee notified the NRC Resident Inspector. Notified R2DO (Rich) and NMSS Events Notification via email.

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Non-Agreement State Event Number: 52087
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-02
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/14/2016
Notification Time: 15:47 [ET]
Event Date: 07/13/2016
Event Time: 15:50 [EDT]
Last Update Date: 07/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
DANIEL RICH (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

LOST/STOLEN U.S. ARMY RADIOACTIVE CHEMICAL ALARMS

On July 13, 2016, the U.S. Army TACOM Radiation Safety Program Manager in Warren, MI was notified of a misplaced U.S. Army chemical alarm containing 250 microcuries of Am-241 from a U.S. National Guard Unit in North Carolina. The chemical alarm was misplaced on April 21. Since the material has not been recovered, the U.S. Army considers the material lost/stolen.

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: 52088
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNKNOWN
Region: 1
City: UNKNOWN State: VA
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/14/2016
Notification Time: 17:20 [ET]
Event Date: 07/11/2016
Event Time: [EDT]
Last Update Date: 07/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE FOUND AT METAL RECYCLING FACULTY

The following report was received from the Commonwealth of Virginia via facsimile:

"On July 11, 2016, Sims Metal Recycling, Petersburg, Virginia, reported to the Virginia Radioactive Material Program (VRMP) that a radioactive source had been found in a shipment of metal. VRMP Radiation Safety Specialists performed an onsite review. Labels indicated that the source was a general license device from EG&G Berthold, model not identified, serial number 001098 with a 100 millicurie (September 1990) cesium-137 source, serial number 3027. The shutter was locked partially open with the opening behind part of the gauge mounting. Maximum radiation levels at contact at the mounting near the shutter were 5 mR; at three feet, maximum levels were less than 0.1 mR/hr. The gauge was placed in a drum using a mechanical hoist and the drum was placed in a secured area. Dose estimates by VRMP personnel indicated no individual was likely to have received more than 1 mrem whole body or 5 mrem extremity dose. On-site tests for leakage indicated no removable contamination. The recycling facility contacted RSO, Inc., a commercial firm, to arrange for disposal. The gauge owner was not identified from review of the VRMP general license database. Berthold Technologies USA is reviewing records to identify the owner of the gauge."

Virginia Event Report ID No.: VA-16-008

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: 52089
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNKNOWN
Region: 1
City: UNKNOWN State: VA
County:
License #: GENERAL LICEN
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/14/2016
Notification Time: 17:24 [ET]
Event Date: 07/12/2016
Event Time: [EDT]
Last Update Date: 07/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE FOUND AT METAL RECYCLING FACULTY

The following report was received from the Commonwealth of Virginia via facsimile:

"On July 12, 2016, Sims Metal Recycling, Richmond Virginia, reported to the Virginia Radioactive Material Program (VRMP) that a radioactive source had been found in a shipment of metal. They said the source was a gauge like the one found the previous day in their Petersburg Virginia Facility [see EN #52088]. Refer to VA-16-008. VRMP Radiation Safety Specialists performed an onsite review. Labels indicated that the source was a general license device from EG&G Berthold, model not identified, serial number 001095, with a 100 millicurie (September 1990) cesium-137 source, serial number 3023. Maximum radiation levels at contact at the mounting near the shutter were 2 mR/hr, at three feet, maximum levels were less than 0.1 mR/hr. The gauge was placed in a drum in a secured area. Dose estimates by VRMP health physicists indicated no individual was likely to have received more than 1 mrem whole body or 5 mrem extremity dose. On-site tests for leakage indicated no removable contamination. The recycling facility will contact a waste broker to arrange for disposal. The gauge owner was not identified from review of the VRMP general license database. Berthold Technologies USA is reviewing records to identify the owner of the gauge.

Virginia Event Report ID No: VA-16-009

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: 52091
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DENIZEN APARTMENTS
Region: 4
City: DENVER State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2016
Notification Time: 10:27 [ET]
Event Date: 07/14/2016
Event Time: 13:51 [MDT]
Last Update Date: 07/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"Detail: The project manager for a newly constructed apartment complex ordered exit signs to be installed. The distributor (LEI Companies) ordered them from a local supplier (Gexpro). The distributor is unable to locate the exit signs. It is unknown as to what occurred with the signs not being installed at the apartment complex nor being returned to their company. Exit signs are reported as lost.

"Manufacturer: SRB Technologies, Winston-Salem, NC; Model # BX-10-WH; Serial # C121961, C121962, C121963, C121964, and C121965; Date Shipped: 4-16-15.

"Designated for: Denizen Apartments, Denver, CO. Ordered through Gexpro, Denver, CO by LEI Companies.

"Event Description: Gexpro reported the exit signs were picked up by an employee of LEI Companies and were not returned. LEI Companies has documentation to return them, however, no record of exit signs being returned has been located. Denizen Apartments never received nor had exit signs installed."

Colorado Event: CO16-I16-12
NMED: C160006

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: 52092
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SYSTEM ONE HOLDINGS, LLC
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-1148
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2016
Notification Time: 14:13 [ET]
Event Date: 07/13/2016
Event Time: [EDT]
Last Update Date: 07/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following was received via email:

"The lock on a radiography camera did not spring back into place when the radiographer retracted the cable and source into the shielded position. He [the radiographer] was able to crank the source back out and when he retracted it back into the camera the second time, the lock sprung closed and secured the source. There was no unexpected radiation exposure to the employee or to the general public. The entire incident lasted less than 10 seconds. Due to the apparent equipment failure it is reportable under 10 CFR 30.50(b)(2).

"The device is identified as:
Manufacturer: QSA Global
Model #: 880 Delta
Device Serial #: 1636
Isotope: lr-192
Activity: 34 Ci

"The licensee (System One) is going to conduct an internal investigation to determine the cause of the malfunction. The Department [Pennsylvania Bureau of Radiation Protection] will be scheduling a reactive inspection.

"Event Report ID: PA160018"

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Agreement State Event Number: 52093
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2016
Notification Time: 14:36 [ET]
Event Date: 07/13/2016
Event Time: [EDT]
Last Update Date: 07/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE MEDICAL EVENT

The following was received via email:

"Event Description: A patient was undergoing a Y-90 Therasphere procedure in two separate treatments (to different liver segments). The delivery kits for both administrations passed the standard pre-administration testing. The physician and team noted no other equipment related issues until the administering Interventional Radiologist Physician noted unusual resistance during the first actual administration. After unsuccessful attempts to 'clear the line,' the efforts to complete the administration were terminated. The team then attempted to treat a second site, with essentially the same sequence of events occurring. Both delivery sets came from the same manufacturing lot, and both dosages of Theraspheres came from the same drug lot. The licensee estimates approximately 25 percent of the written directive dose was delivered.

"Cause of the Event: Unknown at this time. It is worth noting, another Theraspheres administration on another patient was performed the following day without incident. The delivery system kits were again from the same lot as those used on the previous day, but the Therasphere dosage was from a different lot.

"Actions: Licensee notified Nordion of the occurrence. The Department [PA Department of Environmental Protection] will perform a reactive inspection next week.

"Event Report ID: PA160019"

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: 52094
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: HOLLINS UNIVERSITY
Region: 1
City: ROANOKE State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2016
Notification Time: 14:24 [ET]
Event Date: 06/17/2016
Event Time: [EDT]
Last Update Date: 07/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE NEEDLE FOUND

The following was received via email:

"On June 17, 2016, RSO, Inc., contacted Virginia Radioactive Material Program (RMP) to arrange an investigation on a lead pig found at Hollins University, Roanoke, Virginia. On June 22, 2016, two inspectors from the RMP went to the University to observe the investigation performed by Health Physicist from the RSO, Inc. The lead pig was found inside the drawer in Dana Science Building Chemistry Lab. A radiation level of 12 mR/hr was measured at about one foot from the pig. The Health Physicist used a hand-held gamma spectrometer (Bicron Identifier) to identify the radionuclide as Ra-226. The health physicist performed calculation and also opened the pig carefully to identify the type of Ra-226. He developed and followed safety procedures to open the pig. Leak tests were performed and no removable contamination was detected.

"Based on the Health Physicist's investigation and activity calculation, the pig contains a one millicurie (1 mCi) Ra-226 needle.

"RSO, Inc., is currently working with the University to arrange for the disposal of the source. This report will be updated when the RMP received the final disposal report.

"Event Report ID: VA-16-11"

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Agreement State Event Number: 52095
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL
Region: 1
City: BURLINGTON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JAY HYLAND
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2016
Notification Time: 14:21 [ET]
Event Date: 07/14/2016
Event Time: 19:35 [EDT]
Last Update Date: 07/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
ANGELA MCINTOSH (NMSS)
ADAM TUCKER (ILTA)
BERNARD STAPLETON (IRD)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL DELIVERED TO PRIVATE RESIDENCE

The following was received via facsimile:

"[Maine Radiation Control Program (MRCP)] was called by [Chase Environmental] at 1935 [EDT] on 7/14/2016. [Chase Environmental] had been contacted (indirectly) by HAZ-MAT One regarding a radiological emergency in Waterford, Maine. [Chase Environmental] had contacted HAZ-MAT One directly and was told that a radioactive package had been delivered, incorrectly, to a private address. [Chase Environmental] was told the package was intact and that the shipping company (YRC) was going to retrieve the package and get it to its addressed location. When [MRCP] contacted HAZ-MAT One on the morning of 7/15/2016, they reported that the correct delivery address for the package was QSA Global in Burlington, MA and that the private residence had ordered a lawn mower. [MRCP] contacted QSA and informed them of the package that was coming and asked the particulars of the package. [MRCP] contacted YRC Freight to obtain more information regarding the package and got the tracking number for the package and that it had been retrieved and was enroute to the YRC terminal in Westbrook, Maine by roughly 1000 [EDT]. [MRCP] called [QSA Global] and gave them the tracking number, then tracked the package and found that it had been delivered to Waterford Maine on or about 6/15/2016. [QSA Global] called [MRCP] back and informed [MRCP] that the package was a 650 source exchanger, with a six (6) curie Iridium 192 source in it from Guatemala. The package had evidently fallen into the box or crate of a lawn mower during shipment and been delivered to the Waterford, Maine address. Additional information regarding dose reconstruction and leak test/package condition will be forthcoming when the package gets to QSA Global in the next few business days.

"Event Report ID: ME-16-001"

Page Last Reviewed/Updated Monday, July 25, 2016
Monday, July 25, 2016