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Event Notification Report for December 1, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/30/2016 - 12/01/2016

** EVENT NUMBERS **


52389 52391 52392 52393

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Agreement State Event Number: 52389
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: INTEGRIS HEALTH
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-11022-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2016
Notification Time: 12:17 [ET]
Event Date: 11/17/2016
Event Time: [CST]
Last Update Date: 11/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - I-125 SEED LEFT INSIDE A PATIENT

"Yesterday (November 21, 2016) we [Oklahoma Department of Environmental Quality] were notified by Integris Health (OK-11022-01) that a brachytherapy seed containing 0.1 mCi of I-125 had been lost. The seed was implanted in a patient on November 14 for localization of a non-palpable breast lesion. The tissue was removed on November 17 and sent to pathology. The patient had also had a sentinel node procedure on the same day and received a dose of Tc-99. The licensee believed that the seed had been removed with the specimen. The specimen was sent to the pathology lab on November 18 and showed no radiation when surveyed there. The licensee initiated a search of their facilities at that time. The patient returned to the hospital yesterday for their post-operative evaluation, was again surveyed, and the seed was detected.

"Yesterday evening, the licensee emailed us that the seed had actually been left in the patient. We are making this notification as a possible medical event. The licensee is performing a dose calculation on the patient. Our investigation is ongoing and we will provide more information as it becomes available."

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: 52391
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: QSA GLOBAL, INC.
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-5934-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/23/2016
Notification Time: 10:21 [ET]
Event Date: 11/03/2016
Event Time: [CST]
Last Update Date: 11/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING KR-85 SOURCE DURING TRANSFER TO APPROVED SHIPPING CONTAINER

The following report was received from the Louisiana Department of Environmental Quality via email:

"On the 3rd of November, 2016, QSA Global, Inc. had an incident during the transfer of Kr-85 sources to approved shipping containers for transportation to Qual-X, Inc. for recycling. The work was being preformed at approximately 1530 to 1600 hrs. [CST]. After the completion of the work, there was no indication at that time of any possible leakage.

"At approximately 1800 hrs., it was noticed that the scintillation counter background had a slightly higher than normal background reading. It was determined that the only possible cause was the Kr-85 sources, as that is all that QSA Global, Inc. had worked with that day. A visual inspection of the possible leaking Kr-85 sources was performed. There was no damage to any of the windows, but QSA Global, Inc. now knows that was the point of origin of the contamination due to the surveys of the lead container that they were stored in. The sources were sealed in a 10 gallon steel drum and then placed in a plastic bag to prevent any additional release of material.

"The sources involved are LFE Model S-70A s/n 9234 at 168 mCi, 9332 at 184 mCi and 9333 at 184 mCi. The original activity of these sources was 1200 mCi.

"The building was ventilated using fans to remove the Kr-85 that had accumulated in the building. The building was surveyed at 0230 hrs. [on November 4, 2016] with no contamination detected. Another survey of the building was performed again at 0530 again with no contamination found.

"After QSA Global discussed the situation with Qual-X, Inc. and using their expertise in these types of situations, it was determined from survey readings and building size, that an estimated amount of less than 1-2 mCi may have been released. They also indicated that the sources were of the type that are known to leak due to the way they are manufactured and their age being 29 years. At this point QSA Global, Inc. believes that all three may be leaking."

Event Report ID No.: LA160015

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Agreement State Event Number: 52392
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BIONOMICS, INC.
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73021
Agreement: Y
Docket:
NRC Notified By: MARK ANDREWS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/23/2016
Notification Time: 12:11 [ET]
Event Date: 11/17/2016
Event Time: [EST]
Last Update Date: 11/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISPLACED AM-241 SOURCE

The following report was received via e-mail:

"The Tennessee Division of Radiological Health was notified on November 22, 2016, of the discovery by Bionomics staff of an Americium-241 source in a shipment to Bionomics of depleted uranium counterweights. The 2 mCi source is reported to be part of an aircraft fuel gauge."

Tennessee Event: TN-16-166

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: 52393
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: GEORGIA PACIFIC CONSUMER PRODUCTS LLC
Region: 4
City: ZACHARY State: LA
County:
License #: LA-2167-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/23/2016
Notification Time: 11:21 [ET]
Event Date: 10/28/2016
Event Time: 11:56 [CST]
Last Update Date: 11/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER FAILS TO CLOSE

The following report was received via e-mail:

"On 10/28/2016, GA-PAC [Georgia Pacific] was shutting down this process to perform routine annual maintenance. In the process of securing the radiation sources from becoming a radiation exposure hazard, it was discovered that the gauge shutter would not close.

"GA-PAC called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. [BBP Sales] was unable to close the shutter and determined the source holder would have to be replaced. Further evaluation determined one of the pins holding the shutter had sheared off and would have to be replaced, not repaired.

"The sources and device with shutter failure will remain installed until the replacement source and device are received. The failed device will be sent for disposal when replaced. This is not a radiation exposure hazard and does not pose a health and safety situation for the GA-PAC employees or the general public.

"The gauge is a RONAN C-10 device/source holder, S/N 9830GG, loaded with a 2,000 mCi Cs-137 source. The manufacturing date was 1994.

"This event is considered to be closed by LDEQ. This event is being reported to the NRC as required by Regulatory Requirement 10 CFR Part 30.50(b)(2)."

Louisiana Event: LA-160016

Page Last Reviewed/Updated Thursday, December 01, 2016
Thursday, December 01, 2016