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Event Notification Report for February 7, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/06/2017 - 02/07/2017

** EVENT NUMBERS **


52514 52515 52536

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Agreement State Event Number: 52514
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHILDREN'S HOSPITAL OF CHICAGO - MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01165-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/27/2017
Notification Time: 12:10 [ET]
Event Date: 01/24/2017
Event Time: [CST]
Last Update Date: 01/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANGELA MCINTOSH (NMSS)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION AT HOSPITAL

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

"On January 25, the licensee's Radiation Safety Officer (RSO) contacted the Agency [Illinois Emergency Management Agency] to report an issue with an administration of a capsule containing I-131 which had occurred the previous afternoon. A nominal dose of 30 milliCi in capsule form was given to a child within the nuclear medicine department of the licensee's facility. Although the patient was being treated on an outpatient basis, the licensee was keeping the patient for a short time to ensure there would be no complications before being sent home. During this period, staff checked in on the patient several times and during one of the visits, discovered that rather than swallowing the capsule as instructed, the patient had spit the capsule out into their hand and was hiding the capsule. This resulted in extensive contamination of the patient's hand, clothing and the chair they were sitting in as well as the immediate surrounding area. During the process to evaluate and decontaminate the patient, additional contamination was discovered in adjacent camera rooms and corridors where the staff had traversed. Staff moved to close the department and restrict passage into/out of the nearby areas to prevent additional spread of contamination. Initial estimates suggest that the patient ingested little if any of the activity and that excessive levels were throughout the area of the nuclear medicine department. Based on this finding, barriers were erected and the department was closed for over 48 hours while assessment and decontamination efforts were ongoing.

"Agency inspectors were at the site on January 26 to perform assessments of exposure, contamination levels, potential uptake by staff and corrective action being taken by the licensee. This matter will remain open while those assessments are on going. Initial bioassay results suggest only negligible uptakes have occurred with staff. Potential exposures/uptakes continue to be evaluated by the licensee throughout the decontamination process. The licensee is exploring the potential for having additional outside resources complete the necessary decontamination and remediation steps so that the department can reopen and provide at least limited services."

Illinois Item Number: IL17002

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Agreement State Event Number: 52515
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: EASTMAN KODAK COMPANY
Region: 1
City: ROCHESTER State: NY
County:
License #: C1347
Agreement: Y
Docket:
NRC Notified By: DANIEL J. SAMSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/27/2017
Notification Time: 13:49 [ET]
Event Date: 11/01/2016
Event Time: 10:00 [EST]
Last Update Date: 01/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILED SEALED SOURCE LEAK TEST

The following information was received via E-mail:

"On November 1, 2016, Eastman Kodak Company informed the Department [New York State Department of Health] that an NRD Model A-2003 static eliminator sealed source leak test result indicated a measurable contamination of 0.00661 microCuries. The device was taken out of service and another leak test was performed on the unit. The second leak test results showed only 0.0003 microCuries."

New York Event Report ID No: NYDOH - NY-16-09

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Research Reactor Event Number: 52536
Facility: UNIV OF MISSOURI-COLUMBIA
RX Type: 10000 KW TANK
Comments:
Region: 0
City: COLUMBIA State: MO
County: BOONE
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: BRUCE MEFFERT
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/06/2017
Notification Time: 17:30 [ET]
Event Date: 02/03/2017
Event Time: [CST]
Last Update Date: 02/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
RESEARCH AND TEST REACTOR EVENT
Person (Organization):
GEOFFREY WERTZ (RTRP)
ANTHONY MENDIOLA (PROB)
ALEXANDER ADAMS (PRLB)

Event Text

AIR EFFLUENT CONCENTRATION EXCEEDED TECHNICAL SPECIFICATIONS

"[The following] is a required notification per MURR [University of Missouri Research Reactor] Technical Specification (TS) 6.6.c.(1) to report to the NRC Operations Center that an Abnormal Occurrence as defined by MURR TS 1.1.b occurred on February 3, 2017. Specifically, MURR was not in compliance with the Limiting Condition for Operations TS 3.7.b.

"On February 3, 2017, MURR released the radioisotope Iodine-131 from the ventilation exhaust stack at a concentration equal to 1.07 times AEC [Air Effluent Concentration] which exceeds the one (1) AEC Maximum Controlled Instantaneous Release Concentration for 'Particulates and halogens with half-lives greater than 8 days'. The Iodine-131 originated from the MURR Iodine-131 Processing Hot Cells, not from the reactor. By February 4, 2017, the ventilation exhaust stack radioisotope concentration was within TS limits.

"Currently, all Iodine-131 processing activities have ceased and will not resume until corrective actions are implemented and permission from the Facility Director is obtained. MURR has convened an Event Review per MURR procedure AP-RR-026 to identify the causes and corrective actions for this departure from specification.

"A detailed event report will follow within 14 days as required by MURR TS 6.6.c.(3)."

Page Last Reviewed/Updated Tuesday, February 07, 2017
Tuesday, February 07, 2017