Event Notification Report for May 01, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/30/2017 - 05/01/2017
EVENT NUMBERS
52723527355299353076
Agreement State
Event Number: 52723
Rep Org: NC DEPT OF HEALTH & HUMAN SERVICES
Licensee: TROXLER ELECTRONIC LABORATORIES
Region: 1
City: RESEARCH TRIANGLE PARK State: NC
County:
License #: 032-0182-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: BETHANY CECERE
Licensee: TROXLER ELECTRONIC LABORATORIES
Region: 1
City: RESEARCH TRIANGLE PARK State: NC
County:
License #: 032-0182-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/02/2017
Notification Time: 16:29 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [EDT]
Last Update Date: 05/02/2017
Notification Time: 16:29 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [EDT]
Last Update Date: 05/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL SHIPMENT EXCEEDING RADIATION LIMITS
The following was received by the state of North Carolina by email:
"On 5/1/2017, licensee received a 5 gallon shielded drum containing 8 Cf-252 sources with a total activity of 148 MBq (4.0 mCi). Shipment of the sources originated from E&Z Isotope Products, License Number: 1509-19. Shipment was made through [a common carrier]. The drum was labeled Yellow-III and had a TI [Transport Index] of 9.4. The licensee followed procedures for receiving and securing radioactive materials shipments. Once the drum was secured, the licensee noted surveys of the drum were higher than expected:
Side survey of the drum was 18 mrem/hr (gamma) on contact and 90 mrem/hr (neutron) for a total of 108 mrem/hr.
Top survey of the drum was 40 mrem/hr (gamma) on contact and 400 mrem/hr (neutron) for a total of 440 mrem/hr.
Bottom survey of the drum was 3 mrem/hr (gamma) on contact and 20 mrem/hr (neutron) for a total of 23 mrem/hr.
"The drum was then shielded with polyethylene and cadmium. Upon resurveying the drum to confirm readings the following differences were noted: With the drum upright and the neutron detector on top of the drum, the reading was 400 mrem/hr. With the drum on its side and the neutron detector in contact with the drum, the reading was 440 mrem. Wipes of the drum were then taken and the results were [less than] MDL (Minimum Detectable Levels).
"The drum was then opened for further inspection by the licensee. It was noticed that a polyethylene bag containing sources was sitting on top of the shield plug and was only about 2 inches from the top of the drum and not covered by any shielding indicating that the sources were not shielded correctly prior to shipment.
"The sources were in-processed by the licensee and are still in the licensee's possession (quantity and activity as approved per their NC License).
"North Carolina Radiation Protection, [the common carrier] and E&Z Isotope Products were notified of the event on 5/1/2017.
"NC Radiation Protection is actively investigating this event at this time.
"Report ID Number (NC): NC170020
"At this time the cause and corrective action is to be determined. NC Radiation Protection will be reaching out to E&Z Isotope Products and [the common carrier] for more information. The licensee was authorized to receive the materials in the quantity and activity they received."
The following was received by the state of North Carolina by email:
"On 5/1/2017, licensee received a 5 gallon shielded drum containing 8 Cf-252 sources with a total activity of 148 MBq (4.0 mCi). Shipment of the sources originated from E&Z Isotope Products, License Number: 1509-19. Shipment was made through [a common carrier]. The drum was labeled Yellow-III and had a TI [Transport Index] of 9.4. The licensee followed procedures for receiving and securing radioactive materials shipments. Once the drum was secured, the licensee noted surveys of the drum were higher than expected:
Side survey of the drum was 18 mrem/hr (gamma) on contact and 90 mrem/hr (neutron) for a total of 108 mrem/hr.
Top survey of the drum was 40 mrem/hr (gamma) on contact and 400 mrem/hr (neutron) for a total of 440 mrem/hr.
Bottom survey of the drum was 3 mrem/hr (gamma) on contact and 20 mrem/hr (neutron) for a total of 23 mrem/hr.
"The drum was then shielded with polyethylene and cadmium. Upon resurveying the drum to confirm readings the following differences were noted: With the drum upright and the neutron detector on top of the drum, the reading was 400 mrem/hr. With the drum on its side and the neutron detector in contact with the drum, the reading was 440 mrem. Wipes of the drum were then taken and the results were [less than] MDL (Minimum Detectable Levels).
"The drum was then opened for further inspection by the licensee. It was noticed that a polyethylene bag containing sources was sitting on top of the shield plug and was only about 2 inches from the top of the drum and not covered by any shielding indicating that the sources were not shielded correctly prior to shipment.
"The sources were in-processed by the licensee and are still in the licensee's possession (quantity and activity as approved per their NC License).
"North Carolina Radiation Protection, [the common carrier] and E&Z Isotope Products were notified of the event on 5/1/2017.
"NC Radiation Protection is actively investigating this event at this time.
"Report ID Number (NC): NC170020
"At this time the cause and corrective action is to be determined. NC Radiation Protection will be reaching out to E&Z Isotope Products and [the common carrier] for more information. The licensee was authorized to receive the materials in the quantity and activity they received."
Agreement State
Event Number: 52735
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: S-2 ENGINEERING, INC.
Region: 4
City: RANCHO CUCAMONGA State: CA
County:
License #: 7192-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: STEVE SANDIN
Licensee: S-2 ENGINEERING, INC.
Region: 4
City: RANCHO CUCAMONGA State: CA
County:
License #: 7192-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/05/2017
Notification Time: 16:02 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [PDT]
Last Update Date: 05/05/2017
Notification Time: 16:02 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [PDT]
Last Update Date: 05/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GREGORY AHERN (ILTA)
CNSNS (MEXICO) (FAX)
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GREGORY AHERN (ILTA)
CNSNS (MEXICO) (FAX)
AGREEMENT STATE REPORT - THEFT OF TROXLER MOISTURE DENSITY GAUGE
The following information was provided by the State of California:
"S-2 Engineering reported the loss of a Troxler 3411-B # [S/N] 12398 moisture density gauge that had been in storage at a job site in Barstow, CA. This device contains 0.296 GBq (8 mCi) of Cs-137 and 1.48 GBq (40 mCi) of Am-241.
"The licensee was conducting a physical inventory of their devices containing radioactive material and found this one to be missing from the locked storage box.
"The licensee checked with all of their authorized gauge users to determine if the device was in use but not checked out properly before reporting it as lost. The last documented use of the density gauge was Sept. 22, 2016.
"This investigation is ongoing."
The licensee notified their Local Law Enforcement Agency (LLEA) of the theft.
CA 5010 Number: 050417
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
The following information was provided by the State of California:
"S-2 Engineering reported the loss of a Troxler 3411-B # [S/N] 12398 moisture density gauge that had been in storage at a job site in Barstow, CA. This device contains 0.296 GBq (8 mCi) of Cs-137 and 1.48 GBq (40 mCi) of Am-241.
"The licensee was conducting a physical inventory of their devices containing radioactive material and found this one to be missing from the locked storage box.
"The licensee checked with all of their authorized gauge users to determine if the device was in use but not checked out properly before reporting it as lost. The last documented use of the density gauge was Sept. 22, 2016.
"This investigation is ongoing."
The licensee notified their Local Law Enforcement Agency (LLEA) of the theft.
CA 5010 Number: 050417
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
Agreement State
Event Number: 52993
Rep Org: KALISPELL REGIONAL MEDICAL CENTER
Licensee: KALISPELL REGIONAL MEDICAL CENTER
Region: 4
City: KALISPELL State: MT
County:
License #: 25-15463-01
Agreement: N
Docket: 3009152
NRC Notified By: ANDRE VANTERPOOL
HQ OPS Officer: VINCE KLCO
Licensee: KALISPELL REGIONAL MEDICAL CENTER
Region: 4
City: KALISPELL State: MT
County:
License #: 25-15463-01
Agreement: N
Docket: 3009152
NRC Notified By: ANDRE VANTERPOOL
HQ OPS Officer: VINCE KLCO
Notification Date: 09/26/2017
Notification Time: 15:39 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [MDT]
Last Update Date: 09/27/2017
Notification Time: 15:39 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [MDT]
Last Update Date: 09/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MEDICAL EVENT WRITTEN DOSE DIRECTIVE IS DIFFERENT THAN PRESCRIBED DOSE
An endocrinologist specified a therapy dose of 20 milliCuries of I-131. An authorized dose directive was incorrectly written for 30 milliCuries of I-131. The patient was administered the initially determined dose of 20 milliCuries of I-131. Medical personnel determined that there was no impact on the patient.
Hospital supervision notified the on-site Authorized User, the Radiation Safety Officer and the Medical Physicist.
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.
* * * UPDATE AT 1345 EDT ON 9/27/17 FROM ANDRE VANTERPOOL TO RICHARD L. SMITH * * *
The actual event date was May 1, 2017, and the discovery date was September 25, 2017, at approximately 1500 MDT.
Notified R4DO (Proulx) and NMSS Events Notification (via email).
An endocrinologist specified a therapy dose of 20 milliCuries of I-131. An authorized dose directive was incorrectly written for 30 milliCuries of I-131. The patient was administered the initially determined dose of 20 milliCuries of I-131. Medical personnel determined that there was no impact on the patient.
Hospital supervision notified the on-site Authorized User, the Radiation Safety Officer and the Medical Physicist.
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.
* * * UPDATE AT 1345 EDT ON 9/27/17 FROM ANDRE VANTERPOOL TO RICHARD L. SMITH * * *
The actual event date was May 1, 2017, and the discovery date was September 25, 2017, at approximately 1500 MDT.
Notified R4DO (Proulx) and NMSS Events Notification (via email).
Agreement State
Event Number: 53076
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LTI SMART GLASS
Region: 1
City: PITTSFIELD State: MA
County:
License #: G0350
Agreement: Y
Docket:
NRC Notified By: ZARA REJAEE
HQ OPS Officer: DONALD NORWOOD
Licensee: LTI SMART GLASS
Region: 1
City: PITTSFIELD State: MA
County:
License #: G0350
Agreement: Y
Docket:
NRC Notified By: ZARA REJAEE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/16/2017
Notification Time: 15:42 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [EST]
Last Update Date: 11/16/2017
Notification Time: 15:42 [ET]
Event Date: 05/01/2017
Event Time: 00:00 [EST]
Last Update Date: 11/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MISSING POLONIUM-210 SEALED SOURCE
The following information was received via E-mail:
"On November 16, 2017, the Massachusetts Radiation Control Program determined that one NRD, LLC, Model P-2021-8201, S/N A2KQ898, static control device, containing a 10 milliCurie, polonium-210 sealed source, could not be located by the licensee (Current decayed activity is approximately 600 microCurie with an original assay date of 5/5/2016).
"When questioned by the Program, the licensee stated that it noticed that the device has been missing since sometime in May of 2017. The licensee believes that they transferred the device from their Lenox, MA facility to their Pittsfield, MA facility and it is somewhere within their Pittsfield facility. However, the licensee stated that it's very unlikely they will find the device due to the facility size and complexity.
"The Program notified the licensee of its responsibility for providing a written report within 30 days of their telephone report in accordance with the requirements of 105 CMR 120.281(B).
"Root cause and corrective action are not known at this time and the Program intends to perform a special inspection.
"This event remains open."
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
The following information was received via E-mail:
"On November 16, 2017, the Massachusetts Radiation Control Program determined that one NRD, LLC, Model P-2021-8201, S/N A2KQ898, static control device, containing a 10 milliCurie, polonium-210 sealed source, could not be located by the licensee (Current decayed activity is approximately 600 microCurie with an original assay date of 5/5/2016).
"When questioned by the Program, the licensee stated that it noticed that the device has been missing since sometime in May of 2017. The licensee believes that they transferred the device from their Lenox, MA facility to their Pittsfield, MA facility and it is somewhere within their Pittsfield facility. However, the licensee stated that it's very unlikely they will find the device due to the facility size and complexity.
"The Program notified the licensee of its responsibility for providing a written report within 30 days of their telephone report in accordance with the requirements of 105 CMR 120.281(B).
"Root cause and corrective action are not known at this time and the Program intends to perform a special inspection.
"This event remains open."
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