Event Notification Report for September 21, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/20/2017 - 09/21/2017
EVENT NUMBERS
530295298352984529855301753025
Agreement State
Event Number: 53029
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: ALLIANCE HEALTHCARE SERVICES, INC.
Region: 1
City: BRONX State: NY
County:
License #: 3263
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: ANDREW WAUGH
Licensee: ALLIANCE HEALTHCARE SERVICES, INC.
Region: 1
City: BRONX State: NY
County:
License #: 3263
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/20/2017
Notification Time: 16:52 [ET]
Event Date: 09/21/2017
Event Time: 22:30 [EDT]
Last Update Date: 10/20/2017
Notification Time: 16:52 [ET]
Event Date: 09/21/2017
Event Time: 22:30 [EDT]
Last Update Date: 10/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSC (CANADA) (EMAI)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSC (CANADA) (EMAI)
AGREEMENT STATE REPORT - LOST Cs-137 VIAL STANDARD
The following information was received from the state of New York via fax:
"On 10/5/17 the Department [New York State Department of Health] was notified of a lost Cs-137 vial standard (Solid Sealed Source, Eckert and Ziegler, S/N: 1258-41-15, Activity 194.4 microCi on 12/01/2007) from the hot lab of a mobile PET imaging service provider coach.
"A report from the licensee [Alliance HealthCare Services, Inc.] gave the following timeline. On 9/21/17 the driver of the mobile imaging coach slammed on the brakes going over the GW [George Washington] bridge to avoid an accident on the way to Bronx-Lebanon Hospital. Upon arrival, the driver went to assess damage in the hot lab and notified an Alliance manager of the incident. The cabinet that held up the L block had fallen away from the wall and broke a portable sink. Some other items had been dislodged. He and another driver put the cabinet back into place and put items back in their respective places. They discarded pieces of the broken sink in a trash can on the side of the parking lot of the client facility. The next morning an Alliance Tech did a visual inventory and confirmed that all sources were present.
"On 10/3/17 another Alliance Tech went into the hot lab on the coach and discovered that the lead pig for the Cs-137 vial standard was empty. The Alliance staff searched for the vial but could not locate it on the coach. It was reported to the RSO [Radiation Safety Officer] on 10/5/17.
"On 10/06/17 a physicist did a survey to determine whether the vial was on the coach and had rolled under a piece of equipment. They determined that the vial was not on the coach and did not find any contamination.
"Alliance believes that the source was thrown out in the general waste stream outside Bronx-Lebanon Hospital, along with pieces of the broken sink from the hot lab. The NYSDOH notified both the NYS Dept. of Environmental Conservation and the New Jersey Dept. of Environmental Protection of possible waste alarm trips.
"Event Report ID No. NYDOH-17-09"
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 from the state of New York via fax:
"On 10/5/17 the Department [New York State Department of Health] was notified of a lost Cs-137 vial standard (Solid Sealed Source, Eckert and Ziegler, S/N: 1258-41-15, Activity 194.4 microCi on 12/01/2007) from the hot lab of a mobile PET imaging service provider coach.
"A report from the licensee [Alliance HealthCare Services, Inc.] gave the following timeline. On 9/21/17 the driver of the mobile imaging coach slammed on the brakes going over the GW [George Washington] bridge to avoid an accident on the way to Bronx-Lebanon Hospital. Upon arrival, the driver went to assess damage in the hot lab and notified an Alliance manager of the incident. The cabinet that held up the L block had fallen away from the wall and broke a portable sink. Some other items had been dislodged. He and another driver put the cabinet back into place and put items back in their respective places. They discarded pieces of the broken sink in a trash can on the side of the parking lot of the client facility. The next morning an Alliance Tech did a visual inventory and confirmed that all sources were present.
"On 10/3/17 another Alliance Tech went into the hot lab on the coach and discovered that the lead pig for the Cs-137 vial standard was empty. The Alliance staff searched for the vial but could not locate it on the coach. It was reported to the RSO [Radiation Safety Officer] on 10/5/17.
"On 10/06/17 a physicist did a survey to determine whether the vial was on the coach and had rolled under a piece of equipment. They determined that the vial was not on the coach and did not find any contamination.
"Alliance believes that the source was thrown out in the general waste stream outside Bronx-Lebanon Hospital, along with pieces of the broken sink from the hot lab. The NYSDOH notified both the NYS Dept. of Environmental Conservation and the New Jersey Dept. of Environmental Protection of possible waste alarm trips.
"Event Report ID No. NYDOH-17-09"
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: 52983
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: TERRACON CONSULTANTS, INC.
Region: 1
City: COLUMBIA State: SC
County:
License #: 688
Agreement: Y
Docket:
NRC Notified By: ANDREW M. ROXBURGH
HQ OPS Officer: JEFF HERRERA
Licensee: TERRACON CONSULTANTS, INC.
Region: 1
City: COLUMBIA State: SC
County:
License #: 688
Agreement: Y
Docket:
NRC Notified By: ANDREW M. ROXBURGH
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2017
Notification Time: 12:13 [ET]
Event Date: 09/21/2017
Event Time: 08:59 [EDT]
Last Update Date: 09/21/2017
Notification Time: 12:13 [ET]
Event Date: 09/21/2017
Event Time: 08:59 [EDT]
Last Update Date: 09/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DAMAGED GAUGE AT CONSTRUCTION SITE
The following report was received from the South Carolina Department of Health and Environmental Control via email:
"The licensee notified the Department [South Carolina Department of Health and Environmental Control] that a piece of heavy equipment backed over a Instrotek Model 3500 moisture density gauge serial number 2323. The gauge contained 10 mCi of Cs-137 and 40 Ci of Am-241:Be. The gauge operator had contacted his RSO [Radiation Safety Officer] at the time of the incident. The BRH [Bureau of Radiation Health] inspector arrived on scene. The gauge was surveyed and tested for removable contamination. The highest reading found was on the bottom of the gauge at the shutter. The shutter was in the closed position. The reading was 15 mR/hr which is consistent with the radiation profile identified in SSD NC-1241-D-101-S. There was no removable contamination found."
The following report was received from the South Carolina Department of Health and Environmental Control via email:
"The licensee notified the Department [South Carolina Department of Health and Environmental Control] that a piece of heavy equipment backed over a Instrotek Model 3500 moisture density gauge serial number 2323. The gauge contained 10 mCi of Cs-137 and 40 Ci of Am-241:Be. The gauge operator had contacted his RSO [Radiation Safety Officer] at the time of the incident. The BRH [Bureau of Radiation Health] inspector arrived on scene. The gauge was surveyed and tested for removable contamination. The highest reading found was on the bottom of the gauge at the shutter. The shutter was in the closed position. The reading was 15 mR/hr which is consistent with the radiation profile identified in SSD NC-1241-D-101-S. There was no removable contamination found."
Power Reactor
Event Number: 52984
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JOSEPH RICHARDSON
HQ OPS Officer: JEFF HERRERA
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JOSEPH RICHARDSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2017
Notification Time: 21:07 [ET]
Event Date: 09/21/2017
Event Time: 17:30 [CDT]
Last Update Date: 09/21/2017
Notification Time: 21:07 [ET]
Event Date: 09/21/2017
Event Time: 17:30 [CDT]
Last Update Date: 09/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)
AARON McCRAW (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROL ROOM EMERGENCY VENTILATION AC SYSTEM INOPERABLE
"On September 21, 2017 at 1730 [CDT] the Control Room Emergency Ventilation Air Condition (CREV AC) system was declared inoperable due a refrigerant leak from the air conditioning compressor. As a result, Technical Specification 3.7.5 Condition A was entered for Units One and Two.
"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.
"This notification is being made in accordance with 10CFR50.72(b)(3)(v)(D) because the CREV system is a single train system. The loss of CREV AC could impact the plant's ability to mitigate the consequences of an accident."
The NRC Resident Inspector has been notified.
"On September 21, 2017 at 1730 [CDT] the Control Room Emergency Ventilation Air Condition (CREV AC) system was declared inoperable due a refrigerant leak from the air conditioning compressor. As a result, Technical Specification 3.7.5 Condition A was entered for Units One and Two.
"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.
"This notification is being made in accordance with 10CFR50.72(b)(3)(v)(D) because the CREV system is a single train system. The loss of CREV AC could impact the plant's ability to mitigate the consequences of an accident."
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 52985
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: OCCIDENTAL CHEMICAL CORPORATION
Region: 4
City: WICHITA State: KS
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: STEVE SANDIN
Licensee: OCCIDENTAL CHEMICAL CORPORATION
Region: 4
City: WICHITA State: KS
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/22/2017
Notification Time: 11:00 [ET]
Event Date: 09/21/2017
Event Time: 16:04 [CDT]
Last Update Date: 09/22/2017
Notification Time: 11:00 [ET]
Event Date: 09/21/2017
Event Time: 16:04 [CDT]
Last Update Date: 09/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - INADVERTENT DISPOSAL OF AN ELECTRON CAPTURE DETECTOR GAS CHROMATOGRAPH
The State of Kansas was notified that an Electron Capture Detector Gas Chromatograph (ECD-GC) owned by Occidental Chemical Corporation (OxyChem) was inadvertently disposed of as electronic waste. The contracted waste company, Clean Harbors Wichita, ships waste to the recycler, ERI, in Fresno, CA. OxyChem provided ERI pictures of the missing Varian ECD GC to aid in identification.
The missing ECD-GC is a model 3400 (Serial Number A-8080), containing 8 mCi Ni-63 as of 1990. The current activity is calculated as 6.58 mCi.
The State of Kansas is providing a courtesy notification to the State of California Radiation Program Office.
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 State of Kansas was notified that an Electron Capture Detector Gas Chromatograph (ECD-GC) owned by Occidental Chemical Corporation (OxyChem) was inadvertently disposed of as electronic waste. The contracted waste company, Clean Harbors Wichita, ships waste to the recycler, ERI, in Fresno, CA. OxyChem provided ERI pictures of the missing Varian ECD GC to aid in identification.
The missing ECD-GC is a model 3400 (Serial Number A-8080), containing 8 mCi Ni-63 as of 1990. The current activity is calculated as 6.58 mCi.
The State of Kansas is providing a courtesy notification to the State of California Radiation Program Office.
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: 53017
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: VINCE KLCO
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: VINCE KLCO
Notification Date: 10/16/2017
Notification Time: 11:08 [ET]
Event Date: 09/21/2017
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2017
Notification Time: 11:08 [ET]
Event Date: 09/21/2017
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (FAX)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (FAX)
AGREEMENT STATE REPORT - POST IMPLANT LOSS OF IODINE-125 SEED
The following information was received from the State of New York via facsimile:
"On September 21, 2017 the Department [New York State Department of Health] was notified that a Best Medical International, Inc., Model #2301 lodine-125 seed used for localization of non-palpable lesions and lymph nodes was lost. On September 18, a patient was implanted with a 125.2 microCurie lodine-125 seed. The seed was verified to be implanted by use of a survey meter. When the patient returned for explant three days later, the iodine-125 seed could not be detected. The licensee surveyed the patient's vehicle, house, laundry, and trash and no radioactivity was detected. The licensee reported placing the seed 'superficially' within the patient and the licensee speculates that the seed may have become dislodged from the patient at some point between the implant and explant."
New York Report ID No.: NYDOH-NY-17-08
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 from the State of New York via facsimile:
"On September 21, 2017 the Department [New York State Department of Health] was notified that a Best Medical International, Inc., Model #2301 lodine-125 seed used for localization of non-palpable lesions and lymph nodes was lost. On September 18, a patient was implanted with a 125.2 microCurie lodine-125 seed. The seed was verified to be implanted by use of a survey meter. When the patient returned for explant three days later, the iodine-125 seed could not be detected. The licensee surveyed the patient's vehicle, house, laundry, and trash and no radioactivity was detected. The licensee reported placing the seed 'superficially' within the patient and the licensee speculates that the seed may have become dislodged from the patient at some point between the implant and explant."
New York Report ID No.: NYDOH-NY-17-08
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: 53025
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: KIMBERLY-CLARK CORPORATION
Region: 1
City: HENDERSONVILLE State: NC
County:
License #: 045-1581-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: DONALD NORWOOD
Licensee: KIMBERLY-CLARK CORPORATION
Region: 1
City: HENDERSONVILLE State: NC
County:
License #: 045-1581-0G
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/18/2017
Notification Time: 14:41 [ET]
Event Date: 09/21/2017
Event Time: 00:00 [EDT]
Last Update Date: 10/18/2017
Notification Time: 14:41 [ET]
Event Date: 09/21/2017
Event Time: 00:00 [EDT]
Last Update Date: 10/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - FAILED FIXED NUCLEAR DENSITY GAUGE SHUTTER
The following information was received via e-mail.
"The licensee discovered that the shutter to a fixed nuclear density gauge was missing on 9/21/17 during routine leak tests. Prominent barriers were immediately put in place around the fenced area containing the gauge to further cordon off the area to prevent any access to the area. Three days prior to discovery, the licensee performed routine cleaning in which the shutter was observed in place at that time. The gauge is located on top of winding equipment 6.5 feet high, located inside of a fenced area. The fenced area provides an additional 4 feet from the gauge separating areas where personnel may traffic on the ground. The radiation beam for the gauge is pointing down from its location and travels about 6 inches to the target plate. By facility design, placement of the gauge includes additional barriers and fencing, access to the gauge by any person is restrictive and following interviews with the licensee, no exposures are suspected to have occurred due to the faulty shutter.
"The manufacturer completed repairs to the fixed gauge on 10/6/17.
"Gauge Information: NDC Amersham Model # 103, Serial # 11302.
"Source Information: Am-241, 150 mCi, QSA Global, Inc. Model # AMC.P6, Serial # 5244AR."
NC Tracking Number: 170042
The following information was received via e-mail.
"The licensee discovered that the shutter to a fixed nuclear density gauge was missing on 9/21/17 during routine leak tests. Prominent barriers were immediately put in place around the fenced area containing the gauge to further cordon off the area to prevent any access to the area. Three days prior to discovery, the licensee performed routine cleaning in which the shutter was observed in place at that time. The gauge is located on top of winding equipment 6.5 feet high, located inside of a fenced area. The fenced area provides an additional 4 feet from the gauge separating areas where personnel may traffic on the ground. The radiation beam for the gauge is pointing down from its location and travels about 6 inches to the target plate. By facility design, placement of the gauge includes additional barriers and fencing, access to the gauge by any person is restrictive and following interviews with the licensee, no exposures are suspected to have occurred due to the faulty shutter.
"The manufacturer completed repairs to the fixed gauge on 10/6/17.
"Gauge Information: NDC Amersham Model # 103, Serial # 11302.
"Source Information: Am-241, 150 mCi, QSA Global, Inc. Model # AMC.P6, Serial # 5244AR."
NC Tracking Number: 170042