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Event Notification Report for October 24, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/23/2017 - 10/24/2017

** EVENT NUMBERS **


53011 53012 53013 53016 53017 53030 53031

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Agreement State Event Number: 53011
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ADENA REGIONAL MEDICAL CENTER
Region: 3
City: CHILLICOTHE State: OH
County: ROSS
License #: 02120720000
Agreement: Y
Docket:
NRC Notified By: MICHAEL J. RUBADUE
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 13:45 [ET]
Event Date: 10/12/2017
Event Time: 11:05 [EDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

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

"On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination."

The patient was informed on the day of the event.

Ohio Item Number: OH170006

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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Non-Agreement State Event Number: 53012
Rep Org: IDAHO STATE UNIVERSITY
Licensee: IDAHO STATE UNIVERSITY
Region: 4
City: POCATELLO State: ID
County: BANNOCK
License #: 1127380-01
Agreement: N
Docket: 030-32-3
NRC Notified By: RICH BREY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 10/13/2017
Notification Time: 15:46 [ET]
Event Date: 10/13/2017
Event Time: [MDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (FAX)

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

Event Text

LOST OR MISSING MATERIAL

A series 50 nuclear accident dosimeter S/N AP237 with a 1 gram 62 mCi Pu-239 source was determined missing on 10/13/17. The dosimeter was one of 14 received by Idaho State University from the Department of Energy (DOE) in 1991. In 2003, this particular dosimeter was found to have detectable surface contamination and determined to have a compromised source. The device was removed from local inventory in 2003 pending transfer. Attempts were made to transfer the device to Idaho National Lab (INEL), but were declined. The device is believed to have been placed in the Idaho State University nuclear waste stream, and may have been transferred in 2006 or 2011 with other waste via Thomas Gray to US Ecology, but there are no supporting records. Investigation is ongoing.

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: 53013
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SOUTHERN RECYCLING
Region: 4
City: WALLS State: MS
County: DESOTO
License #: GL-397
Agreement: Y
Docket:
NRC Notified By: BENJAMIN CULPEPPER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 15:38 [ET]
Event Date: 09/08/2017
Event Time: [CDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOSS OR THEFT OF LICENSED NUCLEAR MATERIAL

The following was reported from the State of Mississippi:

Description of Incident: Licensee reported that their Niton gun was discovered to be misplaced or stolen on September 8, 2017. A letter was received by Mississippi State Department of Health: Division of Radiological Health (DRH) from the licensee on October 13, 2017 briefly detailing that their equipment had been lost or stolen.

DRH intends to issue a violation letter to Southern Recycling due to the late notification. Also, due to lacking information, DRH cannot confirm if the device reported to have been stolen/lost contains radioactive material.

DRH has attempted to contact the Licensee a number of times to acquire more information; however, there has been no response. DRH will continue contacting the licensee for more information and will update this report once complete.

Isotope(s): Cd-109 (potentially lost source not confirmed), with an activity of 10 mCi.

The DRH Health Physicist stated that this would give a reading of approximately 20 mRem at one foot if unshielded.

Mississippi has assigned an incident number of MS17006.

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: 53016
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ROKE TECHNOLOGIES
Region: 4
City: REDLANDS State: CA
County:
License #: 7897
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/16/2017
Notification Time: 08:36 [ET]
Event Date: 10/15/2017
Event Time: 17:00 [PDT]
Last Update Date: 10/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)
ILTAB (EMAI)

This material event contains a "Category 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN WELL LOGGING SOURCES

The following information was received from the State of California:

"The Licensee discovered at approximately [1700 PDT] on 10/15/17 that two 3 Ci Am-241Be well logging sources had been stolen from their storage area at Weller Ranch in Kern County. Locks had been cut and the sources were removed from the approximate 12-foot storage pipe. Additionally, an approximate 2500 [pound] calibration water tank was also missing.

"The FBI was notified by CA Radiologic Health Branch [RHB] at approximately [2030 PDT] on 10/15/17.

"RHB will be onsite 10/16/17."

California 5010 Number: 101517


* * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1511 EDT ON 10/16/2017 * * *

"The two well logging sources have been accounted for. An unauthorized individual had accessed the sources, removing them from their storage location on his father's ranch land and discarding them a short distance away without any knowledge of what they were. The unauthorized individual also took the water calibration tank for his personal use.

"The well logging sources are back in the possession of the licensee."

Notified R4DO (Vasquez) , NMSS Events Notification, CNSNS (MEXICO) and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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
Notification Date: 10/16/2017
Notification Time: 11:08 [ET]
Event Date: 09/21/2017
Event Time: [EDT]
Last Update Date: 10/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (FAX)

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

Event Text

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

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Non-Agreement State Event Number: 53030
Rep Org: WEST BRANCH REGIONAL MEDICAL CENTER
Licensee: WEST BRANCH REGIONAL MEDICAL CENTER
Region: 3
City: WEST BRANCH State: MI
County:
License #: 09-32781-03MD
Agreement: N
Docket:
NRC Notified By: DAVID BARRATT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/23/2017
Notification Time: 09:11 [ET]
Event Date: 10/23/2017
Event Time: 07:40 [EDT]
Last Update Date: 10/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

DELIVERY OF TC-99 SHOWED INCREASED RADIATION LEVEL ON CONTACT WITH PACKAGE

At 0740 EDT on 10/23/2017, while performing equipment quality control, the nuclear medical technician identified that the incoming case containing less than 100 milliCuries of Tc-99 measured from 190-220 mR/hr on contact. The technician performed a surface wipe to identify contamination and determined that there was no leakage or spill of contamination. At 0850 the radiation safety officer was notified of the event. The case was then placed into a waste decay storage area away from other personnel. The company that shipped the package was also contacted regarding the situation.

The type of isotopes provided were provided based on the ordered quantity, however, the technician reported that there might be other isotopes in the container, however could not verify without opening the container to look inside.

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Power Reactor Event Number: 53031
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [ ] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: JOSH SMITH
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/23/2017
Notification Time: 09:35 [ET]
Event Date: 10/23/2017
Event Time: 04:00 [EDT]
Last Update Date: 10/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

LEAKAGE IDENTIFIED ON ONE INCH LINE SOCKET WELD FOR THE B RECIRCULATION PUMP

"On Monday, October 23, 2017, with PBAPS [Peach Bottom Atomic Power Station] Unit 3 in Mode 3 at the beginning of a refueling outage, personnel entered the drywell to perform an inspection. At approximately 0400 [EDT], leakage was identified on a one-inch diameter instrument line socket weld for the 'B' recirculation pump. Because the leak was misting, the leakage rate could not be quantified. However, Unit 3 reactor coolant unidentified leakage prior to plant shutdown was 0.18 gpm. This line is considered part of the primary coolant pressure boundary.

"This event is being reported as an occurrence of an event or condition that results in the condition of the nuclear power plant, including its principal safety barriers being seriously degraded under 10 CFR 50.72(b)(3)(ii).

"The Station is preparing an evaluation and repair plan at this time.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Tuesday, October 24, 2017
Tuesday, October 24, 2017