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Event Notification Report for November 1, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/31/2017 - 11/01/2017

** EVENT NUMBERS **


53013 53032 53033 53046

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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: 10/31/2017
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.

* * * UPDATE AT 1055 EDT ON 10/31/17 FROM H. BENJAMIN CULPEPPER TO S. SANDIN VIA EMAIL * * *

"DRH was able to contact Licensee regarding the lost source. Licensee originally bought the device in 2007 to use at their facility. After a period of time, the device was more ineffective than effective, causing the Licensee to send the Niton gun for repairs. Licensee was informed that the source would have to be changed in order to alleviate the issue, but Licensee did not seek that avenue due to high costs. Even with the Niton gun being ineffective, Licensee maintained possession of the device until losing it three (3) years ago.

"The Licensee's coworker recently reminded them that DRH should be informed about the missing source.

"After contacting DRH about the missing source, DRH contacted a representative from Thermo Scientific to discuss the lifetime of the source. It was discovered that the source's assay date is 2/1/2006 and was shipped to the first owner on 12/6/2006. No other radioactive material was shipped to the Licensee in question from Thermo Scientific.

"Knowing that the lost source is Cd-109, which has a half-life = 462.6 days, it was discovered that the 10 mCi source will have decayed (as of today) to an activity level of 0.01618 mCi. Also, if the source was one (1) foot away from the target, the target would receive a dose-rate = 33.86 microR/hr."

DRH closed this case on 10/30/2017.

Notified R4DO (Werner) and NMSS Events Notification via email.

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: 53032
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PROVIDENCE HEALTH SERVICES OREGON
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90946
Agreement: Y
Docket:
NRC Notified By: DARLY LEON
HQ OPS Officer: STEVEN VITTO
Notification Date: 10/23/2017
Notification Time: 12:34 [ET]
Event Date: 10/20/2017
Event Time: 10:00 [PDT]
Last Update Date: 10/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE MALFUNCTION

On 10/20/17, at 1000 PDT, a Gamma knife treatment was in process when the machine malfunctioned and recorded an error. The backup battery on the UPS (Uninterruptible Power Source) was low and resulted in the machine pausing and returning the source to the shielded position. The patient received approximately one third of the prescribed dose. The service provider was contacted and is scheduled to report to the hospital today (10/23/2017) to replace the backup battery.

Elekta Leksell Gamma Knife Model Perfexion
Serial number NM-001-NM201

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: 53033
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP, INC.
Region: 4
City: GEISMAR State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: STEVEN VITTO
Notification Date: 10/23/2017
Notification Time: 17:30 [ET]
Event Date: 10/19/2017
Event Time: 11:05 [CDT]
Last Update Date: 10/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - WHOLE BODY MONITOR EXCEEDED THE ANNUAL OCCUPATIONAL EXPOSURE LIMIT

The following was received via email from the State Of Louisiana:

"The RSO [Radiation Safety Officer] was notified by Landauer that an individual's August 1-31, 2017, personal whole body monitor exceeded the annual occupational exposure limit. MG [Mistras Group, Inc.] contacted the Radiography Instructor (RI) and conducted an internal investigation with the radiation safety personnel and the RI that concluded September 20, 2017. It concluded with the exposures were incremental over the annual monitoring period and there was no evidence the whole-body badge had received the exposures and the RI had not received the exposures to his monitor. At this time MG is not pursuing this issue further to reduce the exposure to the whole-body monitor. The RI was issued safety equipment that was not under the RI's constant control or observation at all times.

"The RI notified the Department, LDEQ [Louisiana Department of Environmental Quality], on October, 19, 2017, [at approximately] 1105 [CDT]. LDEQ was notified due to the fact the RI was not employable to perform radiography work in his field due to the radiation exposure levels.

"This was a complaint from a Radiography Instructor (RI) whose personal whole-body badge exposure reading levels exceeded the 5,000 mRem/5 Rem occupational annual limit. The RI called in a complaint because he was no-longer employed by MG and with the excessive exposure he was not employable to work in a radiation restricted area.

"A LDEQ investigator took the call from the RI. The excessive exposure reported by Landauer to MG for the August 2017 monitoring period was 5,440 mRem Dose Equivalent. MG reported the excessive exposure during a phone call during the LDEQ preliminary investigation. The MG went on to explain that the RI was still in possession of his September 2017 personal whole body monitor."

Event Report ID: LA-170016

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Fuel Cycle Facility Event Number: 53046
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: RICARDO MEDINA
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/31/2017
Notification Time: 12:02 [ET]
Event Date: 09/07/2017
Event Time: [MDT]
Last Update Date: 10/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
FRANK EHRHARDT (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)
FUELS GROUP (EMAI)

Event Text

WRONG IROFS PROCEDURE FOLLOWED PRIOR TO FILLING CYLINDER

The following event occurred on 9/7/17 but was not discovered until 1511 MDT on 10/30/17.

"Appendix A to 10 CFR 70(b)(2).

"While performing an extent of condition on a previous condition report in the UUSA [URENCO USA] corrective action program, UUSA discovered a product cylinder that had been introduced to the process inadvertently as a new or washed cylinder when it in fact was a heeled cylinder. The discrepancy caused the incorrect IROFS [Items Relied On For Safety] to be applied when connecting the cylinder to the process; IROFS16a for new/washed cylinders and IROFS16e/f for heeled cylinders.

"The IROFS applicable (16e/f), administratively limits moderator (hydrogenous) mass in heeled cylinders containing enriched uranic material to ensure sub-criticality by limiting cylinder vapor pressure and heeled 30B cylinder weight. IROFS16e was completed SAT using the IROFS16a surveillance and the Product connect procedure. IROFS16f, an independent weight check and vapor pressure check, was not completed during the cylinder connect.

"The IROFS performed (16a), administratively limits moderator mass (hydrocarbon oil and water) in new and cleaned 30B cylinders containing enriched uranic material to ensure sub-criticality by allowing no visible oil and by limiting cylinder vapor pressure.

"Both of the aforementioned IROFS prevent criticality by limiting moderator mass, however the performance is different in heeled cylinders. IROFS16e/f are implemented by independently limiting cylinder vapor pressure and weight prior to introducing product into the cylinder.

"Cylinder UREU103960 was connected to the process on September 7, 2017, filled with product material, heated, and liquid sampled. A criticality DID NOT occur. Existing sample results show normal for contaminants boron, technetium, and silica. Sample testing for purity showed UF6 at a temperature 24C acceptable per ASTM C996 standards of [greater than] 99.5 [percent].

"10 CFR 70.50(c)(1)(iii):

"(A) The IROFS not performed prevent criticality. No criticality occurred, no radiological hazard, nor chemical hazards were present.

"(B) No exposure occurred.

"(C) UUSA Shift Operations inadvertently treated the cylinder with the wrong classification. The pedigree of the cylinder was misinterpreted and the IROFS16a surveillance was performed instead of the correct IROFSI6e/f surveillance.

"(D) IROFS remain available and reliable to perform their function. IROFS16 series are applicable during cylinder connects and are established by the performer of the cylinder connect evolution. The IROFS are not affected for future cylinder evolutions.

"(iv) The cylinder is currently inside the Cylinder Receipt and Dispatch Building. No external conditions affect this event.

"(v) UUSA immediately treated the cylinder as an anomalous condition in accordance with internal procedures and Operations Reporting Manual. The cylinder had been through the sampling process and the results are being reviewed by UUSA NCS/ISA Engineering staff.

"(vi) No criticality event occurred. The cylinder is in a criticality safety anomalous condition. There are currently no other cylinders immediately adjacent and the area has been roped off.

"(vii) No emergencies have been, nor will any be declared.

"(viii) No state or other federal agencies will be notified.

"(ix) No press releases are planned.

"SAFETY SIGNIFICANCE OF EVENTS: No Event Occurred

"SAFETY EQUIPMENT STATUS: The cylinder is in a criticality safety anomalous condition. Existing sample results from cylinder contents are being reviewed.

"STATUS OF CORRECTIVE ACTIONS: Condition has been entered into facility's Corrective Action Program"

The licensee will inform NRC Region 2 (Sykes).

Page Last Reviewed/Updated Wednesday, November 01, 2017
Wednesday, November 01, 2017