United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2017 > December 6

Event Notification Report for December 6, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/05/2017 - 12/06/2017

** EVENT NUMBERS **


53093 53094 53105

To top of page
Non-Agreement State Event Number: 53093
Rep Org: GEORGE WASHINGTON UNIVERSITY
Licensee: GEORGE WASHINGTON UNIVERSITY HOSPITAL
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-30607-01
Agreement: N
Docket:
NRC Notified By: ARNOLD ABLE
HQ OPS Officer: STEVEN VITTO
Notification Date: 11/27/2017
Notification Time: 12:06 [ET]
Event Date: 11/07/2017
Event Time: [EST]
Last Update Date: 11/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOST IODINE-125 IMPLANT SEED

The following is an excerpt from the 30 day report submitted from George Washington University Hospital:

"On Tuesday, 11/7/2017, one of the pathologists' assistants completed the first seed case of the new week. After placing the seed in the vial which included the prior week's seeds, she counted only 10 seeds. However, there should have been 11; e.g. 10 from the previous week plus the new one from the current week.

"Radiation safety confirmed that there were 10 seeds in the vial. Since only 10 lot numbers were written on the vial, this suggests that only 10 seeds were ever placed in the vial (as opposed to 11 being put in the vial, and one of them falling out at some point.)

"Radiation safety confirmed that there were 11 flow sheets. Each flow sheet was initialized by a pathologists' assistant that the seed had been recovered and stored in the cabinet. This suggests that one of the pathologists' assistants was distracted and signed the sheet without placing the seed in the vial as per procedure.

"The pathology laboratory was surveyed by two individuals from the Radiation Safety Office. The surveys covered all areas of the lab including the work stations, sinks, floors, waste specimens, desks, and storage cabinets. The seed was not located.

"The licensed material that has been lost is a single I-125 seed, made by IsoAid for the localization of nonpalpable breast lesions. The seed is a sealed source approximately 5 mm in length. It had a nominal activity of 200 microCi on October 24, 2017."


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

To top of page
Agreement State Event Number: 53094
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ALT & WITZIG ENGINEERING, INC.
Region: 3
City: WEST CHESTER State: OH
County:
License #: 31210990003
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: STEVEN VITTO
Notification Date: 11/27/2017
Notification Time: 15:26 [ET]
Event Date: 11/24/2017
Event Time: [EST]
Last Update Date: 11/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
CNSC (CANADA) (EMAI)

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

Event Text

AGREEMENT STATE EVENT REPORT - STOLEN PORTABLE GAUGE

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

"The licensee's technician performed work using the gauge at a job site in Blue Ash, Ohio on 11/24/17. After leaving the job site, the technician stopped at several locations [before] arriving home. The gauge was discovered missing on 11/27/17 when the technician arrived at the licensee's facility. The storage container for the gauge was not broken into indicating that it had not been locked. A report was filed with the Cincinnati Police Department.

"Device Name: PORTABLE GAUGE
Manufacturer: CAMPBELL PACIFIC NUC
Model Number: MC-1
Serial Number: 70603768
Activity: Cs-137:10mCi and Am-Be: 50mCi"

Ohio Reference Number: OH 2017-070

* * * UPDATE AT 0919 EST ON 11/29/2017 FROM STEPHEN JAMES TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On 11/28/17 ODH [Ohio Department of Health] inspectors visited each of the locations the technician visited after leaving the job site on 11/24/17. The inspectors searched in dumpsters, other containers, and around the buildings to try to locate the device. They also took radiation surveys in each of the areas. The surveys indicated no increased radiation levels and the gauge was not found by the ODH inspectors. This incident remains open."

Ohio Report: OH170010

Notified the R3DO (Duncan) and NMSS Events Resource (via e-mail).

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

To top of page
Power Reactor Event Number: 53105
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHRISTOPHER METZ
HQ OPS Officer: BETHANY CECERE
Notification Date: 12/06/2017
Notification Time: 01:55 [ET]
Event Date: 12/05/2017
Event Time: 20:00 [CST]
Last Update Date: 12/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)

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

Event Text

UNPLANNED LOSS OF MULTIPLE RADIATION MONITORS DURING MAINTENANCE

"At 2000 (CST), Comanche Peak experienced a failure of SCADA B of the PC11 Radiation Monitor System. This failure caused a loss of Unit 1 Main Steam Line 1-01 and 1-03 Radiation Monitors (1-RE-2325 and 1-RE-2327) and Train A and Train B Station Service Water Radiation Monitors (1-RE-4269 and 1-RE-4270). With the Main Steam Line Radiation Monitors nonfunctional, all of the emergency action levels for a steam generator tube rupture in steam generators 1-01 and 1-03 could neither be evaluated nor monitored. With the Station Service Water Radiation Monitors non-functional, all of the emergency action levels for a radioactive release through station service water could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii).

"Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity, reactor coolant system integrity, and fuel cladding integrity and there is a negligible safety significance to condition from a public health and safety perspective. Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator, reactor coolant system, or the fuel cladding. Until these radiation monitors were restored, Operations implemented compensatory measures to monitor the Condenser Off Gas Radiation Monitor for early signs of a steam generator tube leak/rupture and Radiation Technicians were briefed on taking local readings with a Geiger-Mueller tube on the Main Steam Lines. Chemistry Technicians were performing hourly samples of Station Service Water and reporting results to the Control Room.

"Corrective actions were pursued to restore the non-functional radiation monitors back to service. Those actions are complete and all radiation monitors have been restored to service.

"The NRC Resident Inspector has been notified."

PC11 is a computer common to both Units. The failure happened during radiation monitor maintenance to a single monitor, which unexpectedly affected multiple monitors.

Page Last Reviewed/Updated Wednesday, December 06, 2017
Wednesday, December 06, 2017