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Event Notification Report for April 24, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/23/2018 - 04/24/2018

** EVENT NUMBERS **


53330 53331 53332 53333 53337 53338 53339

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Agreement State Event Number: 53330
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: WILCO NDT
Region: 4
City: NEEDVILLE State: TX
County:
License #: L06916
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2018
Notification Time: 11:44 [ET]
Event Date: 04/12/2018
Event Time: [CDT]
Last Update Date: 04/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA PIGTAIL CONNECTOR FAILED

The following information was obtained from the state of Texas via email:

"On April 13, 2018, the Agency [Texas Department of State Health Services] received notice that a radiography camera had an equipment failure yesterday, April 12, 2018. The radiography crew was on a temporary jobsite and was setting up for a job. When the radiographer tried to connect the guide tube, the pigtail on the cable broke and the camera/cable was unusable. The radiographer contacted his radiation safety officer who informed the crew to bring the camera back to the office. The source did not leave the camera. No exposure to an individual occurred. The camera was a Spec-150, #2489 with an Iridium-192 source, G60 -VC1403 at 80 Curies. The manufacturer will be sent the equipment and a full report will be provided by the radiation safety officer within the next few days. Updates will be provide as received in accordance with SA300."

Texas Incident #9558

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Fuel Cycle Facility Event Number: 53331
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2018
Notification Time: 15:00 [ET]
Event Date: 04/12/2018
Event Time: 19:00 [EDT]
Last Update Date: 04/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
MARVIN SYKES (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MARGIE KOTZALAS (NMSS)

Event Text

POTENTIALLY DEGRADED ITEMS RELIED ON FOR SAFETY

"GNF-A's [Global Nuclear Fuels - Americas] Fuel Manufacturing Operation maintains a safe geometry Radwaste accumulation tank to receive certain liquid discharges from operations. During the annual shutdown work activities and routine inspections, an accumulation of material was identified in a safe geometry Radwaste accumulation tank.

"The accumulation appears to have occurred due to reduced recirculation flow, an engineered feature that mixes the contents of the tank as part of a density control. The accumulation of material is an indication that the tank density control had degraded.

"Plant operations attempted to remove and quantify the material per normal requirements. On 4/12/18 at approximately 1900 [EDT], GNF-A determined that the material could not be quantified in a timely manner.

"In the absence of quantification, GNF-A has conservatively determined that this condition is a failure to meet performance requirements and is therefore reporting it within 24 hours of discovery pursuant to Part 70 Appendix A (b)(2).

"Additional controls on the tank geometry remained intact and at no time was an unsafe condition present. In addition, there are no sources that could result in a rapid addition of uranium to the system.

"Additional corrective actions, extent of condition, and extent of cause are being investigated."

The licensee will be notifying their NRC Program Manager (Vukovinsky), the Radiation Protection Section at North Carolina Department of Health and Human Services, and Hanover County Emergency Management Agency.

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Agreement State Event Number: 53332
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TECHCORR USA MANAGEMENT LLC
Region: 4
City: PASADENA State: TX
County: BRAZOS
License #: L05972
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2018
Notification Time: 16:12 [ET]
Event Date: 04/13/2018
Event Time: [CDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - OVEREXPOSURE TO A RADIOGRAPHER

The following information was obtained from the State of Texas via email:

"On April 13, 2018, the Agency [Texas Department of State Health Services] was notified by the Licensee's Radiation Safety Officer (RSO) that an overexposure occurred after a film badge that was sent off earlier this week for an immediate reading came back with a total whole body dose of 6 Rem. On or about April 9, 2018, a radiographer working at a fabrication shop was using a QSA 880D [camera] containing 70 Curies of Iridium-192. After the camera was used to conduct some shots at one location, the radiographer carried the camera and attached cables to a different location. When he walked by a Radiographer Supervisor, the Supervisor's rate alarm starting alarming. The camera was put down, the cranks operated and the source was then fully locked inside the camera. Details of why the source was not fully inserted in the camera are not known at this time. The RSO is enroute to conduct an investigation and interviews on April 16, 2018. The camera and cranks were tested several times and appear to be working normally. No other personnel appeared to receive any significant dose. Additional information will be supplied as it is received in accordance with SA-300."

Texas Incident Number: 9559


* * * UPDATE ON 4/18/18 AT 0940 EDT FROM KAREN BLANCHARD TO BETHANY CECERE * * *

The update was obtained from the State of Texas via email:

"Per new information received from the licensee, please change the activity of the source from 70 Curies to 102.8 Curies.

"Investigation into this event is still ongoing."

Notified R4DO (O'Keefe) and NMSS Events Notification (email).

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Agreement State Event Number: 53333
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: IRISNDT INC
Region: 4
City: HOUSTON State: TX
County:
License #: L06435
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/13/2018
Notification Time: 17:18 [ET]
Event Date: 04/13/2018
Event Time: [CDT]
Last Update Date: 04/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - ATTEMPTED BREAK-IN AT A FACILITY HOUSING RADIOGRAPHY EQUIPMENT

The following information was obtained from the state of Texas via email:

"On April 13, 2018, the Agency [Texas Department of State Health Services] received notification from a radiation safety officer (RSO) for a radiography company. The RSO stated that they experienced an attempted theft at one of their locations. The workday ended at 6:00 p.m. [CDT] yesterday and began at 6:00 a.m. today. At some point during the night hours, the lock on the complex gate was forced to the point of breakage. The complex is surrounded by a six foot fence and contains radiography vehicles, an office, and a radiography storage vault. The attempt to enter the complex was not successful. The company found the bent/broken lock and noted no items disturbed or stolen. The company informed the local law enforcement servicing the area. The company also increased its video surveillance by adding more cameras and signs communicating the area was under surveillance to deter any future attempts of criminal activity."

Texas Incident #9560

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Agreement State Event Number: 53337
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BJ SERVICES LLC
Region: 4
City: HOUSTON State: TX
County:
License #: L06859
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/14/2018
Notification Time: 20:55 [ET]
Event Date: 04/13/2018
Event Time: 20:55 [CDT]
Last Update Date: 04/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

TEXAS AGREEMENT STATE REPORT - RECOVERY BY U.S. CUSTOMS AND BORDER PROTECTION OF A FIXED NUCLEAR GAUGE

The following information was obtained by the state of Texas via email:

"On April 13, 2018, at approximately 8:55 p.m. [CDT], U.S. Customs and Border Protection (CBP) notified the Agency [Texas Department of State Health Services] that it had discovered and identified a cesium [fixed] gauge - Thermo Fisher Scientific Model 5192, containing 200 milliCuries of cesium-137, SN: B8087 - in the bed of a pickup truck of an individual (road construction worker) who was crossing from Texas into Mexico at the Tornillo-Marcelino Serna port of entry in Tornillo, Texas. The individual told the CBP officer that he had found the gauge on the side of the road near Kermit, Texas, and had picked it up and put it in the back of his truck as he was leaving that area to travel to Mexico ('home'); he collects scrap metal and sells it across the border. CBP took possession of the device and the Agency contacted the owner/licensee. The licensee dispatched an employee who retrieved the device at approximately 6:00 a.m. on April 14, 2018. The licensee reported that the device packaging appeared to be secure and has performed a leak test which was sent to a third party for analysis. While there has been no indication that any individual has been exposed above any regulatory limit, the licensee's and Agency's investigations thus far have not been able to definitively make that determination. Therefore, this report is being submitted. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #I-9561

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Agreement State Event Number: 53338
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MAYO CLINIC
Region: 1
City: JACKSONVILLE State: FL
County:
License #: 1812-3
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/14/2018
Notification Time: 21:39 [ET]
Event Date: 04/13/2018
Event Time: [EDT]
Last Update Date: 04/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

FLORIDA AGREEMENT STATE REPORT - PATIENT RECEIVED 65 PERCENT OF PRESCRIBED DOSE TO INTENDED TREATMENT SITE

The following information was obtained from the state of Florida via email:

"An underdose of Y-90 Theraspheres to the patient's liver was reported to the BRC [Florida Bureau of Radiation Control] on 4/14/2018 at 3:15 p.m. [EDT]. Incident occurred on Friday, 4/13/2018 sometime during the afternoon. 60 mCi of Y-90 Theraspheres prescribed, of which 65% was delivered to patient's liver and 35% went to the waist. The RSO [Radiation Safety Officer] to follow up with documentation and a corrective action plan."

Florida Incident No.: FL18-050

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: 53339
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: GE HEALTHCARE
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: GRAY FORSEE
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/16/2018
Notification Time: 16:36 [ET]
Event Date: 04/16/2018
Event Time: 14:15 [CDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ADAM TUCKER (ILTA)

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

Event Text

AGREEMENT STATE REPORT - TECHNETIUM-99m GENERATOR LOST IN TRANSIT

The following was received from the State of Illinois via E-mail:

"The Agency [Illinois Emergency Management Agency] received a call on 4/16/18 from GE Healthcare (IL-01109-01, Arlington Heights) stating that a Mo/Tc generator in transit to their facility was unaccounted for. The generator was one of eight being returned from pharmacies in Michigan and was shipped as a Yellow-II package through [common carrier]. The Mo-99 activity was estimated to be 10.35 GBq on 4/11/18. GE Healthcare stated the empty packaging for the generator was returned in the shipment with the bottom of the box having been re-taped. [The common carrier] is working to search their hubs (Grand Rapids, Chicago Heights, and Wheeling). The shipping pharmacies have been interviewed and provided signed manifests.

"Details will be provided as they become available. There is currently no reason to believe a deliberate intent to misplace the device [occurred]."

GE Healthcare (Emile Poisson) also notified the NRC Operations Center regarding this event. The package was initially shipped from the Kentwood Michigan GE Healthcare location. The outer package was delivered to the correct location at 1415 CDT.

GE Healthcare Michigan Licensee Number: 21-26707-01MD.

Illinois Item Number: IL180027.


* * * UPDATE FROM EMILE POISSON TO HOWIE CROUCH AT 1752 EDT ON 4/17/18 * * *

GE Healthcare notified the NRC Operations Center that the missing generator had been located. When the shipping box broke, the generator fell into a box of office chairs that was shipping to St. Mary's Hospital in South Dakota. Personnel at the hospital recognized the generator as radioactive material and turned it over to the hospital's radiology department. The radiology department notified GE Healthcare. GE Healthcare is making arrangements to have the generator shipped to its Illinois facility. There were no reported overexposures.

* * * The following additional information was received from the State of Illinois (Foresee) via email:

"On 4/17/18, at approximately 1630 CDT, [GE Healthcare] notified IEMA that the package had been located at St. Mary's Hospital in Pierre, SD. Reportedly, hospital staff opened boxes of steel chairs and the generator had been packaged inside. It is unknown if the chairs/associated packaging has been assessed for removable contamination. GE Healthcare is unsure if the hospital is authorized for possession of the generator. GE Healthcare and IEMA are notifying NRC Region IV staff concurrently. The generator arrived in shrink wrapped boxes, delivered by a secondary carrier. GE Healthcare and [the original common carrier] are retracing the shipment to determine at what point the packages were comingled. Terminals at Kentwood, Ml, Chicago Heights, IL and St. Paul, MN are in question. There is currently no reason to believe a deliberate intent to misplace the device [occurred]. GE Healthcare is working to take possession of the generator at this time. Additional details will be provided as they become available."

Notified R3DO (Riemer), R4DO (O'Keefe), ILTAB (E-mail) and NMSS Events Notification (E-mail).


* * * UPDATE FROM DAN KANE TO STEVEN VITTO AT 1317 EDT ON 4/18/18 * * *

Associates In Medical Physics, LLC notified the NRC on behalf of Avera St. Mary's Hospital, South Dakota, regarding the receipt of the generator. Upon receiving the package the hospital surveyed the device and determined no surface contamination was present. The device was shielded and locked within the hospital's hot lab. Arrangements are being made with GE Healthcare to retrieve the generator.

Notified R3DO (Riemer), R4DO (O'Keefe), ILTAB (E-mail) and NMSS Events Notification (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

Page Last Reviewed/Updated Tuesday, April 24, 2018
Tuesday, April 24, 2018