Event Notification Report for August 24, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/23/2018 - 08/24/2018
EVENT NUMBERS
5356853561535635356253564
Agreement State
Event Number: 53568
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: IRISNDT
Region: 4
City: PORT OF CATOOSA State: OK
County: ROGERS
License #: OK-30246-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BRIAN LIN
Licensee: IRISNDT
Region: 4
City: PORT OF CATOOSA State: OK
County: ROGERS
License #: OK-30246-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BRIAN LIN
Notification Date: 08/27/2018
Notification Time: 13:26 [ET]
Event Date: 08/24/2018
Event Time: 21:40 [CDT]
Last Update Date: 08/29/2018
Notification Time: 13:26 [ET]
Event Date: 08/24/2018
Event Time: 21:40 [CDT]
Last Update Date: 08/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
DOUGLAS BOLLOCK (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NICK TAYLOR (R4DO)
DOUGLAS BOLLOCK (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO A RADIOGRAPHER
The following information was obtained from the State of Oklahoma via email:
"On August 27, 2018 [Oklahoma Department of Environmental Quality (DEQ)] were informed of an incident which occurred approximately 2140 CDT on August 24, 2018 involving 3 radiographers working for IRISNDT (OK-30246-02). The crew was working at a fabrication shop in Port of Catoosa, OK using a 95 curie Ir-192 source. The crew consisted of one certified radiographer, one radiographer trainer, and one assistant radiographer. The radiographer approached the collimator and knelt down over the guide tube. The assistant and the instructor unlocked the camera and walked back to the crank. Looking back at the camera, they did not see the radiographer and assumed he had already left the area. They began to crank out the source when the radiographer yelled and ran from the area. A re-enactment of the event using a pocket dosimeter recorded a dose of 62.1 mR, the direct reading dosimeter worn by the radiographer recorded a dose of 6 mR, probably due to shielding by the radiographers body. The whole-body badge reported a dose of 211 mR for the current month. A review of the daily exposure records for this monitoring period showed that the individual should have received approximately 155 mR previously, so the dose recorded for this incident is approximately 56 mR. Immediately after the incident the radiographer began complaining of a burning sensation and inflammation of his right shin area. [Oklahoma DEQ] are arranging with a local hospital to have him seen by a radiation oncologist. [Oklahoma DEQ] will conduct a reactive inspection of the licensee."
* * * UPDATE FROM KEVIN SAMPSON TO OSSY FONT AT 1046 EDT ON 8/29/18 * * *
The following was received via email from the State of Oklahoma via email:
"After the reactive inspection yesterday, [Oklahoma Department of Environmental Quality] has determined that the injury reported by the radiographer was due to his hitting his shin on a stand as he ran from the area. It does not appear that this incident resulted in an over-exposure to anyone."
Notified R4DO (Hay) and Doug Ballock and NMSS Events Notification via email.
The following information was obtained from the State of Oklahoma via email:
"On August 27, 2018 [Oklahoma Department of Environmental Quality (DEQ)] were informed of an incident which occurred approximately 2140 CDT on August 24, 2018 involving 3 radiographers working for IRISNDT (OK-30246-02). The crew was working at a fabrication shop in Port of Catoosa, OK using a 95 curie Ir-192 source. The crew consisted of one certified radiographer, one radiographer trainer, and one assistant radiographer. The radiographer approached the collimator and knelt down over the guide tube. The assistant and the instructor unlocked the camera and walked back to the crank. Looking back at the camera, they did not see the radiographer and assumed he had already left the area. They began to crank out the source when the radiographer yelled and ran from the area. A re-enactment of the event using a pocket dosimeter recorded a dose of 62.1 mR, the direct reading dosimeter worn by the radiographer recorded a dose of 6 mR, probably due to shielding by the radiographers body. The whole-body badge reported a dose of 211 mR for the current month. A review of the daily exposure records for this monitoring period showed that the individual should have received approximately 155 mR previously, so the dose recorded for this incident is approximately 56 mR. Immediately after the incident the radiographer began complaining of a burning sensation and inflammation of his right shin area. [Oklahoma DEQ] are arranging with a local hospital to have him seen by a radiation oncologist. [Oklahoma DEQ] will conduct a reactive inspection of the licensee."
* * * UPDATE FROM KEVIN SAMPSON TO OSSY FONT AT 1046 EDT ON 8/29/18 * * *
The following was received via email from the State of Oklahoma via email:
"After the reactive inspection yesterday, [Oklahoma Department of Environmental Quality] has determined that the injury reported by the radiographer was due to his hitting his shin on a stand as he ran from the area. It does not appear that this incident resulted in an over-exposure to anyone."
Notified R4DO (Hay) and Doug Ballock and NMSS Events Notification via email.
Agreement State
Event Number: 53561
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: STERICYCLE
Region: 4
City: STROUD State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: DONG HWA PARK
Licensee: STERICYCLE
Region: 4
City: STROUD State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2018
Notification Time: 11:29 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2018
Notification Time: 11:29 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL
The following information was received via E-mail:
"This morning Oklahoma DEQ [Department of Environmental Quality] Radiation Management learned of an improper disposal of radioactive material in Oklahoma. Stericycle, an autoclave facility authorized to treat biomedical waste, rejected a load of material from a Kansas facility due to radioactivity. It appears the waste was received by SteriCycle on Wednesday, August 22 (because of an error in the report, this isn't totally clear), and is being picked up today (August 24) for return to the generating facility. SteriCycle did not provide DEQ with any specifics on radiation levels measured, quantity, etc. DEQ has notified the Kansas radiation program, which will investigate.
"SteriCycle identified the waste generator as: Cancer Center of KS - Wichita
"SteriCycle is located at: Stroud, OK
"We are informed that Kansas radiation control regulates the facility under the name Via Christi.
"Since the material is being picked up today, Oklahoma DEQ did not attempt a site visit to investigate the material. We have informed the Kansas radiation program and understand they will be following up. There are no known significant exposures to workers or the public, and none are expected at this time. It is not clear that this is reportable, but we are notifying NRC out of an abundance of caution."
See EN# 53564.
The following information was received via E-mail:
"This morning Oklahoma DEQ [Department of Environmental Quality] Radiation Management learned of an improper disposal of radioactive material in Oklahoma. Stericycle, an autoclave facility authorized to treat biomedical waste, rejected a load of material from a Kansas facility due to radioactivity. It appears the waste was received by SteriCycle on Wednesday, August 22 (because of an error in the report, this isn't totally clear), and is being picked up today (August 24) for return to the generating facility. SteriCycle did not provide DEQ with any specifics on radiation levels measured, quantity, etc. DEQ has notified the Kansas radiation program, which will investigate.
"SteriCycle identified the waste generator as: Cancer Center of KS - Wichita
"SteriCycle is located at: Stroud, OK
"We are informed that Kansas radiation control regulates the facility under the name Via Christi.
"Since the material is being picked up today, Oklahoma DEQ did not attempt a site visit to investigate the material. We have informed the Kansas radiation program and understand they will be following up. There are no known significant exposures to workers or the public, and none are expected at this time. It is not clear that this is reportable, but we are notifying NRC out of an abundance of caution."
See EN# 53564.
Power Reactor
Event Number: 53563
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: KARA STACY
HQ OPS Officer: THOMAS KENDZIA
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: KARA STACY
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 08/24/2018
Notification Time: 15:14 [ET]
Event Date: 08/24/2018
Event Time: 10:34 [EDT]
Last Update Date: 08/24/2018
Notification Time: 15:14 [ET]
Event Date: 08/24/2018
Event Time: 10:34 [EDT]
Last Update Date: 08/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
BRIAN BONSER (R2DO)
FFD GROUP (EMAIL)
BRIAN BONSER (R2DO)
FFD GROUP (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Under Construction | 0 | Under Construction |
| 4 | N | N | 0 | Under Construction | 0 | Under Construction |
CONTRACTOR SUPERVISOR SUBVERTS A FOLLOW-UP FITNESS FOR DUTY TEST
"At 1034 [EDT] on August 24, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD)
program by subverting a follow-up Fitness for Duty Test. The contractor's site access has been terminated.
"The NRC Resident Inspector was notified."
"At 1034 [EDT] on August 24, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD)
program by subverting a follow-up Fitness for Duty Test. The contractor's site access has been terminated.
"The NRC Resident Inspector was notified."
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 53562
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: DONG HWA PARK
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2018
Notification Time: 15:01 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2018
Notification Time: 15:01 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HIRONORI PETERSON (R3DO)
HIRONORI PETERSON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
INOPERABLE SEISMIC MONITORING SYSTEM
"At 0745 EDT on August 24, 2018, the Active Seismic Monitoring System failed a planned surveillance test and was declared inoperable. Compensatory measures to provide alternative methods for event classification of a seismic event have been implemented in accordance with the Fermi 2 Emergency Plan procedures. The compensatory measures include the use of information provided by the United States Geological Survey (USGS) to confirm if an earthquake has occurred within a 100 mile radius.
"The loss of the Active Seismic Monitoring System is reportable to the NRC within 8 hours of discovery in accordance with 10CFR50.72(b)(3)(xiii).
"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.
"The NRC Resident Inspector bas been notified."
* * * RETRACTION FROM JEFF GROFF TO VINCE KLCO ON SEPTEMBER 13, 2018 AT 1524 EDT * * *
"After further review the Active Seismic Monitoring system was removed from service for planned maintenance for a duration less than 72 hours with appropriate compensatory measures established. Therefore, no major loss of emergency assessment capability occurred. In addition, the surveillance tests were re-performed and the Active Seismic Monitoring System was declared Operable. Therefore, no reportable condition existed and EN 53562 reported on August 24, 20I8 is being retracted.
"The NRC Resident Inspector has been notified."
Notified the R3DO (Hanna).
"At 0745 EDT on August 24, 2018, the Active Seismic Monitoring System failed a planned surveillance test and was declared inoperable. Compensatory measures to provide alternative methods for event classification of a seismic event have been implemented in accordance with the Fermi 2 Emergency Plan procedures. The compensatory measures include the use of information provided by the United States Geological Survey (USGS) to confirm if an earthquake has occurred within a 100 mile radius.
"The loss of the Active Seismic Monitoring System is reportable to the NRC within 8 hours of discovery in accordance with 10CFR50.72(b)(3)(xiii).
"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.
"The NRC Resident Inspector bas been notified."
* * * RETRACTION FROM JEFF GROFF TO VINCE KLCO ON SEPTEMBER 13, 2018 AT 1524 EDT * * *
"After further review the Active Seismic Monitoring system was removed from service for planned maintenance for a duration less than 72 hours with appropriate compensatory measures established. Therefore, no major loss of emergency assessment capability occurred. In addition, the surveillance tests were re-performed and the Active Seismic Monitoring System was declared Operable. Therefore, no reportable condition existed and EN 53562 reported on August 24, 20I8 is being retracted.
"The NRC Resident Inspector has been notified."
Notified the R3DO (Hanna).
Agreement State
Event Number: 53564
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: STERICYCLE
Region: 4
City: STOUD State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID LAWRENZ
HQ OPS Officer: DONG HWA PARK
Licensee: STERICYCLE
Region: 4
City: STOUD State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID LAWRENZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2018
Notification Time: 16:35 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2018
Notification Time: 16:35 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL
The following information was received via E-mail:
"Oklahoma DEQ [Department of Environmental Quality] notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr on surface of the waste package."
See EN 53561.
* * * UPDATE ON 8/25/2018 AT 1737 EDT FROM DAVID LAWRENZ TO OSSY FONT * * *
The following update was provided via E-mail:
"The originator of the waste has a radioactive material license, however the package containing the contaminated waste was not from the radiology department where licensed activity occurs. Furthermore the licensee does not use I-131 or any isotope with a half-life nearly as long. [Kansas Radiation Control] will visit the site next week to determine what the dose estimates are for those in the waiting room, lab staff (both blood draw and blood testing), waste transporter and waste handlers. [Kansas Radiation Control] also intend to identify where the blood vial and associated potentially contaminated waste is stored/disposed.
"It will likely prove impossible to discover the licensee who administered the I-131 to the patient as the individual did not report they were recently treated, there was no surveys in their unrestricted portion of their facility that is unaffiliated with their RAM [radioactive material] work, and the waste is mixed in with several other patients over the course of several days."
* * * UPDATE FROM DAVID LAWRENZ TO VINCE KLCO ON 9/24/2018 AT 1509 EDT * * *
The following update was provided via E-mail:
"Oklahoma DEQ notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas on 8/24/2018. This was reported to the HOO by David Lawrenz on the same day.
"The Cancer Center of Kansas (CCK) was contacted by Stericycle, the company that handles sharps disposal, August 23, 2018. Stericycle stated they had received a radioactive sharps container from CCK. During a phone call with Stericycle, David Lawrenz learned the sharps container had been picked up last week and delivered to the incinerator facility on Monday August 20th.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn, and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr. on surface of the waste package on 8/24/18 when [redacted] picked up the container from Stericycle.
"After [redacted] picked up the sharps container on 8/24/18, it was determined the sharps container came from the CCK lab. [redacted] took surveys on the exterior of the container and found 500 microR/hr for the highest reading prior to returning to CCK. The CCK lab is separate from the CCK radiology department and the sharps containers are used separately as well. The CCK lab is not a restricted area and no radioactive material is used there. Consequently, the sharps from the lab were not monitored for radioactive contamination.
"With the knowledge that the sharps came from a department that does not handle radioactive material and the fact that so much time had passed we determined the radioactive contamination must have originated from outside CCK. CCK only uses Tc99m. CCK is authorized for 35.100 and 35.200 use only. CCK is a cancer specialty clinic so the most likely scenario is that a patient had very recently undergone I-131 therapy at another facility and then came to CCK for lab work. The discarded lab detritus from that patient was then placed in the sharps container that Stericycle collected.
"On August 27, 2018 [two individuals from the Kansas Department of Health and Environment] arrived at CCK and met with [the Lab Supervisor]. [redacted] took surveys of the sharps container and lab area. This area is separate from the radiology department. No areas were above background.
"[The Lab Supervisor took Kansas personnel] to the hot lab used under the Adams Diagnostics 12-B880. The rejected waste is now stored for decay in the regulated area. [The Lab Supervisor] surveyed the container at 259 microR/hr on contact.
"New procedures are being written to include surveys of the labs sharps container to prevent the issue from happening in the future. The licensee was found to not be in violation of any requirements and there will be no enforcement action as a result of this investigation unless new information comes to light.
"Root cause analysis is a patient failed to follow instructions after the medical procedure."
Notified the R4DO (Alexander) and NMSS Events via email.
The following information was received via E-mail:
"Oklahoma DEQ [Department of Environmental Quality] notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr on surface of the waste package."
See EN 53561.
* * * UPDATE ON 8/25/2018 AT 1737 EDT FROM DAVID LAWRENZ TO OSSY FONT * * *
The following update was provided via E-mail:
"The originator of the waste has a radioactive material license, however the package containing the contaminated waste was not from the radiology department where licensed activity occurs. Furthermore the licensee does not use I-131 or any isotope with a half-life nearly as long. [Kansas Radiation Control] will visit the site next week to determine what the dose estimates are for those in the waiting room, lab staff (both blood draw and blood testing), waste transporter and waste handlers. [Kansas Radiation Control] also intend to identify where the blood vial and associated potentially contaminated waste is stored/disposed.
"It will likely prove impossible to discover the licensee who administered the I-131 to the patient as the individual did not report they were recently treated, there was no surveys in their unrestricted portion of their facility that is unaffiliated with their RAM [radioactive material] work, and the waste is mixed in with several other patients over the course of several days."
* * * UPDATE FROM DAVID LAWRENZ TO VINCE KLCO ON 9/24/2018 AT 1509 EDT * * *
The following update was provided via E-mail:
"Oklahoma DEQ notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas on 8/24/2018. This was reported to the HOO by David Lawrenz on the same day.
"The Cancer Center of Kansas (CCK) was contacted by Stericycle, the company that handles sharps disposal, August 23, 2018. Stericycle stated they had received a radioactive sharps container from CCK. During a phone call with Stericycle, David Lawrenz learned the sharps container had been picked up last week and delivered to the incinerator facility on Monday August 20th.
"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn, and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr. on surface of the waste package on 8/24/18 when [redacted] picked up the container from Stericycle.
"After [redacted] picked up the sharps container on 8/24/18, it was determined the sharps container came from the CCK lab. [redacted] took surveys on the exterior of the container and found 500 microR/hr for the highest reading prior to returning to CCK. The CCK lab is separate from the CCK radiology department and the sharps containers are used separately as well. The CCK lab is not a restricted area and no radioactive material is used there. Consequently, the sharps from the lab were not monitored for radioactive contamination.
"With the knowledge that the sharps came from a department that does not handle radioactive material and the fact that so much time had passed we determined the radioactive contamination must have originated from outside CCK. CCK only uses Tc99m. CCK is authorized for 35.100 and 35.200 use only. CCK is a cancer specialty clinic so the most likely scenario is that a patient had very recently undergone I-131 therapy at another facility and then came to CCK for lab work. The discarded lab detritus from that patient was then placed in the sharps container that Stericycle collected.
"On August 27, 2018 [two individuals from the Kansas Department of Health and Environment] arrived at CCK and met with [the Lab Supervisor]. [redacted] took surveys of the sharps container and lab area. This area is separate from the radiology department. No areas were above background.
"[The Lab Supervisor took Kansas personnel] to the hot lab used under the Adams Diagnostics 12-B880. The rejected waste is now stored for decay in the regulated area. [The Lab Supervisor] surveyed the container at 259 microR/hr on contact.
"New procedures are being written to include surveys of the labs sharps container to prevent the issue from happening in the future. The licensee was found to not be in violation of any requirements and there will be no enforcement action as a result of this investigation unless new information comes to light.
"Root cause analysis is a patient failed to follow instructions after the medical procedure."
Notified the R4DO (Alexander) and NMSS Events via email.