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Event Notification Report for September 04, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/3/2018 - 9/4/2018

** EVENT NUMBERS **


53561 53564 53567 53568 53569 53579

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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.

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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.

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Agreement State Event Number: 53567
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: ARDAMAN & ASSOCIATES, INC.
Region: 1
City: TALLAHASSEE   State: FL
County:
License #: 3456-7
Agreement: Y
Docket:
NRC Notified By: PAUL NORMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/27/2018
Notification Time: 13:11 [ET]
Event Date: 08/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

FLORIDA AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

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

"Ardaman & Associates, Inc., reported to [the Florida Bureau of Radiation Control] a damaged Troxler Gauge at Lake Brantley High School, 991 Sand Lake Rd, Altamonte Springs, FL 32714. Gauge was backed into by heavy equipment. Sources were not extended at the time, and are not damaged. All radiation readings taken after damage were normal expected values. The gauge was immediately retrieved and removed from work site.

"Gauge is being transferred to Troxler Orlando Office for evaluation and determination for repair or replacement."

The gauge contained an 8 mCi Cs-137 source and a 40 mCi AmBe-241 source.

Florida Incident No. FL18-112

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
DOUGLAS BOLLOCK (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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.

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Agreement State Event Number: 53569
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOLOGIC ASSOCIATES
Region: 4
City: SANTA ROSA   State: CA
County: SONOMA
License #: 7439-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: BRIAN LIN
Notification Date: 08/27/2018
Notification Time: 18:16 [ET]
Event Date: 08/26/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

CALIFORNIA AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On August 27, 2018, [the licensee's radiation safety officer] RSO contacted the Brea Office of the [California] Radiologic Health Branch to report that a moisture density gauge had been stolen from a gauge operator's truck in Santa Rosa, California. The operator stated that the gauge was stolen sometime between the evening of Saturday, August 25, 2018 and the morning of Sunday, August 26, 2018. The gauge was a CPN model MC-3, S/N M320906734 containing nominally 10 mCurie of Cs-137 and 50 mCurie of Am-241:Be. A report was filed with the Santa Rosa Police Department."

California Report Number 5010-082718

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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Power Reactor Event Number: 53579
Facility: NORTH ANNA
Region: 2     State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: DAVID MOSSER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/03/2018
Notification Time: 15:20 [ET]
Event Date: 09/03/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BINOY DESAI (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

AUTOMATIC START OF THE EMERGENCY DIESEL GENERATOR

"At 1045 [EDT] on 9/3/18, with Unit 1 and Unit 2 at 100% power, off-site power feed to the 'A' Reserve Station Transformer was lost which resulted in a loss of power to Unit 1'J' Emergency Bus. As a result of the power loss, the 1'J' Emergency Diesel Generator started as designed and restored power to the Emergency Bus. During this event, the Unit 1 'A' Charging Pump, 1-CH-P-1A automatically started as designed due to the loss of power event.

"The valid actuation of these ESF [Engineered Safety Features] components due to the loss of power is reportable per 10 CFR 50.72 (b)(3)(iv)(A).

"The Unit 1 'J' Emergency bus off-site power source was restored via the Unit 2 'B' Station Service bus and the 1 'J' Emergency Diesel was secured and returned to Automatic. The Unit 1 'A' Charging pump has been stopped and returned to Automatic.

"Both Units are in a stable condition. The apparent cause for the loss of power appears to be a bird strike to the 'A' RSST [Reserve Station Service Transformer] Overhead Cable."

The licensee notified the NRC Resident Inspector.


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