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Event Notification Report for October 02, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/1/2018 - 10/2/2018

** EVENT NUMBERS **


53573 53616 53618 53637

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 53573
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
Region: 2
City: ERWIN   State: TN
County: UNICOI
License #: SNM-124
Docket: 07000143
NRC Notified By: TIM KNOWLES
HQ OPS Officer: OSSY FONT
Notification Date: 08/30/2018
Notification Time: 09:58 [ET]
Event Date: 08/29/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
BINOY DESAI (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FUELS GROUP (EMAIL)

Event Text

CONCURRENT REPORT FOR AN OFFSITE NOTIFICATION MADE TO THE STATE OF TENNESSEE

"This is a concurrent report of a 24-hour report that was made to the Tennessee Department of Environment and Conservation (TDEC) regarding an unauthorized storm water discharge. As permitted by the State of Tennessee, emulsified vegetable oil was being injected into ground water wells located on the North Site of NFS property. At approximately 11:00 [EDT], Environmental Safety was notified of a cloudy oil substance that was observed in the west storm water ditch. Injections were immediately ceased and immediate corrective actions were implemented. Oil absorbent pads and socks were deployed and samples were collected. Before noon on 8/29/2018, the cloudy substance was observed at the discharge of the storm water ditch into Martins Creek. Because of the discoloration observed at the entrance to Martins Creek, this event required a 24-hour notification to TDEC (made at 16:15 on. 8/29/18) and a five day written report will be submitted. Analysis of the grab samples indicated no radioactive material release.

"The licensee notified the NRC Resident Inspector."

* * * RETRACTION AT 1039 EDT ON 10/02/18 FROM TIMOTHY KNOWLES TO JEFF HERRERA * * *

"On 8/30/2018, NFS made an event report to the NRC Operations Center regarding a concurrent report of a 24-hour report that was made to the Tennessee Department of Environment and Conservation (TDEC) regarding an unauthorized stormwater discharge. Based on the determination that the unauthorized stormwater discharge involved a minor non-radioactive chemical spill that did not affect the safety of NRC licensed material, NFS is retracting the event report. This is consistent with guidance provided in FCSS Interim Staff Guidance - 12, 10 CFR Part 70, Appendix A - Reportable Safety Events, Section 3.5.2 Other Government Notifications."

Notified the R2DO (Coovert), NMSS and Fuels Group (via email).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53616
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: RSO   State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: AMY ETTLING
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2018
Notification Time: 17:40 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

POSSIBLE EXTRAVASATION OF RA-223

"The patient's first dose of 110.3 microCuries, 4.3 mL, of Ra-223 (Xofigo) was administered today, 9/21/18 at 1040 CDT. An IV was placed by RN [Registered Nurse] in the patient's left wrist. The IV was flushed with saline and blood return was checked and present prior to administration of Ra-223 by [the] MD [medical doctor]. The Ra-223 was delivered by MD. After delivery, the MD began [a] saline flush and after approximately 5cc of saline, noted resistance and a cold bulge near the infusion site. He was not able to get blood return. The RN was called in to check the IV and was not able to get blood return. It was noted an infiltration/extravasation had occurred. The IV was removed with catheter noted to be intact. Prior to the infusion the patient was told that the infusion should not be painful and he did not acknowledge any pain or discomfort during or after infusion. At this time it is not known if there was an extravasation of Ra-223 because the infiltration/extravasation was not noted until during the second saline flush. The patient and patient's family were notified at the time of the incident."

* * * RETRACTION ON 10/03/18 AT 1525 EDT FROM TOM MOENSTER TO RICHARD SMITH * * *

The licensee does not believe there was more than 10 percent of therapy dose that was not infiltrated. Based on the fact that the swelling went down in less than 45 minutes post imaging of the wrist, compared to the body, leads the Radiation Safety Officer (RSO) to believe most of the therapy dose went throughout the body.

Notified R3DO (Orth) and NMSS vis email.

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: 53618
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BOCA RATON REGIONAL HOSPITAL WOMEN'S IMAGING CENTER
Region: 1
City: BOCA RATON   State: FL
County:
License #: 0550-1
Agreement: Y
Docket:
NRC Notified By: RENO FABII
HQ OPS Officer: BETHANY CECERE
Notification Date: 09/24/2018
Notification Time: 11:29 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - POTENTIAL LOSS OF I-125 SEED

The following was received by the State of Florida by email:

"[Boca Raton Regional Hospital Women's Imaging Center] Radiation Safety Officer, contacted [the State of Florida Bureau of Radiation Control] by phone on Friday, September 21, 2018 at approximately 1500 EDT to report the potential loss of a 170 microCurie Iodine-125 seed, from Boca Raton Regional Hospital Women's Imaging Center. ISOAID Seed Company has been contacted to assure the seed was not received in an earlier shipment. Seed can be tracked to the Nuc Med Hot lab. Staff has confirmed it is not in the patient or in the Pathology lab. Sealed source certificate will be sent later. Full investigation report will be submitted within 30 days."

Florida Incident Number: FL18-124

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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Fuel Cycle Facility Event Number: 53637
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
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/02/2018
Notification Time: 14:38 [ET]
Event Date: 10/01/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
OMAR LOPEZ (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT NOTIFICATION

"At approximately 1525 [EDT] on October 1st, 2018, Fire Riser 318 which serves both non-contaminated and contaminated areas in [Fuel Manufacturing Operations] (FMO), was taken out of service due to a pin hole leak in the pipe. Water was contained and surveys were completed to ensure no contamination was released into non-contaminated areas. The New Hanover County Deputy Fire Marshall was notified at 1655 [EDT] on October 1st, 2018, per State code requirements. An hourly fire watch was implemented for surveillance of the affected areas. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will notify NRC Region 2 and the State of North Carolina Radiation Protection Section.

* * * UPDATE ON 10/4/18 AT 1335 EDT FROM PHILLIP TO OLLIS * * *

"The leaking sprinkler pipe fitting was replaced this morning and the system was restored to service at approximately 11 AM, 10/4/18. The NHC [New Hanover County] Deputy Fire Marshal was notified via telephone of the return to service at 11:50 AM, 10/4/18."

Notified the R2DO (Lopez), NMSS Events Notification via email.


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Friday, May 03, 2019