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Event Notification Report for November 08, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/7/2018 - 11/8/2018

** EVENT NUMBERS **


53705 53706 53707 53725

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53705
Rep Org: SSM HEALTH ST. MARY'S HOSPITAL
Licensee: SSM HEALTH ST. MARY'S HOSPITAL
Region: 3
City: JEFFERSON CITY   State: MO
County:
License #: 24-17477-01
Agreement: N
Docket:
NRC Notified By: JEANINE TREADWAY
HQ OPS Officer: VINCE KLCO
Notification Date: 10/30/2018
Notification Time: 16:33 [ET]
Event Date: 10/30/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

MISSING LICENSED MATERIAL

Replacement camera sources were properly delivered by the common carrier to St. Mary's Hospital located in Jefferson City, Missouri. The sources were received by the Biomed Hospital Imaging Specialist and placed in the biomed office. Currently, the package containing the sources is missing. The licensee investigation continues. Sources are two Gd-153 (10 mCi each) and two Co-57 (0.5 microCi each).

* * * RETRACTION ON 10/31/2018 AT 1425 EDT FROM KEN WOHLT TO ANDREW WAUGH * * *

This event is being retracted. The sources were discovered to be delivered to SSM Hospital's biomed office instead of nuclear medicine. The sources were secured and in control of the SSM Hospital at all times. There were no exposures to personnel.

The licensee notified NRC Region 3 (Warren).

Notified R3DO (Stoedter) and NMSS Events Notification and ILTAB via email.

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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Non-Agreement State Event Number: 53706
Rep Org: PACE ANALYTICAL SERVICES
Licensee: PACE ANALYTICAL SERVICES
Region: 3
City: MINNEAPOLIS   State: MN
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: ADAM NETZER
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/31/2018
Notification Time: 10:18 [ET]
Event Date: 10/01/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

MISSING ELECTRON CAPTURE DEVICES

The following was received via email:

"Specific Location Information Where Incident Occurred:
Pace Analytical Services, Beaver-WV Environmental Laboratory

"Incident, Amount:
In [Pace's] inventory, [Pace] had six spare Agilent ECDs [Electron Capture Devices]. [Pace] believes they were accidentally placed in the trash for disposal and were subsequently placed in the local landfill. The ECDs have a sealed source with approximately 15 milliCuries of Nickel 63 each. These were the ECDs only and not the entire instrument, Gas Chromatograph (GC).

"ECDs / Models:
F6470 / 19233
F6526 / 19233
L2643 / 19233
L7189 / 19233
F4602 / 19233
F6242 / 19233

"Date of Lost/Misplaced ECDs, Last Time Seen:
Identified as missing October 1, 2018.
Confirmed to be missing October 3, 2018
Last seen September 26, 2018.
Believed to be placed in the laboratory trash September 26th-29th, 2018.

"Root Cause:
During a clean-up/lean event employees were going through the lab and reorganizing/disposing of unneeded materials. The six ECDs were used as reserves for GC instrumentation and placed in a bag in efforts to not dispose of them. At some point later in the week, it is believed that either an employee or cleaning person mistook the bag as garbage and threw them away.

"Measures to Recover:
Upon discovering the lost ECDs, Pace contacted the trash hauler - Raleigh County Solid Waste Authority. They stated that, due to the length of time that has passed since disposal, the likelihood of recovery is essentially zero. Due to the process of filling hollow-like areas, anything disposed has approximately 20 feet of additional material over it, and they have no way of knowing where the truck would have dumped the materials."

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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Agreement State Event Number: 53707
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: LUDLUM MEASUREMENTS
Region: 1
City: KNOXVILLE   State: TN
County:
License #: R-47214-K21
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/31/2018
Notification Time: 15:57 [ET]
Event Date: 08/13/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AMERICIUM-241 SOURCE

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

"On 10/31/18, the Tennessee Division of Radiological Health was contacted via phone by Ludlum Measurements RSO regarding the loss of a licensed source. It appears the source was last seen on 8/10/18. The licensee realized the source was missing on 8/13/18. The licensee has been searching for the source from 8/13/18 to date. The whereabouts of the source are still unknown at this time.

"Isotope and activity: Am-241, 1.057911 microCi
Manufacturer: Eckert and Ziegler
Model and Source Serial #: 1637-72-2

"A follow-up report will be submitted within 30 days."

Tennessee State Event Report ID No.: TN-18-195

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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Non-Power Reactor Event Number: 53725
Facility: REED COLLEGE
RX Type: 250 KW TRIGA MARK I
Comments:
Region: 0
City: PORTLAND   State: OR
County: MULTNOMAH
License #: R-112
Agreement: Y
Docket: 05000288
NRC Notified By: MELINDA KRAHENBUHL
HQ OPS Officer: OSSY FONT
Notification Date: 11/08/2018
Notification Time: 16:51 [ET]
Event Date: 11/08/2018
Event Time: 00:00 [PST]
Last Update Date: 11/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
NON-POWER REACTOR EVENT
Person (Organization):
GEOFF WERTZ (PM)
ELIZABETH REED (NPR)

Event Text

TECHNICAL SPECIFICATION VIOLATION - UNSECURED REACTOR LEFT UNATTENDED

The following is a synopsis of a notification received from Reed College:

The licensee made an official notification of a violation of technical specification (TS) 6.1.3 a 1 as well as TS 1, which defines the reactor as operating when it is not shutdown or secured. The Reactor Operator (RO) left the control room for approximately 30 seconds while the reactor was subcritical but not secured. Per the TS definition, the reactor is not secured if the reactor console key is in the console. The RO immediately returned to the control room and removed the key and ensured the reactor scrammed.

The Senior Reactor Operator (SRO) was in the next room and was informed. Another SRO was in the control room but was not requalified.


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