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Event Notification Report for December 27, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/26/2018 - 12/27/2018

** EVENT NUMBERS **


53792 53794 53795

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Agreement State Event Number: 53792
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KRUGER TECHNOLOGY INC
Region: 4
City: LENEXA   State: KS
County:
License #: 22-B659-01
Agreement: Y
Docket:
NRC Notified By: DAVID M LAWRENZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2018
Notification Time: 11:51 [ET]
Event Date: 12/17/2018
Event Time: 00:00 [CST]
Last Update Date: 12/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following was received from the state of Kansas via email:

"Yesterday the Kansas Radiation Control Program was notified by a licensee, Kruger Technology Inc (dba KTI) 22-B659-01, of a Troxler gauge which was hit and damaged at a construction site in Edgerton ,KS. No one was injured. The source was in the shielded position. Initial surveys indicate [that] the shielding is intact. The rod was slightly bent, fortunately the device still fit in the transport case. The licensee reported by phone that the device was hit [at] approximately 1530 CST. The initial report was made to the State at 1615 CST. The RSO was on scene within an hour of the incident. The incident occurred on a new road construction site. It was the end of the day and few workers were present, no public traffic is permitted on the road. The site is an industrial complex in a rural area and there is no public access to the site.

"Currently the device is secured in the licensee's storage room. An inspector was dispatched this morning to conduct a reactive inspection and verify survey results. More information will be provided to the NRC as it is available, including the device make and model, serial number, survey meter information, verified survey results, more information on how the incident occurred, enforcement actions taken if applicable, and more precise location information."

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Agreement State Event Number: 53794
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: ENGLEWOOD   State: CO
County:
License #: CO 251-02
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 12/19/2018
Notification Time: 11:10 [ET]
Event Date: 12/15/2018
Event Time: 00:00 [MST]
Last Update Date: 12/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received from the State of Colorado via email:

"[Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018.

"Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected.

"The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee."

Colorado Event Report ID No.: CO180032

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: 53795
Rep Org: COLORADO DEPT OF HEALTH
Licensee: THERMO MF PHYSICS, LLC
Region: 4
City: COLORADO SPRINGS   State: CO
County:
License #: CO 803-02
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: KAREN COTTON
Notification Date: 12/19/2018
Notification Time: 17:28 [ET]
Event Date: 12/19/2018
Event Time: 00:00 [MST]
Last Update Date: 12/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT- CONTAMINATED PACKAGE

The following was received from the State of Colorado via email:

"Event description: Thermo MF Physics, LLC received 2 packages of radioactive materials, both containing approximately 700 Ci of H-3. When performing contamination surveys as part of the package receipt, wipe tests indicated approximately 600 dpm/cm2 of removable H-3. A third package that was received at the same time, which did not contain any radioactive materials, also exhibited removable contamination. Thermo MF Physics, LLC has contacted the final delivery carrier and made them aware of the situation. Thermo MF Physics, LLC is continuing to count removable contamination samples to determine the extent of the contamination event."

Colorado Event Report ID No.: CO180033


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Friday, May 03, 2019