Event Notification Report for February 19, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/15/2019 - 2/19/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State	Event Number: 53844
Rep Org: TILDEN MINING COMPANY L.C. Licensee: TILDEN MINING COMPANY L.C. Region: 3 City: ISHPEMING State: MI County: License #: 21-26748-01 Agreement: N Docket: NRC Notified By: LAWRENCE GRAY HQ OPS Officer: DONALD NORWOOD	Notification Date: 01/24/2019 Notification Time: 11:14 [ET] Event Date: 01/24/2019 Event Time: 00:00 [EST] Last Update Date: 02/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): HIRONORI PETERSON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 2/19/2019

EN Revision Text: FAILURE TO CLOSE AND LOCK NUCLEAR GAUGE SHUTTER

The following was received via e-mail:

"Between 2200 EST on January 23, 2019 and 0000 EST on January 24, 2019 a Ronan RLL1 [Density Scale Source] was unbolted from the frame on which it was mounted and placed on the floor. (Source was a Cs-137 0.54 milliCurie decayed to 0.45 milliCurie, Serial #212785A)

"No permit was pulled to remove the scale source, and the shutter wasn't closed and locked out.

"After it was unbolted, and was placed on the floor with the beam pointed towards a conveyor belt and the ceiling.

"Balling line 10, Conveyor 21 was approximately 6 feet above the placed source, and the ceiling is at 60 feet.

"No employees worked in front of the beam once placed on the floor.

"No one noticed the scale sitting on the floor unlocked until January 24, 2019 around 1500 EST.

"Once the source was found, trained personnel put the shutter block in place and locked out the source.

"The RSO then authorized a permit.

"Once the source was secured, and permit posted, the RSO did a full investigation.

"Basic cause - The maintenance employee that unbolted the source entered the area from a direction that could only be accessed during a maintenance down. There was a radiation label on the scale itself, but no sign from his access point."

* * * RETRACTION ON 2/18/19 AT 1311 EST FROM LAWRENCE GRAY TO THOMAS KENDZIA * * *

Based on the findings of an NRC inspector, this event was determined to not be reportable since the shutter was fully functional and no exposure to personal occurred.

Notified R3DO (Duncan), NMSS Events Notification Group by email.

Non-Agreement State	Event Number: 53865
Rep Org: MRIGLOBAL Licensee: MRIGLOBAL Region: 3 City: KANSAS CITY State: MO County: JOHNSON License #: 24-02564-02 Agreement: N Docket: NRC Notified By: ERIC JEPPESEN HQ OPS Officer: JEFFREY WHITED	Notification Date: 02/08/2019 Notification Time: 09:46 [ET] Event Date: 01/29/2019 Event Time: 00:00 [CST] Last Update Date: 02/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): KENNETH RIEMER (R3DO) ADAM TUCKER (ILTAB) NMSS_EVENTS_NOTIFICATION (EMAIL) FRANK TRAN (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOSS OF ELECTRON CAPTURE DETECTOR WITH NICKEL-63 SOURCE

The following is a summary of a discussion with the licensee:

On approximately January 29, 2019, MRIGlobal in Kansas City, Missouri determined that they had lost a 15 milliCurie Nickel-63 source contained in an Electron Capture Detector (ECD - SN Agilent Technologies - U-2802).

The detector was taken out of service in 2015, though an employee continued to note that leak testing had been done on the detector since then. During the performance of an inventory in December 2018, they noticed that the Serial Number did not match and attempted to locate the detector. The facility was closed over the holiday season, but the licensee searched after returning from the break. It was previously believed that the detector had been given to staff to be placed in a storage area. During their search, the licensee found e-mails stating the detector had been taken out of service. Based on the e-mails, the licensee believes the detector has been missing since 2015. The licensee is not certain of the current location of the ECD.

During an attempt to locate the source, the licensee checked in the safety storage room, the old radiation storage shed, and other file cabinets and drawers in the facility. There is no risk from exposure due to the loss of the source.

The licensee notified the Region 3 materials inspector (Tran).

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.

Agreement State	Event Number: 53866
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: PRAIRIE MEADOWS Region: 4 City: OMAHA State: NE County: License #: GL0762 Agreement: Y Docket: NRC Notified By: LARRY HARISIS HQ OPS Officer: BRIAN P. SMITH	Notification Date: 02/08/2019 Notification Time: 15:58 [ET] Event Date: 08/01/2018 Event Time: 00:00 [CST] Last Update Date: 02/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF TRITIUM EXIT SIGNS

The following was received via email from the Nebraska Department of Health and Human Services:

"Nebraska Department of Health and Human Services, Office of Radiological Health followed up with a phone call to Nebraska General Licensee GL0762 concerning their Annual Radioactive Materials License Renewal and Inventory Sheet on 2/7/2019. The licensee indicated over the phone that 2 tritium exit signs have not been seen or on the property since at least August 2018. The licensee was instructed to search the entire facility and report their findings.

"On 2/8/2019, the licensee conducted a complete search of the property grounds and could not locate the exit signs. Records were searched and no indication was made to the disposal of the signs. The property manager believes that they may have been disposed of in the regular trash and moved to the local landfill.

"The exit signs were from the Isolite Corporation, model SLX60, containing 6 Curies of H-3 each."

State Event Report ID No.: NE-19-0001

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

Agreement State	Event Number: 53868
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: EASTERN REGIONAL MEDICAL CENTER Region: 1 City: PHILADELPHIA State: PA County: License #: PA-0980 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: JEFF HERRERA	Notification Date: 02/11/2019 Notification Time: 14:15 [ET] Event Date: 02/08/2019 Event Time: 00:00 [EST] Last Update Date: 02/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE TO PATIENT LESS THAN PRESCRIBED DOSE

The following report was received from the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection via email:

"The licensee reported that on February 8, 2019, while reviewing a patient treatment plan, it was discovered that the patient had received a dose from a high dose rate remote afterloader containing iridium-192 that was less than the prescribed dose in the written directive. The original treatment plan was prescribed for 7.0 Gy per fraction, however at the beginning of the 3rd fraction it was noticed that the total dose delivered was 4.67 Gy instead of the prescribed 14 Gy they should have received for the same 2 fractions. The physician has informed the patient and will amend the written directive to add additional fractions at different doses to achieve the original prescribed dose to the treatment area. No more information is available at this time from the licensee. We will update this event as soon as more information is provided.

"Cause of the Event: Unknown / Human error.

"ACTIONS: The Department [Pennsylvania Department of Environmental Protection] will perform a reactive inspection. More information will be provided upon receipt."

* * * UPDATE AT 1227 EST ON 02/14/2019 FROM JOHN CHIPPO TO TOM KENDZIA * * *

The following update was received from the Pennsylvania Department of Environmental Protection via email:

"The patient received treatment on January 29, 2019, and February 5, 2019. The patient had not finished her initially scheduled 3rd fraction. The Medical Event was identified on Friday, February 8, 2019. The equipment manufacturer is Varian, model VariSource iX(t), Serial Number 00400. The source activity as of February 11, 2019 was 6.819 Ci. The licensee is still in the process of identifying root cause and corrective action."

Pennsylvania Report: PA190003

Notified the R1DO (Ferdas) and NMSS Events (via 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.

Page Last Reviewed/Updated Wednesday, March 24, 2021