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Event Notification Report for February 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/25/2019 - 2/26/2019

** EVENT NUMBERS **


53876 53877 53878 53879 53880 53881 53896 53897

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Non-Agreement State Event Number: 53876
Rep Org: KINGSFORD MANUFACTURING COMPANY
Licensee: KINGSFORD MANUFACTURING COMPANY
Region: 3
City: BELLE   State: MO
County:
License #: 24-20121-01
Agreement: N
Docket:
NRC Notified By: MARK NILGES
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/15/2019
Notification Time: 09:40 [ET]
Event Date: 10/09/2018
Event Time: 00:00 [CST]
Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NUCLEAR GAUGE SHUTTER STUCK OPEN

The following is a summary from a phone call with the licensee:

The licensee decided to remove seven nuclear gauges from service. Ronan Engineering performed the removal. During the device removal on October 9, 2018, one device was found to have a stuck shutter in the open position. The gauge was removed and repaired.

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Agreement State Event Number: 53877
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALBERT EINSTEIN HEALTHCARE NETWORK
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0135
Agreement: Y
Docket:
NRC Notified By: JOSHUA MYERS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/15/2019
Notification Time: 11:47 [ET]
Event Date: 02/13/2019
Event Time: 00:00 [EST]
Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EDWARD HARVEY (NMSS DAY)
WILLIAM GOTT (IRD)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE TO UNINTENDED ORGANS RESULTS OR WILL RESULT IN UNINTENDED PERMANENT DAMAGE

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

"On February 13, 2019, the patient was prescribed 31.3 milliCuries (mCi) Yttrium-90 (Y-90) Sirsphere for metastatic colorectal cancer and 31.69 mCi was delivered at time of treatment. From the post Y-90 Bremsstrahlung scan, performed on the day of treatment, it was discovered by the nuclear medicine physician, that some of the Y-90 microspheres also traveled to the stomach and left lobe of liver. The doctor has informed the patient and the patient is being monitored for potential complications. The doctor is working to determine the percentage of the Y-90 that went to stomach and left lobe of liver. No more information is available at this time from the licensee. The DEP will update this event as soon as more information is provided.

"The DEP will perform a reactive inspection."

The licensee reported this to the state per 10 CFR 35.3045 (b).

Pennsylvania Report: PA190004

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: 53878
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: MISSISSIPPI DEPARTMENT OF TRANSPORTATION
Region: 4
City: RED CREEK   State: MS
County:
License #: MS-261-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: ANDREW WAUGH
Notification Date: 02/15/2019
Notification Time: 13:33 [ET]
Event Date: 02/15/2019
Event Time: 00:00 [CST]
Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - THEFT OF A MOISTURE DENSITY GAUGE

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

"Mississippi Department of Transportation (MS-261-01) reported that a Troxler Model 3440 (serial number: 19297) portable gauge containing 10 milliCuries of cesium-137 and 44 milliCuries of americium-241/beryllium was stolen from the licensee's job site trailer closet in Red Creek, Mississippi. The gauge was padlocked in its original carrying case. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC on the recovery of the stolen gauge and entered into the Nuclear Material Events Database."

Mississippi Report Number: MS-190001

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: 53879
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Region: 4
City: LITTLE ROCK   State: AR
County:
License #: ARK-0001-02110
Agreement: Y
Docket:
NRC Notified By: ANGIE HALL
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/15/2019
Notification Time: 17:07 [ET]
Event Date: 02/13/2019
Event Time: 07:24 [CST]
Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED WAS LESS THAN PRESCRIBED

The following was received from the Arkansas Department of Health, Radiation Control Program (the Department) via email:

"The treatment prescribed activity was for 0.54 GBq (14.5 mCi) on February 13, 2019. The calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter Terumo-Progreat Microcatheter (2.0 French Catheter). The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST].

"The Department performed exposure surveys of the connector confirming activity stuck at the connector site. The connector site read the highest and in that concentrated area, reading 430 mR/hr, on February 15, 2019, at approximately 1415 [CST].

"There were no spills and/or contamination during this event.

"The licensee notified the manufacturer and the manufacturer will be performing an investigation on the tubing and radiopharmaceutical/sealed sources. The licensee is continuing to investigate the root cause and is preparing an initial fifteen day written report.

"The Department is waiting on information from the manufacturer(s) and licensee for further investigation. The Department will update this report when the licensee provides additional information."

Arkansas Event AR-2019-001

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: 53880
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GE HEALTHCARE
Region: 4
City: SAN DIEGO   State: CA
County:
License #: 5796-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: OSSY FONT
Notification Date: 02/17/2019
Notification Time: 08:25 [ET]
Event Date: 02/14/2019
Event Time: 00:00 [PST]
Last Update Date: 02/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DENNIS ALLSTON (ILTAB)
- CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST MO-99/TC-99 GENERATOR

The following is a synopsis from information received from the state of California via email.

The California radiation protection program was notified by the licensee of a partially depleted, missing Mo-99/Tc-99m generator. The generator was shipped using a commercial carrier on October 31, 2018, from the licensee's California facility to their facility in Arlington Heights, Illinois. Near the beginning of February 2019, the licensee became aware that the generator did not arrive at its destination. The commercial carrier spent the last couple of weeks searching their facilities for the missing generator with no success and has suspended the search and considering the package lost.

At the time of shipment, the generator contained 10.35 GBq (280 mCi), greater than 1000 times the 10 CFR 20 Appendix C activity for Mo-99, making it reportable under 10 CFR 20.2201(a)(1)(i). It is housed in a 12.7 kg depleted uranium shield. The package was shipped as a label category Yellow II, with a TI [transportation index] of 0.2. By November 5, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(i) reporting criteria. By November 23, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(ii) reporting criteria.

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: 53881
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNC HOSPITALS
Region: 1
City: CHAPEL HILL   State: NC
County:
License #: NC 068-0565-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/18/2019
Notification Time: 15:01 [ET]
Event Date: 02/16/2019
Event Time: 00:00 [EST]
Last Update Date: 02/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IRIDIUM 192 SEEDS LOST DURING MEDICAL TREATMENT

The following was received from the state of North Carolina via email.

"A patient underwent an Interstitial OBGYN Implantation on 2/14/19, consisting of 45 seeds of Iridium 192 (5 seeds per strand; total of 9 strands) with an activity of 34.1 mCi. The morning of 2/16/19, the patient, still located at the licensee's facility, removed the strands containing the sources, placing some in the room's trash and some in the toilet and flushed the sources. Four strands containing 20 seeds were flushed and the remainder in the room were recovered by radiation safety. The licensee confirmed surveys of the patient and room. No other sources were found. The patient room had been isolated when licensee personnel found the patient with the removed sources. The licensee's maintenance crew determined that waste pipes from the room were accessible through confined space entry via manholes to sewer system only. The NC RPS [North Carolina Radiation Protection Section] dispatched an investigator as soon as it was notified, same day. The licensee will not be pursuing the collection of these sources due to the added hazards of attempting searches in a sewer system."

North Carolina Event Tracking ID 190003

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: 53896
Facility: PERRY
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ALEX HALLMARK
HQ OPS Officer: ANDREW WAUGH
Notification Date: 02/25/2019
Notification Time: 03:44 [ET]
Event Date: 02/25/2019
Event Time: 00:24 [EST]
Last Update Date: 02/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ERIC DUNCAN (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 74 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO GENERATOR TRIP

"At 0024 EST on 2/25/19, with Unit 1 in Mode 1 at 74 percent power, the reactor automatically tripped due to a generator trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Reactor water level is being maintained via the feed system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The generator trip is under investigation, but is believed to be due to grid perturbations.

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Power Reactor Event Number: 53897
Facility: SEABROOK
Region: 1     State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: BRUCE FIELDING
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/25/2019
Notification Time: 11:59 [ET]
Event Date: 02/25/2019
Event Time: 07:04 [EST]
Last Update Date: 02/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVE WERKHEISER (R1DO)
FFD GROUP (EMAIL)
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

FITNESS-FOR-DUTY - LICENSEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL

A non-licensed, licensee supervisory employee failed a for-cause FFD test for alcohol.

The individual's authorization for site access has been denied.

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Tuesday, February 26, 2019
Tuesday, February 26, 2019