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Event Notification Report for February 27, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/26/2019 - 2/27/2019

** EVENT NUMBERS **


53881 53882

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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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Agreement State Event Number: 53882
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BLUE CUBE SOLUTIONS, LLC
Region: 4
City: PLAQUEMINE   State: LA
County:
License #: LA-13286-L01AI#196702
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/19/2019
Notification Time: 11:32 [ET]
Event Date: 02/18/2019
Event Time: 00:00 [CST]
Last Update Date: 02/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEVEL DENSITY GAUGE SHUTTER MALFUNCTION

"On 02/18/2019, BCS [Blue Cube Solutions] was performing their routine operational checks of their RAM LICENSED devices. During their routine maintenance checks, the shutter malfunction was discovered. The gauge shutter would not close. BCS called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem.

"The sources and device with the shutter stuck open will remain installed on the process until the repairs are made. This is not a radiation exposure hazard and does not pose a health and safety situation for the BCS employees or the general public.

"The Level Gauge is a KAY RAY Model 7062B device/source holder, S/N KR23306B, loaded with an approximately 100 mCi Cs-137 source.

"LDEQ [Louisiana Department of Environmental Quality] was notified when BCS called the LDEQ Radiation Emergency Hot Line at 0800 CST. The notice was forwarded to the LDEQ/ERSD/Radiation Section. The notification was to get the preliminary information report and meet the 24 hour reporting requirement. Additional information will be provided when available. BCS will provide LDEQ a corrective action and a final report no later than 30 days of the corrective action.

"This event is being reported to the NRC OPERATIONS CENTER as required by Regulatory Requirements 10 CFR Part 30.50(b)(2) & LAC 33:XV 340.B."

Louisiana report LA-190002.


Page Last Reviewed/Updated Wednesday, February 27, 2019
Wednesday, February 27, 2019