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Event Notification Report for March 19, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/18/2019 - 3/19/2019

** EVENT NUMBERS **

Agreement State	Event Number: 53916
Rep Org: ARKANSAS DEPARTMENT OF HEALTH Licensee: GTS, INC. Region: 4 City: ROGERS State: AR County: License #: ARK-0995-03121 Agreement: Y Docket: NRC Notified By: CHRISTOPHER HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/08/2019 Notification Time: 09:50 [ET] Event Date: 03/05/2019 Event Time: 00:00 [CST] Last Update Date: 03/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE DESTROYED WHEN RUN OVER

The following was received from the Arkansas Department of Health via e-mail:

"The Department [Arkansas Department of Health Radioactive Materials Program] received notification on March 5, 2019, from licensee GTS, Inc. that a Troxler gauge model 3440 [serial number: 73390, 40mCi Am-241, 8 mCi Cs-137] had been struck by a skid steer while performing routine measurements at a road construction site. As a result of the incident, the source had been pulled from its testing position and become partially exposed.

"Upon review of the event, it was noted that the technician quickly created a thirty (30) foot containment barrier and notified his company's Radiation Safety Officer [RSO]. The [RSO] for GTS mobilized to the event location and contacted the [Department].

"Upon receiving an exemption from the Department, the RSO was able to manipulate the source into the shielded position and place the remnants into the transportation container for transport to the permanent storage location. The gauge was returned to the permanent storage location at approximately 1330 [CST] on March 5, 2019. The licensee performed leak tests of the sources, surveys of the gauge transport container, and surveys of the storage location.

"[Department] inspectors visited the licensee on March 6, 2019, to investigate the event. Surveys at the exterior of the transport container were determined to be 3-5 mR/hr. Surveys performed inside of the transport container were measured to be a maximum of 15 mR/hr at a location close to the surface of the shielded source.

"The [Department] considers this investigation open pending receipt and review of the licensee's 30 day report"

State of Arkansas Event Report No. : AR-2019-002

Agreement State	Event Number: 53917
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: KELLER, SCHLEICHER, MACWILLIAM ENGINEERING & TESTING Region: 1 City: SEBASTIAN State: FL County: License #: FL 3686-1 Agreement: Y Docket: NRC Notified By: MATT SENISON HQ OPS Officer: BETHANY CECERE	Notification Date: 03/08/2019 Notification Time: 15:15 [ET] Event Date: 03/08/2019 Event Time: 11:30 [EST] Last Update Date: 03/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ART BURRITT (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) JEFFERY GRANT (IRD)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following is a synopsis of an email from the state of Florida:

A nuclear density gauge (CPN Model: MC-1 Elite, Serial number: 30803) was not secured properly on the licensee's transport truck and released during a traffic accident with a passenger vehicle at the intersection of Knotty Pine Road and US-192 in West Melbourne, FL. The truck was on its way to a job site for further testing.

Brevard County Fire and Rescue HazMat teams and the Brevard County Emergency Management radiological coordinator responded to the scene. The 10 mCi Cs-137 source separated from the gauge housing, but the 50 mCi Am/Be source was intact. No injuries or fatalities were reported. No evacuations were reported, however a 15 ft. perimeter was established around the material until surveys were completed. Surveys were 592 mR/hour at 1 inch, 23 mR/hour at 1 foot, and there was no removable contamination detected. There was no release of radioactive material during this event, and the personnel who picked up the item were surveyed and cleared.

The sources were secured by the licensee, placed in a transport case (with added shielding), and taken to their permanent storage location in Sebastian. The licensee will return the gauge to CPN for repair or replacement.

Florida Incident Number: FL19-033.

Agreement State	Event Number: 53919
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: TAMKO BUILDING PRODUCTS INC Region: 4 City: DALLAS State: TX County: License #: GLA 02152 Agreement: Y Docket: NRC Notified By: MATTHEW KENNINGTON HQ OPS Officer: JEFF HERRERA	Notification Date: 03/08/2019 Notification Time: 16:59 [ET] Event Date: 03/08/2019 Event Time: 00:00 [CST] Last Update Date: 03/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE SHUTTER FAILED TO OPEN COMPLETELY

The following report was received from the Texas Department of State Health Services via email:

"On March 8, 2019, a licensee reported to the Agency [Texas Department of State Health Services] that a shutter on a fixed nuclear gauge failed to open completely. The gauge is a Thermo Fisher Scientific model SCL-1C, serial number UM900, containing 100 milliCuries of strontium-90. No individuals received any exposure due to this equipment failure. The manufacturer has repaired the gauge and the shutter now functions as intended."

Texas Incident #: 9662

Agreement State	Event Number: 53920
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: A&R ENGINEERING AND TESTING INCORPORATED Region: 4 City: HOUSTON State: TX County: License #: L05318 Agreement: Y Docket: NRC Notified By: MATTHEW KENNINGTON HQ OPS Officer: JEFF HERRERA	Notification Date: 03/08/2019 Notification Time: 17:50 [ET] Event Date: 03/08/2019 Event Time: 00:00 [CST] Last Update Date: 03/08/2019
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 - MOISTURE DENSITY GAUGE RECOVERED BY FIRE DEPARTMENT

The following report was provided by the Texas Department of State Health Services via email:

"On March 8, 2019, the Agency [Texas Department of State Health Services] was notified by the Houston Fire Department that they had recovered a moisture density gauge belonging to a Texas licensee. The gauge contained 10 milliCuries of cesium-137 and 40 milliCuries of americium-241. The Agency has not yet been notified by the licensee about this loss. Investigation is ongoing. Updates will be provided in accordance with SA-300."

Texas Incident #: 9663

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: 53925
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: St. LUKES HOSPITAL - NORTH CAMPUS Region: 1 City: BETHLEHEM State: PA County: License #: PA-0073 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/11/2019 Notification Time: 10:17 [ET] Event Date: 02/13/2019 Event Time: 00:00 [EDT] Last Update Date: 03/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRED BOWER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSAGE TO PATIENT DURING I-131 TREATMENT

The following was received from the state of Pennsylvania:

"On 2/13/19, a patient was administered 171 milliCuries (mCi) of liquid iodine 131 (I-131) through a feeding tube inserted into the patient's gastric tube as he was unable to swallow I-131 in pill form. While flushing the feeding tube with saline, a technologist noticed a pool of liquid next to the patient on a disposable drape, on the patient, and on the imaging table, that was determined to be radioactive. The feeding tube was removed from the gastric tube, and flushed, without any further leaking. All non-essential personnel were cleared from the room and the nuclear medicine staff contained the spill, decontaminated the patient and the site. All radioactive trash was contained in a lead-lined storage drum and secured. No hospital personnel were contaminated during this event. The licensee reported that given the I-131 dose was diluted with saline, the total amount of I-131 that was spilled could not be determined at the time of the event. In an effort to determine the activity and dose the licensee surveyed all contaminated items in their storage drum. Using this data and conservative decay calculations the licensee estimates 97.2 mCi was spilled. This resulted in an under-dose of 56.8 percent. The patient is scheduled for another administration to complete the therapy. The DEP [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] will update this event as soon as more information is provided."

Pennsylvania Event Report Number: PA190007

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.

Agreement State	Event Number: 53926
Rep Org: OREGON HEALTH AUTHORITY Licensee: OREGON WASHINGTON LABORATORIES, LLC Region: 4 City: PORTLAND State: OR County: License #: ORE-91149 Agreement: Y Docket: NRC Notified By: DARYL LEON HQ OPS Officer: CATY NOLAN	Notification Date: 03/11/2019 Notification Time: 13:55 [ET] Event Date: 03/05/2019 Event Time: 00:00 [PDT] Last Update Date: 03/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEREMY GROOM (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST IR-192 SOURCE

The following is a summary of the phone call with the state of Oregon:

On March 5, 2019, the licensee realized that a 9.4 Curie Ir-192 industrial radiography source was missing when the scheduled shipment was not received on March 4, 2019. Last known location was Memphis, TN on March 1, 2019.

* * * UPDATE AT 1110 EDT ON 3/13/2019 FROM DARYL LEON TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"On March 11 at 11:38 AM (PDT), the licensee (OWL) emailed and stated that the lost package and source have been found after an extended telecon (1 hour) with the carrier. No location given in email but a statement that [the common carrier] had held the shipment because they needed a copy of the shipping papers to send it on to its destination (QSA in Baton Rouge, LA). OWL emailed a copy of the shipping papers to [the common carrier] and the package was released to continue on to QSA.

"On March 12 at 9:15 AM (PDT), [the state of Oregon] contacted the licensee (OWL) by phone. The package and source were found by [the common carrier] in their Memphis, TN shipping center. [The common carrier] did not have shipping papers for the package when received in Memphis and placed it into their 'Overgoods' department where 'lost dangerous goods' are taken and held if there is a paperwork issue preventing a shipment from continuing on its way. The package in this case was released on March 11th as previously indicated and arrived at QSA in Baton Rouge at 10:02 AM (CDT)."

Notified the R4DO (Groom), and NMSS Events Resource and ILTAB (via e-mail).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

Agreement State	Event Number: 53927
Rep Org: LOUISIANA DEPT OF ENV QUALITY Licensee: GEORGIA PACIFIC CONSUMER PRODUCTS, LLC Region: 4 City: ZACHARY State: LA County: License #: LA-2162-L01, AI #2617 Agreement: Y Docket: NRC Notified By: JOSEPH NOBLE HQ OPS Officer: BETHANY CECERE	Notification Date: 03/11/2019 Notification Time: 15:17 [ET] Event Date: 03/11/2019 Event Time: 13:30 [CDT] Last Update Date: 03/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEREMY GROOM (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK IN OPEN POSITION

The following was received by email from the state of Louisiana:

"On 03/11/2019, Georgia Pacific Consumer Products [GA-PAC] Port Hudson Operations was shutting down a process to perform a disposal decommission maintenance. In the process of securing the radiation sources for shipping and disposal, it was then discovered the shutter [on a level density gauge] would not close.

"GA-PAC has called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. GA-PAC will have BBP Sales determine the proper disposal for this device. The device was manufactured in 1967.

"The sources and device with shutter failure will be sent for disposal and not replaced. GA-PAC is decommissioning this unit. This is not a radiation exposure hazard and does not pose a health and safety situation for the GA-PAC employees or the general public.

"THIS EVENT IS CONSIDERED CLOSED BY LDEQ. This event is being reported to the NRC as required by Regulatory Requirement 10 CFR Part 30.50 (b) (2) & LAC 33:XV341.B."

The Gauge is an OHMART HM8 device/source holder, S/N 6563 with a 100 mCi Cs-137 source.

LA Event Report ID No.: LA-190003

Page Last Reviewed/Updated Wednesday, March 24, 2021