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Event Notification Report for March 20, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/19/2019 - 3/20/2019

** EVENT NUMBERS **


53925 53926 53927 53944

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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.

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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)

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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

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Power Reactor Event Number: 53944
Facility: HATCH
Region: 2     State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JASON BUTLER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/19/2019
Notification Time: 07:41 [ET]
Event Date: 03/19/2019
Event Time: 01:40 [EDT]
Last Update Date: 03/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SCOTT SHAEFFER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 1 Startup 1 Startup

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

"At 0140 [EDT] on 03/19/2019, while the unit was at approximately 1% power and 154 psig pressure in MODE 2, it was discovered that Unit 2 High Pressure Coolant Injection (HPCI) was INOPERABLE. HPCI does not have a redundant system, therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).

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

Unit 2 entered LCO 3.5.1.c for the HPCI being inoperable.

There is no effect on Unit 1.


Page Last Reviewed/Updated Wednesday, March 20, 2019
Wednesday, March 20, 2019