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Event Notification Report for April 11, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/10/2019 - 4/11/2019

** EVENT NUMBERS **


53916 53969 53970 53971 53972 53974 53991

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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 TALLEY
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: 04/10/2019
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

* * * UPDATE AT 1437 EDT ON 4/10/19 FROM CHRISTOPHER TALLEY TO KARL DIEDERICH * * *

The following was received via e-mail:

"Upon review of the licensee's 30 day report, received April 5, 2019, it was noted that the dosimetry badge worn by the RSO during the retraction and transportation of the source showed no measurable dose. The dosimetry badge was new for the month of March.

"The report also contained leak test results for the sources both prior to the event, January 19, 2019, and after the event, March 6, 2019. The results for the leak tests in both instances were measured to be below 185 Bq (0.005 microCuries), considering the sources to be non-leaking sources.

"The company conducted mandatory safety meetings with all staff who work with the portable gauges and also sent a companywide e-mail to all employees as a result of the event. Topics discussed during the meetings and e-mail included radiation safety, worksite safety, portable gauge specific safety and use, emergency response procedures, and gauge security. The contractor responsible for the skid steer also conducted an on-site safety meeting immediately following the event on March 5, 2019.

"The Department now considers this event to be closed providing that no new information is received by the Department."

Notified R4DO (Werner) and NMSS Events (via e-mail).

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Agreement State Event Number: 53969
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: PARSONS
Region: 1
City: CAMILLUS   State: NY
County:
License #: NYS G5571
Agreement: Y
Docket:
NRC Notified By: NATHANIEL KISHBAUGH
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/02/2019
Notification Time: 13:47 [ET]
Event Date: 03/15/2019
Event Time: 16:00 [EDT]
Last Update Date: 04/02/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSC (CANADA) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGES

The following was received via fax:

"The Radiation Safety Officer [RSO] for Parsons called to report that four (4) generally licensed fixed slurry moisture gauges were missing. Each gauge contained 90 microCuries of cesium-137. All devices were of Ronan Engineering RLL-1 1619 5L2A3 make and model, and sources were of Ronan SRC-PT-CS-90UCL make/model. The device serial nos. are: DX-520 with source s/n DE-520; DX-814 with source s/n DE-814; DX-816 with source s/n DE-816; and DX-818 with source s/n DE-818. These sources were inadvertently left at 522 Gerelock Road, Camillus, New York 13031 following completion of extensive contract work for Honeywell International. The sources were identified as lost by the RSO on March 15, 2019, at 1600 EDT. These sources were not found upon the RSO's return to the Camillus facility, and the RSO reported the lost sources to NYSDOH [New York State Department of Health] on March 18, 2019, at 0830 EDT. Parsons will be contacting Honeywell International and other contractors at this facility to locate the missing sources. NYSDOH Incident number 1272 assigned to track this event."

New York Event Report ID No.: NY-19-01

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: 53970
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS GROUP
Region: 4
City: LONG BEACH   State: CA
County:
License #: 4832-19
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/02/2019
Notification Time: 18:39 [ET]
Event Date: 04/01/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/02/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANDREA KOCK (NMSS)
SILAS KENNEDY (IRD)
JIM WHITNEY (ILTAB)
This material event contains a "Category 2" level of radioactive material.

Event Text

LOST THEN FOUND CATEGORY 2 RADIOGRAPHY EXPOSURE DEVICE

The following information was received via E-mail:

"The licensee RSO [Radiation Safety Officer] reported that a Mistras technician lost an INC IR-100 radiography camera, serial number 6744, on April 1, 2019, between approximately 0000 and 0100 PDT. The camera contained an Ir-192 sealed source, number 159E, with 85.3 curies.

"The radiography camera was left unsecured on the tailgate of a company darkroom vehicle upon departing the licensee's Long Beach office. The camera was being transported to the Chevron refinery in El Segundo for radiographic operations during the night. The lost camera was reported to the Long Beach office (at approximately 0110 PDT) by the technician upon arrival at the El Segundo refinery, and a radiography crew was sent from the Long Beach office to search the route taken by the first individual. The camera was found and recovered by the radiography crew approximately 0130 PDT on the breakdown lane of limited-access CA Hwy 91 westbound, approximately 4 miles from the Long Beach facility (near Wilmington Ave).

"The recovered radiography camera was returned to the Long Beach facility, where a leak test was performed, showing no leakage. The radiography camera was sent to a repair facility for further inspection. RHB [Radiation Health Branch] will investigate the cause of the incident, take appropriate enforcement action, and ensure appropriate corrective actions by the licensee."

California 5010 Number: 040119

Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC.

Notified External via E-mail and/or FAX: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC.


THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 53971
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UMASS MEMORIAL HEALTH CARE
Region: 1
City: WORCHESTER   State: MA
County:
License #: 60-0096
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 04/03/2019
Notification Time: 12:25 [ET]
Event Date: 04/02/2019
Event Time: 10:42 [EDT]
Last Update Date: 04/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE ADMINISTRATION OF Y-90 MICROSPHERES

The following was received from the Commonwealth of Massachusetts via e-mail:

"On 4/2/19, 1430 EDT, the licensee reported a medical event involving Nordion TheraSpheres (SS&D NR-0220-D-131-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-vial Y-90 62 mCi (13 mCi and 49 mCi vials) microsphere therapy treatment delivered to the patient's liver on 4/2/19 was stuck in the catheter causing delivery of approximately 37 mCi Y-90. This was discovered immediately after treatment. The administered dose to the treatment area differed from the prescribed dose by approximately 40 percent. The licensee stated that the primary cause was an equipment malfunction. The first vial of 13 mCi was delivered fully, but only 24 mCi of the second vial containing 49 mCi was actually administered to the patient. The prescribing physician, referring physician and patient have been notified. The licensee stated that there were no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment will be required. Corrective actions will include removal of the suspect equipment (catheter) and return of said equipment to the manufacturer for evaluation. A larger diameter catheter will be used during future therapy treatments. The licensee will submit a written report within 15 days of the discovery date. Agency on-site investigation is pending. This is a next day reportable medical event per regulations.

"Investigation ongoing. Agency considers this event docket to still be OPEN."

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: 53972
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: BAPTIST HEALTH LEXINGTON
Region: 1
City: LEXINGTON   State: KY
County:
License #: 202-004-27
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: JIM DRAKE
Notification Date: 04/03/2019
Notification Time: 13:40 [ET]
Event Date: 03/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- ELUATE EXCEEDED BREAKTHROUGH LIMITS ON RUBIDIUM - 82 GENERATOR

The following was received from the State of Kentucky via fax.

"On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO [Radiation Safety Officer] was notified and the hospital was instructed to discontinue use."

Kentucky Event Report ID No.: KY190003

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: 53974
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NRD, LLC
Region: 1
City: GRAND ISLAND   State: NY
County:
License #: NYS C1391
Agreement: Y
Docket:
NRC Notified By: DESMOND GORDON
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/03/2019
Notification Time: 17:09 [ET]
Event Date: 04/01/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MATT YOUNG (R1DO)
ANDREA KOCK (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POSSIBLE INTERNAL OVEREXPOSURE

The following was received from the State of New York via fax:

"The Radiation Safety Officer [RSO] of NRD, LLC, called to report an incident in which three individuals may have been exposed to Americium-241. NRD, LLC has a specific radioactive material license with the NYS [New York State] Department of Health to Manufacture Radioactive Products. Below is a brief description of the information reported so far.

"On Monday [4/1/19] evening an individual (Person1) was trying to clean up a 'small rusty contamination' in the change area using a HEPA vac. The vacuum was previously used in a different area (Silver Recovery) area to clean up Americium-241 metal. He turned on the vacuum and noticed it was blowing stuff out. He turned it off and told a second individual (Person 2) to shut the doors. After doing so, Person 2 went into another room. During this time the RSO (Person 3) was notified. Person 3 'stuck his head in the room for a minute.' Person 1 and person 2 were in the area for about a minute. Person 1 was in the area for approximately 20 minutes.

"The reading on a nose swab done on Person 1 read 6600 dpm [see update below]. After his clothing was removed and he took a shower and blew his nose, a second swab was done. The reading on the those swabs were 4884 dpm (right nostril), 1729 dpm (left nostril). On day 2 a third set of swab were done with the following reading: 67 dpm (right nostril), 36 dpm (left nostril).

"The lab remains closed and there is no work being done. They are trying to set up an access control point to enter the lab.

"The RSO indicated he was in communication with REACTS [Radiation Emergency Assistance Center/Training Site]. They suggested the Person 1 and Person 2 see their medical doctors. The bioassays collected were going out today, Wednesday, April 3, 2019.

"Based on the results reported for the initial nose swab, this incident is reportable under 10 CFR 20.2202(a)(1). NYSDOH [New York State Department of Health] Incident No. 1278 has been assigned to track this event."

New York Event Report ID No.: NY-19-04

Exposure to person 1 may have resulted in an intake five times the occupational Annual Limit on Intake (ALI).

* * * UPDATE ON 4/4/19 AT 1055 EDT FROM DESMOND GORDON TO BETHANY CECERE * * *

The initial report was incorrect for the nose swab done on person 1 - it read 66,000 dpm, not 6,600 dpm.

Notified R1DO (Young), and NMSS_Events_Notification email group.

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Power Reactor Event Number: 53991
Facility: WATERFORD
Region: 4     State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: DAVID LITOLFF
HQ OPS Officer: JEFFREY WHITED
Notification Date: 04/11/2019
Notification Time: 10:28 [ET]
Event Date: 04/11/2019
Event Time: 02:00 [CDT]
Last Update Date: 04/11/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GREG WERNER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM ENVELOPE INOPERABLE DUE TO DOOR HANDLE DETACHING

"On April 11, 2019, at 0200 CDT the shift operating crew declared the control room envelope inoperable in accordance with Technical Specification (TS) 3.7.6.1 due to the door handle for Door 86 (H&V Airlock Access Door) being detached. Operations entered TS 3.7.6.1 action b, which requires that with one or more control room emergency air filtration trains inoperable due to inoperable control room envelope boundary in MODES 1, 2, 3, or 4, then: 1. Immediately initiate action to implement mitigating actions; 2. Within 24 hours, verify mitigating actions ensure control room envelope occupant exposures to radiological, chemical, and smoke hazards will not exceed limits; and 3. Within 90 days, restore the control room envelope boundary to OPERABLE status. Action b.1 was completed by sealing the hole in Door 86 at 0232 CDT. This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), 'event or condition that could have prevented fulfilment of a safety function of structures or systems that are needed to (D) mitigate the consequences of an accident,' due to the control room envelope being inoperable.

"The licensee notified the NRC Resident."


Page Last Reviewed/Updated Thursday, July 11, 2019
Thursday, July 11, 2019