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Event Notification Report for April 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/25/2019 - 4/26/2019

** EVENT NUMBERS **


54006 54007 54009 54010 54027

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Agreement State Event Number: 54006
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TSI LABORATORIES INC.
Region: 4
City: VICTORIA   State: TX
County:
License #: RAM-L04767
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2019
Notification Time: 12:22 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On April 16, 2019, the licensee notified the Agency that one of its Humboldt model 5001-C moisture/density gauges (SN: 2076), containing 40 milliCuries americium-241/beryllium (SN: 47-6041) and 10 milliCuries of cesium-137 (SN: 40-6862), had been run over and damaged by a dump truck at a temporary job site in Danbury, Texas. While a density test was being performed and the cesium source was extended into the ground, a dump truck backed up into the test area. The technician had to jump out of the way. The truck tire ran over and shattered the housing on one side of the gauge. The source was retracted, with some difficulty, into its shielded position. Radiation surveys indicated the shielding was intact. However, the technician reported that the source rod could be pulled completely out of the top of the housing. With the source in the normal shielded position, the gauge was placed inside its transport case and returned to the licensee's facility. The licensee is making arrangements for repair/disposal. There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident: 9675

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Agreement State Event Number: 54007
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER BOSWELL MEDICAL CENTER
Region: 4
City: SUN CITY   State: AZ
County:
License #: 07-138
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2019
Notification Time: 12:52 [ET]
Event Date: 04/17/2019
Event Time: 00:00 [MST]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TRITIUM EXIT SIGNS DISMANTLED

The following report was received via e-mail:

"The Department [Arizona Department of Health Services] received notification from the licensee that they dismantled 24 tritium exit signs by removing the outer glass and aluminum housing, and then releasing the glue that held the glass ampules onto the inner plastic. The licensee said they were attempting to reduce the cost of shipping the signs for disposal. The Department has requested additional information and continues to investigate the event.

"The Licensee is:

Arizona License Number- 07-138
Banner Boswell Medical Center
10401 Thunderbird Blvd
Sun City, Arizona 85351"

Arizona Incident: 19-005

None of the vials were damaged and the wipe tests were all negative.

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Agreement State Event Number: 54009
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: ALLERION CONSULTING GROUP DBA AC&S MATERIALS TESTING
Region: 4
City: REDDING   State: CA
County:
License #: 7922-45
Agreement: Y
Docket:
NRC Notified By: ARUNIKA HEWADIKARAM
HQ OPS Officer: ANDREW WAUGH
Notification Date: 04/18/2019
Notification Time: 17:44 [ET]
Event Date: 04/18/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received via email:

"On 4/18/2019, [California Department of Public Health-Radiologic Health Branch (CDPH-RHB)] received a notification from [the California Governor's Office of Emergency Services] regarding a stolen moisture density gauge. The gauge involved is a Troxler Model 3430, S/N 31163, containing 9 mCi of cesium-137 and 44 mCi of americium-241. The gauge was stolen from an authorized user's truck parked near his residence at 1830 PDT on 4/17/2019. At the time of the incident, the device was secured in a Type A package, chained to the bed of the truck. On 4/18/2019, around 1000 PDT, the user discovered that the gauge was stolen from his vehicle. Immediately after the incident a report was filed with the Sacramento County Sherriff Office. RHB will be following up on this investigation."

CA 5010 Number: 041819

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: 54010
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT ATLANTA HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 292-1
Agreement: Y
Docket:
NRC Notified By: IRVIN GIBSON
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/18/2019
Notification Time: 18:00 [ET]
Event Date: 04/11/2019
Event Time: 00:00 [EDT]
Last Update Date: 04/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSAGE OF YTTRIUM 90 THERASPHERES

The following report was received from the Georgia radioactive materials program environmental protection division via email:

"GA 292-1 reported on Friday 4/11/19 that a misadministration of Y-90 Theraspheres occurred on 4/3/19. It was discovered that the male patient only received 65 percent of the prescribed dose. The total dose consisted of 2 vials; the first vial was administered without any issues, but the second vial was observed as still being relatively full after being returned to nuclear medicine department for disposal. A radiation survey was completed on the vials after they were returned to the nuclear medicine department and it was noted by the department personnel that vial 2 had a higher activity then what was expected. It was later determined that vial 2 contained more dose [than expected] after performing the procedure as prescribed. The remainder of the prescribed dose was delivered to the patient on 4/5/19. Preliminary results indicate there may have been an issue with the delivery equipment (perhaps with the tubing). The radioactive materials were fully accounted for and results were confirmed by performing contamination survey, following the procedure. The RSO will submit a detailed report to the radioactive materials program within 5 days of this notification.

"[On 4/18/2019] the licensee provided a written report pertaining to the event. Based on the report, no root cause has been determined at this time. The licensee suggests that the equipment can possibly be examined or sent back to the manufacturer after the radioactivity in the waste container has decreased to background levels, to determine whether any equipment defects can be found."

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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Power Reactor Event Number: 54027
Facility: SAINT LUCIE
Region: 2     State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: LOUIS ENGELKE
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 04/25/2019
Notification Time: 12:04 [ET]
Event Date: 04/25/2019
Event Time: 09:18 [EDT]
Last Update Date: 04/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
EUGENE GUTHRIE (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO TURBINE GENERATOR TRIP

"At 0918 [EDT] on 4/25/19, with [Saint Lucie] Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a Turbine Trip. The reactor trip was uncomplicated with all systems responding normally.

"Operations is maintaining the plant stable in Mode 3. Decay heat removal is being accomplished by main feed water and the main condenser using the turbine steam bypass valves.

"Unit 2 is not affected and remains at 100% power.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B).

"The NRC Resident Inspector has been notified."


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