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Event Notification Report for April 29, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/26/2019 - 4/29/2019

** EVENT NUMBERS **


54009 54010 54011 54013 54031

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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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Agreement State Event Number: 54011
Rep Org: ALABAMA RADIATION CONTROL
Licensee: AMERICAN TESTING LABS
Region: 1
City: BESSEMER   State: AL
County:
License #: 1052
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2019
Notification Time: 11:42 [ET]
Event Date: 04/12/2019
Event Time: 06:45 [CDT]
Last Update Date: 04/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FAILURE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following report was received from the Alabama Department of Public Health Radiation Control via facsimile:

"On 4/12/19, at 0645 CDT, a radiographer was shooting in the vault at ATL [American Testing Labs], when the source became un-retractable. [The radiographer] closed the vault door and called the RSO [Radiation Safety Officer].

"The RSO arrived 45 minutes later and checked the status of the crank and the positioning of the camera in the vault. The RSO then took apart the handle of the crank and manually pulled the source through the cable into a safe position within the camera.

"The crank was serviced and the RSO found some debris within the crank. The crank was cleaned and placed back into service. After several shots, the crank was operational.

"The RSO received 24 mR on his dosimeter and the radiographer received 0 mR."

Alabama Incident #19-09

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Agreement State Event Number: 54013
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City:   State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2019
Notification Time: 15:08 [ET]
Event Date: 04/15/2019
Event Time: 00:00 [PDT]
Last Update Date: 04/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING INTRAVASCULAR BRACHYTHERAPY DEVICE IDENTIFIED

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

"UW [University of Washington] Radiation Safety (RS) conducts semi-annual sealed source leak test during the months of April and October. After analyzing a leak test for a Sr-90 Intravascular Brachytherapy (IVB) device it was found to be leaking. Details provided by the University of Washington radiation safety office are as follows:

"'The results of the sample's analysis were reviewed and it was discovered that a sample for one of the IVB source trains indicated contamination at 3737 cpm. A second sample of both IVB source trains was obtained. The sample for the 40 mm source train indicated 177 cpm and the sample for the 60 mm source train indicated 7998 cpm. The RS staff member discussed the contamination with the Radioactive Materials Compliance Manager (RMCM) and the Radiation Safety Officer (RSO). It was then discovered that the leak test procedure specified in the Novoste Beta-Cath User's Manual was not performed correctly. A swab of the water sample obtained during the leak test was analyzed rather than the whole 5 ml of water. The RS staff member performed another leak test of both IVB source trains, and analyzed the 5 ml water samples (The results are provided below). The IVB device was placed out of service and removed from Radiation Oncology. The RS staff member contacted the RSO at Best Vascular who requested the sources and items used for the leak testing be returned to Best Vascular for investigation.

"'Radiation Safety counted the 5 ml water samples using one of their liquid scintillation counters (LSC) [Packard Tricarb 2900TR - S/N 426395]. Using an efficiency of 100 percent for Sr-90 (Beckman Coulter's Isotope Booklet for Liquid Scintillation Counters - 2002) the activity calculated was:

"'40 mm source train: 396 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 6.6 Bq

"'60 mm source train: 17429 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 290 Bq

"'The activity level of the 60 mm source train leak test sample exceeded the limit of 185 Bq. The contamination in the leak test for the 40 mm source train is believed to be a result of cross contamination from the 60 mm source train leak test.'"

WA Event Report ID No.: WA-19-013

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Power Reactor Event Number: 54031
Facility: RIVER BEND
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JOHN FRALICK SR.
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/26/2019
Notification Time: 20:19 [ET]
Event Date: 04/26/2019
Event Time: 11:47 [CDT]
Last Update Date: 04/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CALE YOUNG (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

THROUGH WALL LEAK ON STANDBY LIQUID CONTROL SYSTEM PIPING

"At 1147 [CDT] on 4/26/19, a through wall leak (reported as 1 drop every 1 to 2 minutes) was identified and confirmed by operation and NDE [Non-Destructive Examination] personnel on the Standby Liquid Control injection line during pressure testing activities. The line is 1.5 inch in diameter and classified as an ASME Section Ill, Class 1 line. The leak is currently isolated from the reactor vessel by a danger tagged manual valve."

The licensee notified the NRC Resident Inspector.


Page Last Reviewed/Updated Monday, April 29, 2019
Monday, April 29, 2019