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Event Notification Report for May 10, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/9/2019 - 5/10/2019

** EVENT NUMBERS **


54041 54042 54054 54055 54060

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Agreement State Event Number: 54041
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGAN   State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/02/2019
Notification Time: 14:47 [ET]
Event Date: 12/06/2016
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - I-125 APPLICATOR LEAK TEST FAILURE

The following was received via e-mail:

During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined.

"While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the [Radiation Safety Officer] RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage."

This indicates that the device failed a leak test, which is a reportable event.

* * * UPDATE ON 05/10/2019 AT 1108 EDT FROM JOSEPH ROSS TO JEFFERY HERRERA * * *

"On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab.

"There is no indication of contamination in the operating room surveys or any expected uptake by the patient."

Notified R3DO (Stoedter) and NMSS Events (via email).


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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Non-Agreement State Event Number: 54042
Rep Org: INTERNATIONAL ISOTOPES, INC.
Licensee: INTERNATIONAL ISOTOPES, INC.
Region: 4
City: IDAHO FALLS   State: ID
County:
License #: 11-27680-01MD
Agreement: N
Docket:
NRC Notified By: JOHN MILLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/03/2019
Notification Time: 01:02 [ET]
Event Date: 05/02/2019
Event Time: 21:30 [MDT]
Last Update Date: 11/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
WILLIAM GOTT (IRD)
ANDREA KOCK (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNPLANNED CONTAMINATION EVENT DUE TO BREACHED CS-137 SOURCE

The Radiation Safety Officer (RSO) at International Isotopes, Inc. reported that at 2130 PDT on 5/2/19, while changing out the Cs-137 source on a research irradiator, they breached the source which resulted in widespread contamination and a possible uptake event. The irradiator is a JL Shepard Mark 168A and is located at the Harborview Research and Training Facility at the University of Washington in Seattle, WA. International Isotopes, Inc. is an NRC licensee working under reciprocity in the State of Washington (an agreement state).

After discovery of the breach, the immediate area was isolated, the building was ordered evacuated, and the ventilation was secured. Indications are that the seven members of the source retrieval team were externally and potentially internally contaminated.

The State of Washington was notified. The University of Washington RSO was sending response teams to the area. A local hazardous material team is on site.

The source was reported to be 2800 Ci.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATE ON 05/03/2019 AT 1545 EDT FROM TRISTAN HAY TO JEFFREY WHITED * * *

The following update was received via E-mail from the Washington State Department of Health:

"University of Washington (UW) was having their research irradiator (Mark-1 SERIES / Cs-137) disposed of by International Isotopes (NRC License 11-27680-01MD). The Agreement state regulators were present to verify dose measurements and observe ALARA practices. During the source removal and transfer into the transport shielded cask, there was a breach of the sealed source and a small portion of the source was released into the working area. The working area was comprised of the irradiator unit, the shielded containment rig, the loading dock, a 100 feet radius around the loading dock, and the Harborview Research and Technology Center floors 1-3 and stair well. The source was encapsulated with International Isotopes' source housing capsule. A breach was identified during the precursor wipe survey performed prior to putting it into the source housing unit. Once contamination was identified, all personnel performed area contamination surveys and secured and taped off the work space area. All personnel who were present at some point during the transfer were notified of the potential contamination and were given special instructions to return to the Harborview Medical Center area for decontamination.

"Simultaneously the NRC, Washington Radiation Emergency Hotline, and the [National Materials Event Database] NMED were notified of the situation by International Isotopes immediately after the incident occurred. Seattle Fire and Seattle Hazmat units were dispatched to the scene to assess the situation and begin decontamination protocols. The International Isotope workers, UW RSO, FBI agent, and other present workers were decontaminated and placed in a contained area of the Harborview Medical Center Emergency Room. Bioassay samples were collected from urine and blood from the contaminated individuals."

Additionally, employees from the State of Washington who responded to the event were surveyed, with the highest level of contamination being 300 cpm on the individual's shoes.

Washington State Licensee: University of Washington
Washington Agreement State License No. C001
Event Report ID No.: WA-19-015

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATE ON 05/04/2019 AT 2136 EDT FROM JOHN MILLER TO JEFFREY WHITED * * *

The following update is a synopsis of information received via E-mail from International Isotopes:

In its E-mail, the licensee provided an initial incident report regarding the breached Cs-137 source incident that occurred during the removal of the source from the Research Irradiator at the Harborview Training and Research Building. The licensee provided a summary of planned work, a summary of the incident, a summary of the whole-body exposures received by International Isotopes and contractor employees, a summary of initial personnel skin contamination results, a summary of post-decontamination personnel skin contamination results, and a summary of recovery actions taken to date.

According to its assessment, the licensee indicated that the highest whole-body exposure to any one individual was 55 mrem. The majority of surveys taken at the loading dock level indicated that surfaces were contaminated in the 50,000 - 300,000 cpm range.

The summary of recovery actions taken to date are as follows:

International Isotopes hired a contractor to perform decontamination and remediation of the affected areas. The Department of Energy, Region 8, Radiological Assistance Program team surveyed the building floors. International Isotopes employees surveyed the parking lot area where emergency response operations took place reducing the size of the controlled area, marking spots with identified levels. The loading dock area was further isolated from the building by covering outdoor louvers and double door between corridor and loading dock with heavy plastic. International Isotopes remains on-site to support the contractor and the University of Washington by performing assessment surveys and development of the decontamination and recovery plan.

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Kock), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE AT 1648 EDT ON 05/16/2019 FROM JOHN MILLER TO JEFF HERRERA * * *

"This report provides an update to the May 2, 2019 incident involving the breached Cs-137 source.

"International Isotopes Inc. (INIS) performed dose estimates based on 24 hour urine samples collected from the INIS employees that were involved in the incident.

"There were seven INIS individuals involved, the INIS estimates are provided in the table below. Note that individuals 6 and 7 are not included in the LANL Report as their urine sample results were released later. These sample results have since been provided to LANL.

"Name; Time Between intake and sample (days); Concentration (pCi/L); Modeled Intake (uCi); Percent ALI; CED (mRem)

"Individual 1: 1.625; 15,700; 2.284; 1.142 Percent; 57.1
Individual 2: 1.396; 6,100; 1.235; 0.618 Percent; 30.9
Individual 3: 1.698; 1,280; 0.186; 0.093 Percent; 4.7
Individual 4: 1.665; 8,540; 1.242; 0.621 Percent; 31.1
Individual 5: 1.697; 19,800; 2.880; 1.440 Percent; 72.0

"Individual 6: 1.687; 5,540; 0.806; 0.403 Percent; 20.1
Individual 7: 1.437; 4,110; 0.624; 0.312 Percent; 15.6"

Notified R4DO (Proulx), IRD MOC (Kennedy), NMSS (Rivera Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 05/20/2019 AT 1050 EDT FROM STEVE LAFLIN TO THOMAS KENDZIA * * *

The following update is a synopsis of information received via email from International Isotopes:

International Isotopes provided a detailed update on internal and whole body doses, skin contamination and decontaminated results for the affected seven individuals. The highest internal dose was 57.1 mrem for individual 1, the highest whole body dose was 55 mrem for individual 7, and the highest dose to the skin from skin contamination was 36 mrem to individuals 3 and 4. Blood sampling of the individuals showed no changes due to radiation.

Facility decontamination continues. International Isotope management is in the process of conducting a detailed investigation in order to determine the direct, contributing, and root causes of this event.

Notified R4DO (Gepford), IR MOC (Kennedy), and NMSS Events Notification via e-mail.

* * * UPDATE ON 7/25/2019 AT 1228 EDT FROM TRISTAN HAY TO ANDREW WAUGH * * *

The following update is a synopsis of an email from the Washington State Department of Health:

In this update the state of Washington provided detailed corrective actions taken and planned for this event and gave the status of current decontamination efforts. The update also states that one of the impacted employees was a University of Washington employee and not a contractor as previously stated.

Notified R4DO (Taylor), IR MOC (Gott), and NMSS Events Notification (email).

* * * UPDATE ON 11/19/2019 AT 1809 EST FROM STEVE LAFLIN TO THOMAS KENDZIA * * *

The following update is a synopsis of information received via email from International Isotopes:

International Isotopes (INIS) has completed their portions of the facility decontamination, which is now being run by the Department of Energy (DOE) and Los Alamos National Laboratory. INIS continues to support the DOE accident investigation. INIS investigation report will be delayed until after the DOE Accident Investigation Board report.

Notified R4DO (O'Keefe), IR MOC (Kennedy), and NMSS Events Notification (email).

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Power Reactor Event Number: 54054
Facility: DRESDEN
Region: 3     State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: RICK GALLAGHER
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/09/2019
Notification Time: 07:01 [ET]
Event Date: 05/09/2019
Event Time: 03:48 [CDT]
Last Update Date: 05/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
KARLA STOEDTER (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO TURBINE TRIP

"On May 9, 2019 at 0348 CDT, an automatic scram was received on Unit 2 following a turbine trip.

"All rods inserted to their full-in positions.

"All Group 2 and Group 3 automatic isolations actuated as expected. Systems operated as expected.

"Reactor vessel inventory and pressure are being maintained in normal control bands.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical.

"The NRC Resident Inspector has been notified."

Decay heat is being removed using the steam bypass valves to the condenser and the safety relief valves did not lift as a result of the trip.

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Power Reactor Event Number: 54055
Facility: SUSQUEHANNA
Region: 1     State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEVEN KOCH
HQ OPS Officer: ANDREW WAUGH
Notification Date: 05/09/2019
Notification Time: 13:51 [ET]
Event Date: 05/09/2019
Event Time: 09:16 [EDT]
Last Update Date: 05/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MEL GRAY (R1DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

EMPLOYEE SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the site has been terminated.

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 54060
Facility: DRESDEN
Region: 3     State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: SCOTT BRILEY
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/10/2019
Notification Time: 15:30 [ET]
Event Date: 05/10/2019
Event Time: 07:20 [CDT]
Last Update Date: 05/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KARLA STOEDTER (R3DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 0
3 N N 0 0

Event Text

PROHIBITED SUBSTANCE INSIDE THE PROTECTED AREA

"At 0720 CDT [on 5/10/19], security was notified of a prohibited item (un-opened alcohol container) reported in the protected area. Security assumed escort of the non-supervisory [contract] individual and took custody of the prohibited item."

The employee's access to the plant has been suspended.

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Monday, May 11, 2020
Monday, May 11, 2020