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Event Notification Report for May 13, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/10/2019 - 5/13/2019

** EVENT NUMBERS **


54041 54042 54043 54044 54045 54048 54050 54060 54061 54062

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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



EN Revision Imported Date : 5/13/2019

EN Revision 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: 05/05/2019
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).

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Agreement State Event Number: 54043
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: NEW-INDY CONTAINERBOARD, LLC
Region: 1
City: CATAWBA   State: SC
County:
License #: 030
Agreement: Y
Docket:
NRC Notified By: ANDREW ROXBURGH
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/03/2019
Notification Time: 10:55 [ET]
Event Date: 05/03/2019
Event Time: 06:00 [EDT]
Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIN CARFANG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BROKEN SHUTTER

The following was received via e-mail:

"On May 3, 2019, the Department [South Carolina Department of Health and Environmental Control] was notified by the licensee that a shutter had broken on one of its gauges while attempting to close the shutter because of a sprinkler failure that was soaking the area where the gauge was mounted. The gauge is a Kay-Ray Model 70628 containing 10 mCi of Cesium 137. The licensee has contacted Systems Services who is specifically licensed to repair the damaged shutter. The [Radiation Safety Officer] RSO stated that he has performed a radiation survey around the gauge where individuals normally work and the radiation readings are background. Access to the gauge has been restricted and the area has been roped off by the RSO until the service provider comes to fix the shutter. The service provider is scheduled to come May 7, 2019."

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Agreement State Event Number: 54044
Rep Org: ALABAMA RADIATION CONTROL
Licensee: FMC
Region: 1
City: AXIS   State: AL
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/03/2019
Notification Time: 11:10 [ET]
Event Date: 05/02/2019
Event Time: 14:41 [CDT]
Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIN CARFANG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was received via fax:

"On May 2, 2019, at approximately 1441 CDT, [an employee] of Alabama general licensee FMC in Axis, AL notified the Alabama Office of Radiation Control [the Agency] that the leak test results from an [electron capture detector] ECD/gas chromatograph source indicated that the source was leaking (results of 1 microCurie). [The employee] stated that the source was not in use, had been in storage for years, that FMC was preparing the source for transfer/disposal, and that FMC is working with Agilent to prepare the source for shipping.

"The Agency did not collect identifying source information before submission of this event. However, the Agency's records indicate that FMC possesses 15 mCi nickel-63 sources only."

Alabama Event 19-11

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Agreement State Event Number: 54045
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: MOSES CONE HOSPITAL
Region: 1
City: GREENSBORO   State: NC
County:
License #: 041-0021-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/03/2019
Notification Time: 15:30 [ET]
Event Date: 05/02/2019
Event Time: 00:00 [EDT]
Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIN CARFANG (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - I-125 SEED LOST

The following information was received via e-mail:

"On 5/1/19 a patient had two [radioactive seed localization] RSL seeds [200 microCuries; I-125] implanted. The same patient returned the following day for an explant procedure. At that time, it was discovered that one seed was missing from the patient. The licensee confirmed through recorded imaging, consultation with the surgeon, patient surveys, and detailed surveys of the implant site and the explant site that the most likely area where the seed was lost was somewhere in between when the patient left the implant site and returned to the explant site the following day. North Carolina Radioactive Materials Branch has started an investigation that is ongoing at this time.

"This event is reportable per 20.2201(a)(1)(ii) - Lost, stolen, or missing licensed material in a quantity greater than 10 times the Appendix C quantities."

North Carolina Tracking ID: NC 190016

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: 54048
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SANTA CLARA HOSPITAL
Region: 4
City: SAN JOSE   State: CA
County:
License #: 0741
Agreement: Y
Docket:
NRC Notified By: JOHN FASSELL
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/03/2019
Notification Time: 18:37 [ET]
Event Date: 05/03/2019
Event Time: 00:00 [PDT]
Last Update Date: 05/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - Y-90 UNDERDOSAGE REPORT

The following was received via e-mail:

"At 1138 PDT on 05/03/2019, the [California Radiation Control Program] received a phone call from the licensee's [Radiation Safety Officer] RSO providing the initial report on a Y-90 radioembolization underdose. Only 76 percent of the planned dose was provided to the organ of interest with the rest having leaked out because of a faulty stopcock assembly. The leak area was contained and cleaned up. All decontamination is complete and the only effect is the underdose to the patient."

CA 5010 Number: 050319

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: 54050
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE   State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: DAVID TORRES
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/05/2019
Notification Time: 21:53 [ET]
Event Date: 05/05/2019
Event Time: 00:18 [YDT]
Last Update Date: 05/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

STUCK RADIOGRAPHY CAMERA SOURCE

The following information was received via E-mail:

"At approximately 0018 YDT on 5/5/2019, a Kakivik radiographic crew working in Alpine, Alaska on drill site CD-4, could not retract a source under normal conditions. Once this was identified the crew initiated emergency procedures by establishing 2mR boundaries and making notifications per O&E procedures. The crew was using a QSA Global 880D device with a model A424-9, 44.6, Ci Ir-192 source along with a 10HVL collimator. The crew had made 15 exposures. The last exposure is when the Radiographer noticed a sudden stop from the drive cable during his retraction and that is what initiated the emergency procedures. At approximately 0308 YDT the source was locked and secured in the 880D device. It was determined that the guide tube was draped low in a 'W' shape at the guide tube extension point which was preventing the source from coming in under normal conditions. The cranks were straightened and a pole was used to raise the guide tube at the extension connection point and the source was retracted in normal conditions. No one was over-exposed and the boundaries were placed at such a distance that the crew and public were safe. It was a four man crew, two of whom received 0mR and the Radiographer and Assistant received 11mR and 8mR, respectively. The emergency response team members received 1mR (two of them) and 3mR (two of them)."

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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.

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Power Reactor Event Number: 54061
Facility: CALLAWAY
Region: 4     State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: LELAND BLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/12/2019
Notification Time: 04:51 [ET]
Event Date: 05/11/2019
Event Time: 23:05 [CDT]
Last Update Date: 05/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RYAN ALEXANDER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

DISCOVERY OF A CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION

"On 5/11/19, Callaway Energy Center entered Mode 4 at 1217 [CDT]. At 2305, the door from the Auxiliary Building to the RAM Storage building was found blocked open. This door is an Auxiliary Building pressure boundary for the Emergency Exhaust system. The Emergency Exhaust system is required in Modes 1,2,3,4, and during movement of irradiated fuel assemblies in the Fuel Building. The door was being blocked open with a large ramp. This rendered the Emergency Exhaust system not capable of performing its design safety function. LCO [Limiting Conditions for Operation] 3.7.13.B was entered, and preparations to move the ramp commenced. LCO 3.7.13.B is for two Emergency Exhaust trains being inoperable due to an inoperable auxiliary building boundary. The allowed outage time is 24 hrs. to restore the boundary to Operable. The door was closed and LCO 3.7.13.B was exited at 0111 on 5/12/19.

"This event is reportable per 10 CFR 50.72(b)(3)(v) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (C) control the release of radioactive material, or (D) mitigate the consequences of an accident.

"The NRC Senior Resident has been notified."

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Power Reactor Event Number: 54062
Facility: GRAND GULF
Region: 4     State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: GERRY ELLIS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/12/2019
Notification Time: 15:28 [ET]
Event Date: 05/12/2019
Event Time: 10:39 [CDT]
Last Update Date: 05/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
RYAN ALEXANDER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 75 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DUE TO PARTIAL LOSS OF SERVICE WATER

"At 1039 CDT the reactor was manually [scrammed] due to a partial loss of plant service water. The loss of plant service water was caused by a loss of [balance of plant] BOP transformer 23. Reactor power was reduced in an attempt to restore pressure to plant service water. Reactor level is being maintained with condensate and feedwater. Reactor pressure is being maintained with bypass control valves. Standby Service Water A and B were manually initiated to supply cooling to Control Room A/C and [Engineered Safety Feature] ESF switchgear room coolers. The cause is under investigation.

"The NRC Resident Inspector has been notified.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B) as any event or condition that results in actuation of the Reactor Protection System (RPS), when the reactor is critical and also reported under 10 CFR 50.72(b)(3)(iv)(A), as any event or condition that results in actuation of RPS and Standby Service Water."

The plant is currently in a normal electrical lineup.

* * * UPDATE ON 5/12/19 AT 1846 EDT FROM GERRY ELLIS TO JEFFREY WHITED * * *

"This is an update to the original notification.

"The Drywell and Containment exceeded the technical specification (TS) temperature limits of 135 degrees F [TS Limiting Condition of Operation (LCO) 3.6.5.5] and 95 degrees F [TS LCO 3.6.1.5], respectively.

"An 8-hour notification is being added for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material per 10 CFR 50.72(b)(3)(v)(C)."

Notified R4DO (Alexander).


Page Last Reviewed/Updated Monday, May 13, 2019
Monday, May 13, 2019