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Event Notification Report for May 14, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/13/2019 - 5/14/2019

** EVENT NUMBERS **

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."

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

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

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.

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)."

Non-Agreement State	Event Number: 54051
Rep Org: UNIVERSITY OF MICHIGAN Licensee: UNIVERSITY OF MICHIGAN Region: 3 City: ANN ARBOR State: MI County: License #: 21-00215-04 Agreement: N Docket: NRC Notified By: MARK DRISCOLL HQ OPS Officer: JEFFREY WHITED	Notification Date: 05/06/2019 Notification Time: 14:00 [ET] Event Date: 11/30/2018 Event Time: 00:00 [EDT] Last Update Date: 05/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): KENNETH RIEMER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) - CNSC (CANADA) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST TRITIUM EXIT SIGNS

The following is a summary of a phone call with the licensee:

After performing an inventory of Tritium exit signs in April of this year, a Senior Health Physicist inquired about the location of two specific missing signs. The Senior Health Physicist found that the building had been under renovation in 2018 and a contractor likely removed the two exit signs in November, 2018. The licensee is currently waiting on information from the contractor regarding the exit signs.

The licensee will be notifying NRC Region III.

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

Page Last Reviewed/Updated Thursday, March 25, 2021