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Event Notification Report for July 08, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/5/2019 - 7/8/2019

** EVENT NUMBERS **


54133 54134 54135 54136 54138 54139 54149

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Agreement State Event Number: 54133
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: FIBER INDUSTRIES
Region: 1
City: DARLINGTON   State: SC
County:
License #: SC-360
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: OSSY FONT
Notification Date: 06/27/2019
Notification Time: 09:21 [ET]
Event Date: 03/01/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE TO MEMBERS OF THE PUBLIC

The following was received from the South Carolina Department of Health and Environmental Control (the Department) via phone:

On June 26, 2019, the Department was officially notified that 22 workers (members of the public) received doses while performing vat cleaning at Fiber Industries, a polymer manufacture. Seven of those individuals received a dose exceeding the annual limit of 100 mrem, as stated in 10 CFR 20.1301. The exposures occurred in March and April 2019, after which the Department was notified of the potential overexposures. The cleaning occurred in two vessels that had the Cs-137 gauge sources in the open position but no tag out. The gauges are a level density gauge (300 mCi, 1974) and a filling dip tube (20 mCi, 1974). The doses were calculated by Chase Environmental Group based on the individuals' time in the vessels and distance from the sources. The midpoint dose estimate for the seven individuals range from 112 to 205 mrem.

The Department conducted a site visit on June 14, 2019, and is currently evaluating the incident. Based on the 30-day notification provided to the Department on June 26, it is unknown if the individuals have been notified and no names were provided.

Additional information will be sent to the NRC once the review is complete.

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Non-Agreement State Event Number: 54134
Rep Org: U.S. NAVAL RESEARCH LABORATORY
Licensee: U.S. NAVAL RESEARCH LABORATORY
Region: 1
City: WASHINGTON   State: DC
County:
License #: 45-23645-01NA
Agreement: N
Docket:
NRC Notified By: JERETTE SPANN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/27/2019
Notification Time: 09:30 [ET]
Event Date: 05/09/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

LEAKING NI-63 SOURCES

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

Two Ni-63 sources (Agilent Technologies S/Ns PRO30 and U11381) used in an electron capture detector were found to be leaking. Both sources contained 15 mCi Ni-63. Leakages were 0.048 and 0.039 microCuries. Both sources will be transferred to Agilent Technologies for disposal. Leak tests are performed every 6-months. The last leak tests were performed on 01/08/2019.

The licensee contacted NRC Region I regarding this event.

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Agreement State Event Number: 54135
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ISOMEDIX OPS INC DBA STERIS APPL STERIL TECH
Region: 1
City: WHIPPANY   State: NJ
County:
License #: 507147
Agreement: Y
Docket:
NRC Notified By: CATHERINE BIEL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/27/2019
Notification Time: 09:45 [ET]
Event Date: 06/25/2019
Event Time: 18:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POOL WATER CONDUCTIVITY EXCEEDS LIMIT

The following was received via e-mail:

"At approximately 1800 EDT on 6/25/2019, the conductivity of the underwater pool irradiator water rose to 308 microSiemens/cm and remained in this range throughout the night. This was in conjunction with low flow through the water circulation pump. The pump was repaired the morning of 6/26/2019 and subsequent conductivity readings have ranged from 24.3 microSiemens/cm to 13.9 microSiemens/cm. The licensee is currently on a plan of changing the deionization tanks every two days to continue cleaning the water. In addition they are working with a supplier on additional methods to clean the pool water."

New Jersey Event Report Identification No.: INV190001-507147

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Agreement State Event Number: 54136
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: THE CLEVELAND CLINIC FOUNDATION
Region: 3
City: SANDUSKY   State: OH
County:
License #: 02230220000
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 06/27/2019
Notification Time: 13:32 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE DUE TO DISLODGING OF DEVICE

The following was received via e-mail:

"A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder.

"The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery.

"The patient and referring physician have been notified."

Ohio Item Number: OH190009

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: 54138
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BHATE GEOSCIENCES CORPORATION
Region: 4
City: D'IBERVILLE   State: MS
County:
License #: MS-1018-01
Agreement: Y
Docket:
NRC Notified By: ROBERT SIMS
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/28/2019
Notification Time: 16:48 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [CDT]
Last Update Date: 06/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
LEAH SMITH (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following is a synopsis of an email from the state of Mississippi:

On June 28, 2019, the Mississippi Division of Radiological Health (DRH), Radioactive Material Branch, reported that a Troxler moisture density gauge serial number 29421, was stolen on June 26 or 27, 2019, from a person's residence in Moss Point, Mississippi. The gauge was stolen from the back of the company pickup truck; the padlocks on the chains were cut and the gauge was removed from the storage box. The company Radiation Safety Officer (RSO) contacted the Moss Point Police Department. The RSO contacted the state of Mississippi Health Physicist (HP) and the state HP contacted the Department of Homeland Security.

The Troxler gauge contained a 9 mCi Cs-137 and a 44 mCi Am/Be-241 sources.

Mississippi Report Number: MS-190003

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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Non-Agreement State Event Number: 54139
Rep Org: TRI STATE MATERIALS TESTING LAB
Licensee: TRI STATE MATERIALS TESTING LAB, LLC
Region: 1
City: BERLIN   State: CT
County:
License #: 06-31462-01
Agreement: N
Docket:
NRC Notified By: HABIB CHAUDHARRY
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/01/2019
Notification Time: 05:55 [ET]
Event Date: 06/30/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

STOLEN TROXLER NUCLEAR DENSITY GAUGE

At approximately 1400 EDT, on 6/30/19, a company technician discovered that his personal vehicle was stolen from his residence driveway in Tolland, CT. The vehicle contained a Troxler density gauge locked in the trunk of the vehicle. The technician contacted the Connecticut State Police and reported the stolen vehicle and the stolen density gauge. The state police are still investigating the issue.

The nuclear density gauge is a Troxler model 3440, serial number 69523, containing 10 mCi of Cs-137 and 40 mCi of Am-241.

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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Non-Power Reactor Event Number: 54149
Facility: UNIV OF MISSOURI-COLUMBIA
RX Type: 10000 KW TANK
Comments:
Region: 0
City: COLUMBIA   State: MO
County: BOONE
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: BRUCE MEFFERT
HQ OPS Officer: JEFFREY WHITED
Notification Date: 07/05/2019
Notification Time: 09:18 [ET]
Event Date: 07/01/2019
Event Time: 11:00 [CDT]
Last Update Date: 07/05/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(1) - DEVIATION FROM T SPEC
Person (Organization):
GEOFFREY WERTZ (NRR/DLP)
EDWARD HELVENSTON (NRR/DLP)
BETH REED (NRR/DLP)

Event Text

NON-POWER REACTOR REPORT - TECHNICAL SPECIFICATION DEVIATION

The following was received via e-mail:

"On July 1, 2019, sometime between 1100 and 1200 CDT with the reactor shut down and during performance of electrical preventative maintenance, the University of Missouri-Columbia Research Reactor (MURR) deviated from Technical Specification (TS) 3.4 because reactor containment integrity did not exist for approximately ten (10) minutes while the reactor was not secured, as defined by TS 1.26.

"During this event time, two (2) shim control rod drive mechanisms were not installed because scheduled work was in progress on these drive mechanisms. Therefore, the reactor was not secured per TS definition 1.26, but the reactor was shut down per TS definition 1.27. Also during this time, and unknown to the Control Room operators, an Electronics Technician opened the two (2) electrical motor breakers to the reactor containment system's two (2) automatically-closing doors one at a time for approximately 5 minutes each.

"Though this event happened on July 1, no NRC-licensed operator knew that the automatically-closing door motor breakers had been opened on July 1 until mid-day on July 3. Once the abnormal occurrence was realized, the Reactor Facility Director was briefed on the situation on the afternoon of July 3, and he gave permission to continue reactor operation in accordance with TS 6.6.c.(4).

"This email is a required notification per TS 6.6.c.(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by TS 1.1.b, has occurred. MURR was not in compliance with all of the Limiting Conditions for Operations as established in TS Section 3.0.

"A detailed event report will follow within 14 days as required by TS 6.6.c.(3)."


Page Last Reviewed/Updated Monday, July 08, 2019
Monday, July 08, 2019