Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for July 16, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/15/2019 - 7/16/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54150
Rep Org: VIRGINIA DEPARTMENT OF HEALTH Licensee: ECS MID-ATLANTIC, LLC Region: 1 City: RICHMOND State: VA County: License #: 760-114-4 Agreement: Y Docket: NRC Notified By: MICHAEL FULLER HQ OPS Officer: BETHANY CECERE	Notification Date: 07/06/2019 Notification Time: 11:01 [ET] Event Date: 07/05/2019 Event Time: 00:00 [EDT] Last Update Date: 07/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER LALLY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) JIM WHITNEY (ILTAB)

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

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED NUCLEAR GAUGE

On July 5, 2019, the licensee discovered that a nuclear gauge was missing from their inventory. The gauge contained a Cs-137 source of approximately 10 mCi and an Am-241 source of approximately 25 mCi. The licensee notified the Virginia Department of Health and the Virginia Emergency Operations Center.

On July 6, 2019, the gauge was found in a parking lot of a funeral home in Hampton, VA. The Hampton Police were notified. Following their procedures, they notified the FBI. The gauge was undamaged. The Radiation Safety Officer for the licensee is en route to retrieve the gauge.

The Virginia Department of Health will supply additional details when they become known.

* * * UPDATE ON 7/8/2019 AT 1156 EDT FROM MICHAEL FULLER TO JEFFREY WHITED * * *

The following information was received via e-mail:

"On Friday, July 5, 2019 at approximately 1600 EDT, the Virginia Office of Radiological Health (VORH) Duty Officer was notified by the Virginia Emergency Operations Center Duty Officer that a Virginia licensee, ECS-Mid Atlantic, located in Richmond, VA (Virginia radioactive materials license # 760-114-4) had reported a missing portable nuclear gauge. The gauge particulars are as follows:
Manufacturer: CPN
Model: MC1DR-P
Serial Number: MD60303074
Source: Cs-137 containing 370 MBq (10 mCi); serial number: 2149GQ
Source: Am-241 containing 1.85 GBQ (50 mCi); serial number: 5396NK

"On Saturday, July 6, 2019 at approximately 1030 EDT, the VORH Duty Officer was informed that the missing gauge had been found in the parking lot of a funeral home in Hampton, VA and that local law enforcement, fire department, and Hazmat personnel were on the scene. Also, in accordance with their procedures, the local police department informed the FBI. The local Hazmat officer performed a visual and radiological survey of the transportation package (labeled Radioactive - Yellow II) and observed that everything appeared to be intact and the radiation readings indicted that the source was in the shielded position (approximately 1.6 mR/hr on contact with the transportation package). Once this information was obtained, the Hazmat officer advised the FBI of the situation (through local law enforcement) and the FBI terminated their involvement. The licensee's identity was determined from the visual inspection and was contacted immediately. The licensee's [Radiation Safety Officer] RSO immediately traveled to the scene, and at 1219 EDT informed the VORH Duty Officer that he (the RSO) had possession of the gauge and was en route back to Richmond, VA.

"The licensee is conducting an investigation into the incident and believes that an employee failed to check out the gauge properly and return it to the storage location in Richmond on Wednesday, July 3, 2019 as required by company procedure, and thought that they could return it after the holiday without being detected. When the gauge was observed to be missing on Friday, July 5, 2019 by the Assistant RSO, she texted all technicians and asked who might have failed to return it. The RSO believes that the technician that failed to properly check out the gauge and check it back in panicked and abandoned it at the funeral home on Friday or Saturday. Once the investigation is completed, the licensee will provide the Virginia Office of Radiological Health with their findings. Future updates, based upon that investigation will be made."

Notified R1DO (Dimitriadis) and NMSS Events Notification and ILTAB via e-mail.

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: 54151
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: THOMAS JEFFERSON UNIVERSITY Region: 1 City: PHILADELPHIA State: PA County: License #: PA-0130 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: JEFFREY WHITED	Notification Date: 07/08/2019 Notification Time: 13:09 [ET] Event Date: 07/05/2019 Event Time: 00:00 [EDT] Last Update Date: 07/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The follow was received via fax:

"On July 8, 2019, the Department [Pennsylvania Department, Bureau of Radiation Protection] became aware of an under-dose event involving yttrium-90 (Y-90) SIR-Spheres. It is reportable as per 10 CFR 35.3045(a)(1)(i).

"On July 5, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The total dosage of 9.58 mCi was split into two equal dosages of 4.79 mCi to be administered to segments 5 and 8 of the liver. The first vial, segment 5, was successfully administered but only 75.7 percent or 3.6 mCi of the second vial was administered to segment 8. The referring physician and the patient were verbally informed. No harm is expected to the patient.

"The Department will perform a reactive inspection."

Event Report ID No.: PA190015

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.

Power Reactor	Event Number: 54163
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: GREG MILLER HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/15/2019 Notification Time: 16:30 [ET] Event Date: 07/15/2019 Event Time: 13:35 [EDT] Last Update Date: 07/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): RHEX EDWARDS (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

OFFSITE NOTIIFICATION DUE TO OIL LEAK

"At 1335 EDT on 7/15/2019, during dredging activities in Fermi 2's General Service Water (GSW) intake canal, a hydraulic line on the dredging machine became disconnected and approximately one quart of hydraulic oil spilled into Lake Erie. The oil leak to navigable waters has been stopped. The oil was contained within a boom, cleanup activities commenced immediately, and cleanup was completed at 1500 EDT. The cause of the oil leak is under investigation.

"Environmental spill reports were made to local, state, and federal government agencies. This is considered a news release or notification to other government agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

The State agencies notified were Michigan Department of Environmental Protection and the Michigan Pollution Emergency Alerting System. The licensee also notified the National Response Center.

Page Last Reviewed/Updated Wednesday, March 24, 2021