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Event Notification Report for July 26, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/25/2019 - 7/26/2019

** EVENT NUMBERS **


54042 54169 54170 54171 54172 54173

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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: 07/25/2019
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 FROM INTERNATIONAL ISOTOPES TO KENDZIA * * *

The following update is a synopsis of information received via E-mail 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) IRD 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) IRD MOC (Gott), and NMSS Events Notification (email).

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Agreement State Event Number: 54169
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: VANDERBILT UNIVERSITY MEDICAL CENTER
Region: 1
City: NASHVILLE   State: TN
County:
License #: R-19266-A26
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: CATY NOLAN
Notification Date: 07/17/2019
Notification Time: 10:24 [ET]
Event Date: 07/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOSEPH DEBOER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"Vanderbilt University Medical Center had a misadministration on 7/16/19. A patient was supposed to receive 14 mCi of I-131 NaI, but the technologist administered 33 mCi of I-131 NaI. The technologist will send a written report within the 15 day requirement."

Item Number: TN-19-098

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: 54170
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKINELMER, INC.
Region: 1
City: BILLERICA   State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/17/2019
Notification Time: 15:11 [ET]
Event Date: 07/12/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOSEPH DEBOER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOST THEN FOUND SHIPMENT OF RADIOACTIVE IODINE-125

The following information was received from the Commonwealth of Massachusetts via email:

"Two shipments of licensed material in the form of Iodine-125 saline, one with an activity of 1.75 Curies and the other, 1.25 Curies, were discovered not to be delivered by [a common carrier] to the licensee's authorized use site at 331 Treble Cove Road, Billerica, MA, on Friday, July 12, 2019. PerkinElmer leases authorized use space from another Massachusetts licensee, Lantheus Medical Imaging, Inc., at the same street address. PerkinElmer subsequently contacted Lantheus and [the common carrier] on 7/12/19 at approximately 1416 EDT to report the missing packages.

"On Monday, July 15, [the package] containing 1.25 curies of I-125 was delivered by [the common carrier] to the PerkinElmer shipping department. [The licensee] subsequently reported to [the common carrier] that one of the packages was delivered; however, the second package containing 1.75 curies of I-125 was not. On Tuesday, July 16, [the common carrier] contacted PerkinElmer to report that both packages were delivered and that the case was closed.

"On Wednesday, July 17, at 1054 EDT, [the common carrier] delivered the second package to the PerkinElmer shipping department and stated that it was just picked up from Lantheus a short time before. It had apparently been in Lantheus's possession since Monday, July 15.

"An investigation of the incident is underway."

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Agreement State Event Number: 54171
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: SAINT AGNES HOSPITAL
Region: 1
City: BALTIMORE   State: MD
County: BALTIMORE
License #: MD-07-010-01
Agreement: Y
Docket:
NRC Notified By: ALAN GOLDEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/17/2019
Notification Time: 15:35 [ET]
Event Date: 07/17/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOSEPH DEBOER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TWO RADIOPHARMACEUTICAL PACKAGES HAD HIGH SURFACE CONTAMINATION LEVELS WHEN DELIVERED

The following information was received from the state of Maryland via email:

"On July 10, 2019, a health physics consultant contacted the Maryland Department of the Environment Radiological Health Program (MDE/RHP) concerning a discovery during a routine audit conducted on July 10, 2019 at a licensed medical facility.

"A review of incoming Department of Transportation wipe/survey listing reports at the licensed facility [St. Agnes Hospital in Baltimore, MD] indicated that two packages received on June 12, 2019 from the radiopharmacy had high wipe test values recorded at 400,000 dpm per 100 cm2. These values were documented for surface and contents of the packages. Both packages were labeled as White I and had no abnormal outer package surface exposure rate readings. The computer record contained a note stating that, 'dpm verified and Cardinal [Health] notified. Case stored for decay.'

"The technologists did not notify the Radiation Safety Officer or MDE/RHP. The cases were opened, the doses unpacked, and used. The computer record indicated good condition for each box. One box contained one syringe of Tc-99m Ceretec at 17.25 mCi. The other box contained one vial of Tc-99m sodium pertechnetate at 104.22 mCi, one syringe of Tc-99m macro aggregated albumin at 10.61 mCi, and one syringe Tc-99m Sestamibi at 30.41 mCi.

"A reactive inspection is planned [by the state of Maryland]."

Cardinal Health was the radiopharmaceutical provider. The delivery vehicle and the driver were both surveyed on June 12, 2019, with negative results. No other contaminations or any overexposures were identified when the hospital performed surveys of the facility.

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Agreement State Event Number: 54172
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CAPITOL ULTRASONICS, LLC
Region: 4
City: BATON ROUGE   State: LA
County:
License #: LA-5838-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/18/2019
Notification Time: 13:22 [ET]
Event Date: 07/17/2019
Event Time: 00:00 [CDT]
Last Update Date: 07/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILURE TO RETRACT

The following is an abstract of information received via E-mail:

On July 17, 2019, a Capitol Ultrasonics (CU) three-person crew was making exposures on a compressor at a chemical plant at ExxonMobil Refinery, at a temporary jobsite in Baton Rouge, Louisiana. The three-person radiography crew consisted of two radiography instructors and an assistant radiographer.

After performing three approximately one minute and 25 second exposures and upon completing the fourth exposure and cranking in the source, the radiography instructor noticed, after rocking the crank-out handle back and forth, that the exposure device auto-lock was not engaging. Before reaching the exposure device, the instructor noticed higher than expected survey readings. Several more attempts were made to crank in the source without success. The instructor at once contacted his Radiation Safety Officer (RSO), as well as the ExxonMobil Safety Superintendent. The crew then immediately extended their restricted area boundary to the 2 mR/hr line. Six to seven radiography technicians of the licensee maintained visual surveillance of the boundary and awaited arrival of their RSO. The exposure device was a QSA Global Model 741OP, serial number, B107, containing 15.1 Ci of Co-60, source Model number, A424-18 and source serial number, 60487B.

The lead technician of the crew leading the incident response prior to the arrival of the RSO, received 30 mR on his direct-reading dosimeter (DRD). The RSO received approximately 17 mR on his DRD by the time that the source was finally placed back in the exposure device in the shielded position. An environmental scientist from the Louisiana Department of Environmental Quality made a site visit to the temporary jobsite of the incident and performed preliminary investigation to include observing the successful retrieval of the source on July 17, 2019, by QSA Global. QSA Radiation Technicians received from 40 to 78.3 mR whole body exposure as a result of performing the source retrieval.

Louisiana Event Report ID No.: LA 190010

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Agreement State Event Number: 54173
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RMA GROUP
Region: 4
City: RANCHO CORDOVA   State: CA
County:
License #: 7565-34
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/18/2019
Notification Time: 19:03 [ET]
Event Date: 07/17/2019
Event Time: 00:00 [PDT]
Last Update Date: 07/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ADAM TUCKER (ILTAB) (EMAIL)
CNSNS (MEXICO) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE-DENSITY GAUGE

The following was received via e-mail:

"On 07/17/19, the California Governor's Office of Emergency Services contacted the Radiologic Health Branch (RHB) to report a stolen moisture-density gauge. The gauge involved is a Troxler Model 3450A, S/N 483, containing 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen out of a gauge technician's truck parked at a Motel 6 parking lot around 2100 PDT in Oakland, CA. The user had immediately called the Oakland Police Department and was advised to call back at a later time. On the morning of 7/18/19, the Oakland Police Department was contacted again and they declined to take a report due to high volume of incidents. The gauge was chained to the bed of the truck and there were guards present at the parking lot. The licensee will be posting a reward for the safe return of the gauge. RHB will be following up on this investigation."

California 5010 Number: 071719

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 Friday, July 26, 2019
Friday, July 26, 2019