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

Event Notification Report for August 20, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/19/2019 - 8/20/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 54207
Rep Org: NVI Licensee: NVI Region: 4 City: GRADE State: LA County: License #: 17-29410-01 Agreement: Y Docket: NRC Notified By: KEITH GRIFFIN HQ OPS Officer: OSSY FONT	Notification Date: 08/09/2019 Notification Time: 10:09 [ET] Event Date: 08/09/2019 Event Time: 07:25 [CDT] Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): GREG WARNICK (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Category 3" level of radioactive material.

Event Text

LOST RADIOGRAPHY CAMERA IN INTERNATIONAL WATERS

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

NVI (Non-Destructive and Visual Inspections) notified the NRC that a radiography camera with a less than 22 Ci Ir-192 source was lost when it fell into approximately 200 feet of international waters from an oil platform in South Pass Section 60-A. The camera (SPEC 150 Model 0605; Source SPEC G-60 S/N AC0160) was locked in the shielded position during setup when the radiographer slipped. The licensee does not plan to retrieve the device.

Additionally, the licensee notified NRC R-IV and the Bureau of Safety and Environmental Enforcement.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

Agreement State	Event Number: 54208
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: NORTH AMERICAN STAINLESS Region: 1 City: GHENT State: KY County: License #: 201-499-57 Agreement: Y Docket: NRC Notified By: AJ BHATTACHARYYA HQ OPS Officer: OSSY FONT	Notification Date: 08/09/2019 Notification Time: 11:14 [ET] Event Date: 08/07/2019 Event Time: 00:00 [EDT] Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAN SCHROEDER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN IN DAMAGED LEVEL DENSITY GAUGE

The following was received from KY Department for Public Health & Safety, Radiation Health Branch (KY RHB) via fax:

"KY RHB was notified by telephone on 8/8/19 by a representative from a specifically licensed facility, North American Stainless, that on 8/7/19 an event occurred when molten steel escaped a mold due to an overflow in a cooling trough, and covered access to the top portion of a Berthold Model LB300ML level gauge (Serial No. 9413), containing a 1 mCi Co-60 rod sealed source (Serial No 1820-11-5). This resulted in the shutter on-off mechanism becoming disabled. After the steel and mold had cooled, it was freed on 8/8/19 and segregated into a secure storage area.

"Initial readings taken with a Ludlum 2241-3 survey instrument measured with a Ludlum 44-7 probe were less than 2 mR/hr outside the gauge storage area. No overexposures were reported.

"On 8/8/19, Radiametric Technologies, a service provider located in Lorain, Ohio, requested reciprocal approval and was granted reciprocity on 8/9/19 in order to assess and remediate the situation, to be conducted on 8/13/19.

"North American Stainless is reviewing the incident to avoid future repeat incidents involving mold flow issues, and a complete report will be provided once the remediation is complete."

Event Report ID No KY190007

Agreement State	Event Number: 54209
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: OHIO STATE UNIVERSITY Region: 3 City: COLUMBUS State: OH County: License #: 02110250037 Agreement: Y Docket: NRC Notified By: MICHAEL J RABADUE HQ OPS Officer: JEFF HERRERA	Notification Date: 08/08/2019 Notification Time: 11:11 [ET] Event Date: 08/06/2019 Event Time: 00:00 [EDT] Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PATRICIA PELKE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING ECKERT & ZIEGLER CS-137 VIAL SOURCE

The following was report was received from the Ohio Department of Health via email:

"The licensee discovered a leaking Eckert & Ziegler Cs-137 vial source. The leak test result, performed on August 6, 2019, identified 0.016 microCuries of removable activity. Notification to the Ohio Department of Health was made on August 8, 2019. The licensee will dispose of the source through a licensed waste broker.

"Device model number: RV-137-250U
Serial number: 171069"

Ohio item number: OH190014

Agreement State	Event Number: 54210
Rep Org: WISCONSIN RADIATION PROTECTION Licensee: THEDACARE REGIONAL MEDICAL CENTER - APPLETON Region: 3 City: APPLETON State: WI County: License #: 087-1014-01 Agreement: Y Docket: NRC Notified By: KYLE WALTON HQ OPS Officer: CATY NOLAN	Notification Date: 08/09/2019 Notification Time: 14:54 [ET] Event Date: 08/09/2019 Event Time: 00:00 [CDT] Last Update Date: 08/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): PATRICIA PELKE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE TO PATIENT

The following was received from the Wisconsin Radiation Protection Section via email:

"On 8/9/19, the Department [State of Wisconsin Department of Health Services] was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit."

The patient will be notified.

Wisconsin Event Report ID: WI190009

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.

Agreement State	Event Number: 54213
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: ROBERT PACKER HOSPITAL SAYRE, PA Region: 1 City: SAYRE State: PA County: License #: PA-0012 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/12/2019 Notification Time: 14:05 [ET] Event Date: 02/21/2019 Event Time: 00:00 [EDT] Last Update Date: 08/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JONATHAN GREIVES (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT

The following report was received from the Pennsylvania Bureau of Radiation Protection (PA DEP) via facsimile:

"As a result of a Departmental [PA DEP] inspection the licensee reported an equipment failure event that occurred on February 21, 2019. The equipment was a Varian GammaMed Plus, Serial #641017, containing 6.518 Ci of lr-192. A patient was receiving her last of three fractions of treatment with total treatment time for this fraction being 222.6 seconds divided through a total of eight positions. Twenty-five seconds into treatment the unit issued an inactive source error and retracted the source. The physicist entered the room to confirm that the source was retracted. The manufacturer was called. At the manufacturer's recommendation, the console key was powered off, then back on, and the remaining treatment was initiated to continue with the untreated area. This time at 25.8 seconds into the treatment the same error occurred. The remaining treatment plan was saved into the planning computer, and the patient had the applicator removed and was sent home. Varian sent a field service representative who successfully replaced the Geiger-Muller board and functionality was verified. The patient was then rescheduled. The continued treatment on February 25, 2019 accurately reflected the partial treatment and was appropriately scaled to reflect the source decay from the previous treatment. The final portion of the treatment was delivered without incident. There was no harm or overexposure to the patient. The patient was informed at the time. The attending physician has not been notified."

Event Report ID No.: PA190018

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.

Agreement State	Event Number: 54214
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: D & S ENGINEERING LABS LLC Region: 4 City: GREENVILLE State: TX County: License #: LL06677 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/12/2019 Notification Time: 14:22 [ET] Event Date: 08/12/2019 Event Time: 00:00 [CDT] Last Update Date: 08/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On August 12, 2019, the licensee's radiation safety officer (RSO) reported to the Agency [Texas Department of State Health Services] that while one of its technician's was using a Troxler Model 3440 moisture/density gauge [device #21053] to perform density testing at a temporary job site in Greenville, Texas, the tip of the insertion rod, which holds an 8 millicurie cesium-137 source, came off in the test hole. The RSO and a representative from a licensed gauge service company met at the site and recovered the source. The RSO stated the source holder, which is screwed onto the end of the insertion rod then welded, was intact with the source, spring, and spacer in place. However, it had broken off approximately 1/4 inch below the weld (below the threads). A survey of the test hole and surrounding area found no readings above background. A wipe test was taken which will be analyzed at the service company's facility, where the source and gauge are being taken for evaluation/repair, before the source is removed from the recovery pig. No overexposures are expected from this event. An investigation into this event is ongoing. Information will be provided as it is obtained in accordance with SA-300."

Texas Incident: 9700

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

Power Reactor	Event Number: 54229
Facility: DAVIS BESSE Region: 3 State: OH Unit: [1] [] [] RX Type: [1] B&W-R-LP NRC Notified By: TIM THOMPSON HQ OPS Officer: KERBY SCALES	Notification Date: 08/19/2019 Notification Time: 14:46 [ET] Event Date: 08/19/2019 Event Time: 09:24 [EDT] Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(B) - POT RHR INOP	Person (Organization): KENNETH RIEMER (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

AUXILIARY FEEDWATER SYSTEM INOPERABLE

"At 0924 EDT, on August 19, 2019, it was discovered that both trains of the Auxiliary Feedwater System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(B). The door separating the two steam-driven Auxiliary Feedwater Pump Rooms was inadvertently left open during maintenance activities for more than an hour. The door was immediately closed upon discovery, restoring operability to the Auxiliary Feedwater System. The non-safety grade Motor-Driven Feedwater Pump remained operable during this time; additionally, the beyond-design basis diesel-driven Emergency Feedwater Pump also remained available. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 24, 2021