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Event Notification Report for September 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/24/2019 - 9/25/2019

** EVENT NUMBERS **


54255 54282 54291

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 54255
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
Region: 2
City: ERWIN   State: TN
County: UNICOI
License #: SNM-124
Docket: 07000143
NRC Notified By: RON RICE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 09/04/2019
Notification Time: 16:55 [ET]
Event Date: 09/04/2019
Event Time: 03:46 [EDT]
Last Update Date: 09/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
SCOTT SHAEFFER (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- FUELS GROUP (EMAIL)

Event Text

UNPLANNED CONTAMINATION EVENT

The following was received via e-mail:

"On September 4, 2019, at approximately 0346 EDT, a glass component failed, resulting in an unplanned contamination event. The release was limited to an area inside of the Radiologically Controlled Area. This area is designed for radiological work. There has been no personnel contamination. Airborne radioactivity samples are below action levels. Cleanup and Decontamination activities were safely and promptly initiated, but due to the complexity and space constraints of the system components, normal access to the area is not likely be restored within 24 hours. There has been no exposures or releases to the environment or public.

"The licensee has notified the NRC Resident Inspector."

* * * RETRACTION ON 9/16/19 AT 1115 EDT FROM RON RICE TO BRIAN LIN * * *

The following retraction information was obtained from the licensee via email:

"The unplanned contamination event was decontaminated to levels that did not require access to be restricted by imposing additional radiological controls within 24 hours, so the event did not require a report per 10CFR70.50(b)(1)(i). The NRC resident inspector has been informed."

Notified R2DO (Ehrhardt), NMSS Events Notification (email), and Fuels Group (email).

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Agreement State Event Number: 54282
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM   State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/17/2019
Notification Time: 13:09 [ET]
Event Date: 09/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information is a summary of an email received from the state of North Carolina:

On September 16, 2019, a patient at Duke University Medical Center was prescribed 43.2 mCi of Y-90 Theraspheres to the liver, but received 89.6 mCi. While the cause of the misadministration is not clear at this time, it is known that the dose received was intended for a different patient. Both the patient and the authorized user have been informed of the incident.

An inspector has been dispatched to conduct a reactive inspection for this event.

North Carolina Tracking Number: 190032


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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Power Reactor Event Number: 54291
Facility: COOK
Region: 3     State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BUD HINCKLEY
HQ OPS Officer: CATY NOLAN
Notification Date: 09/24/2019
Notification Time: 15:02 [ET]
Event Date: 09/24/2019
Event Time: 09:30 [EDT]
Last Update Date: 09/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT DALEY (R3DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY REPORT

"On September 24, 2019, at 0930 EDT, a non-licensed employee contract supervisor had a confirmed positive test result for illegal drugs during a random test. The employee's access to the plant has been denied.

"The licensee has notified the NRC Resident Inspector."


Page Last Reviewed/Updated Wednesday, September 25, 2019
Wednesday, September 25, 2019