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Event Notification Report for November 20, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/19/2019 - 11/20/2019

** EVENT NUMBERS **

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: 11/19/2019
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

EN Revision Imported Date : 11/20/2019

EN Revision 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 EDT FROM STEVE LAFLIN TO THOMAS KENDZIA * * *

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

* * * UPDATE ON 11/19/2019 AT 1809 EST FROM STEVE LAFLIN TO THOMAS KENDZIA * * *

The following update is a synopsis of information received via email from International Isotopes:

International Isotopes (INIS) has completed their portions of the facility decontamination, which is now being run by the Department of Energy (DOE) and Los Alamos National Laboratory. INIS continues to support the DOE accident investigation. INIS investigation report will be delayed until after the DOE Accident Investigation Board report.

Notified R4DO (O'Keefe), IR MOC (Kennedy), and NMSS Events Notification (email).

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54338
Facility: RIVER BEND Region: 4 State: LA Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: DAVID DABADIE HQ OPS Officer: HOWIE CROUCH	Notification Date: 10/18/2019 Notification Time: 10:45 [ET] Event Date: 10/18/2019 Event Time: 02:07 [CDT] Last Update Date: 11/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): HEATHER GEPFORD (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Power Operation

Event Text

EN Revision Imported Date : 11/20/2019

EN Revision Text: INADVERTENT OPENING OF MAIN TURBINE BYPASS VALVES POTENTIONALLY AFFECTED SAFE SHUTDOWN CAPABILITY

"At 0207 [CDT], the Bypass Electro-Hydraulic Control (EHC) system was secured for planned maintenance. When the Bypass EHC pumps were secured, both of the Main Turbine Bypass Valves unexpectedly opened to approximately 4.5 percent. Plant parameters indicated no impact to Turbine Control Valve position, Reactor Pressure, Turbine First Stage Pressure, or Main Steam Line flows. There were no other abnormal indications noted. With the Turbine Bypass Valves partially open, there is a potential to affect instrumentation that trips on high Turbine First Stage Pressure. Therefore, this event is being reported as a potential loss of Safety Function. At 0256, the Bypass EHC system pumps were restored and the Turbine Bypass Valves Closed.

"No radiological releases have occurred due to this event from the unit."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM THONG LE TO HOWIE CROUCH AT 1019 EST ON 11/19/19 * * *

"This Event Notification was contingent on the Main Turbine Bypass Valves opening which resulted in the inoperability of Turbine First Stage Pressure monitoring instrumentation. A detailed review of system design and plant parameter trends has confirmed that the Main Turbine Bypass Valves remained closed for the duration of the event, permitting the instrumentation systems dependent on accurate Turbine First Stage Pressure to perform their respective design and licensing basis functions. Valve drift in the open direction was observed by position indication when hydraulic control pressure was removed. However, the valves were at an over-travel closed position prior to the event allowing the valves to settle at a position where an internal spring could provide closing force to the valve disc. Multiple plant parameter trends including Turbine First Stage Pressure, Reactor Pressure, Main Steam Line flows, and Main Turbine Bypass Valve discharge line temperatures indicate that the Main Turbine Bypass Valves remained closed for the duration of the event."

The licensee has notified the NRC Resident Inspector.

Notified R4DO (O'Keefe).

Agreement State	Event Number: 54368
Rep Org: MISSISSIPPI DIV OF RAD HEALTH Licensee: MISTRAS Region: 4 City: Pascagoula State: MS County: Jackson License #: 12-16559-02 Agreement: Y Docket: NRC Notified By: JASON MOHA HQ OPS Officer: DAN LIVERMORE	Notification Date: 11/03/2019 Notification Time: 11:38 [ET] Event Date: 11/02/2019 Event Time: 10:40 [CST] Last Update Date: 11/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM	Person (Organization): JOHN DIXON (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 11/20/2019

EN Revision Text: POTENTIAL OVEREXPOSURE OF RADIOGRAPHER

The following was received from the Mississippi Division of Radiological Health via phone:

A radiographer was exposed to a 100 Curie Ir-192 source for 8 minutes while changing film during a radiography shot. The radiographer was not wearing dosimetry and did not have a hand held radiation meter. While changing film, the radiographer realized the source had not been retracted and left the area. This was not an equipment malfunction, and the source was retracted when it was realized that the radiographer had been exposed. The radiographer reported the event to the Mistras Radiation Safety Officer (RSO). Estimated dose is 20 Rem to the hands and 19.6 to 19.7 Rem whole body. The radiographer was sent to a local hospital for bloodwork.

* * * UPDATE FROM ROBERT SIMS TO HOWIE CROUCH VIA EMAIL AT 1706 EST ON 11/8/19 * * *

"[A state of Mississippi Health Physicist investigator] interviewed the RSO on 11/7/2019 and investigated the incident. After reviewing and questioning the incident details, [the investigator] found the following evidence that may determine this may not have been an overexposure. The assistant radiographer retracted the source, but did not perform the bump test to fully retract the source into the locked position. This caused the assistant radiographer to believe the source was still in the collimator. When returning to change the film, he saw the red button on the camera instead of green which would indicate the source was in the locked position. The assistant was not using dosimetry, rate alarm or survey instrumentation. He appears to have panicked, came down the ladder, and couldn't get the crank to move in. The lead radiographer then grabbed the crank and cranked out and back in immediately to fully retract the source into the camera. [The investigator] reviewed compliant leak tests of camera and wipes along with maintenance and service reports before and after the incident and the RSO could not replicate any problems that would prevent them from retracting the source. There was no malfunction with the camera or the cranks. It appears that the source was in the end of the camera but not in the fully shielded position, which could allow some radiation out of the tube that the source enters. However, we do not know how much because the assistant was not wearing any dosimetry. The other assistant's dosimetry [assistant radiographer 2] only picked up 1 milliRem of dose but he was approximately 25 ft. away with steel shielding from the tank they were working on in between him and the source. [The investigator is] waiting on the emergency reading of the doses recorded on the OSL badges used by the crew and follow up doctor's visit. [The investigator] interviewed [the assistant radiographer on] 11/8/2019 at 1549 CST. [The assistant radiographer] reports that he had more blood drawn today and will provide results next week. He said he feels great and has had no sickness such as nausea, pain or redness and swelling in the hands. Will update again next week after receiving lab results."

* * * UPDATE FROM ROBERT SIMS TO THOMAS KENDZIA VIA EMAIL AT 1409 EST ON 11/19/19 * * *

"[A state of Mississippi Health Physicist investigator] interviewed the assistant radiographer [who was not wearing dosimetry] on 11/12/2019. [The assistant radiographer] reported that lab was drawn on 11/3/2019 and 11/8/2019. Both labs results returned within normal limits and [the assistant radiographer] has no physical symptoms of radiation sickness. [The assistant radiographer] remains at regular work duties recommended in his physician reports that he provided to [the investigator]. [The RSO] was interviewed on 11/11/2019 and provided the Landauer dosimetry report for the three RT crew members. The crew received new dosimeters on 11/1/2019 and they were sent for an emergency read the day after the incident.

"[The] lead radiographer received 109 millirem, [assistant radiographer 2 who was wearing dosimetry] received 269 millirem and [the assistant radiographer] received 150 millirem although he was not wearing his dosimeter during this incident. [The assistant radiographer] is also on UT and other duties until the end of the year until his new annual dose limit year starts January 1, 2020. This is upon the recommendation of [the investigator] because although it has been determined that [the assistant radiographer] did not receive an over exposure equaling or exceeding the 15 to 25 RAD to cause radiation sickness, it does not rule out if he did or did not exceed his 5 rem TEDE. The licensee's personnel believe that the source was in the end of the camera, but not in the fully locked position because the red button was showing on the QSA 880 camera when [the assistant radiographer] returned from changing the digital film plate. Due to his elevation up on the tank and the tank shielding we cannot use any of the other crew members dosimetry to make any determinations. However based on the medical reports and physical evidence it appears that [the assistant radiographer] has no physical symptoms from radiation sickness. [The assistant radiographer] will have his last lab test on 11/22/2019, if it is normal, [the assistant radiographer] states that the physician intends to release him completely from all medical care related to this incident."

Notified the R4DO (O'Keefe) and NMSS Events Notification via email.

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State	Event Number: 54376
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: LEHIGH VALLEY HEALTH NETWORK Region: 1 City: ALLENTOWN State: PA County: License #: PA-0232 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: BRIAN P. SMITH	Notification Date: 11/07/2019 Notification Time: 14:08 [ET] Event Date: 11/05/2019 Event Time: 00:00 [EST] Last Update Date: 11/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 11/20/2019

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Commonwealth of Pennsylvania via email:

"The Department [Pennsylvania Department of Environmental Protection] received notification from a licensee on November 6, 2019 that on October 8, 2019 they performed a prostate seed implant on a patient including seventy (70) stranded I-125 seeds that were implanted into the prostate treatment volume. They were Best Medical, Model 2301, Lot 48917, at 0.350 mCi per seed and 24.5 mCi total activity. The patient had an appointment on November 5, 2019 for a 30-day post-plan analysis. The CT from November 5, 2019 noted 2 seeds that were outside the prostate volume in the peril-prostatic fat. The post-plan analysis showed that 68 of 70 seeds are within the treatment volume and 94.4 percent of the treatment volume is covered by the prescription dose, which are within appropriate specifications for a prostate seed implant. The two seeds in question are considered discontinuous from the treatment volume. The licensee believes when the needle was retracted, the strand of seeds drug back with the needle and was deposited inferior from their intended location. An analysis was performed by the licensee and no adverse effects to the patient are expected. Both the patient and referring physician were notified. The Department will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190026

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.

* * * RETRACTION ON 11/19/19 AT 1148 EST FROM JOHN CHIPPO TO THOMAS KENDZIA * * *

The following was received from the Commonwealth of Pennsylvania via fax:

"As a result of a reactive inspection by the Department and an extensive review by the licensee, the licensee has determined the tissue containing the two seeds is within the contiguous peril-prostatic fat, which is actually physically adjacent to or touching the prostate, therefore this is not a reportable event. Further, changes noted in the radiograph taken on the day of the implant and the post-plan CT can be accounted for by the difference in patient positioning; from the lithotomy position for the implant image to the supine position for the post-plan image."

Notified the R1DO (Cahill) and NMSS Event Notification via email.

Agreement State	Event Number: 54381
Rep Org: ALABAMA RADIATION CONTROL Licensee: NUCOR STEEL TUSCALOOSA Region: 1 City: Tuscaloosa State: AL County: License #: Agreement: Y Docket: NRC Notified By: MYRON RILEY HQ OPS Officer: THOMAS KENDZIA	Notification Date: 11/12/2019 Notification Time: 08:42 [ET] Event Date: 11/09/2019 Event Time: 00:00 [CST] Last Update Date: 11/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED SHUTTER ON GAUGE

The following was received from the Alabama Office of Radiation Control (AORC) via fax:

"On Saturday, November 9, 2019, Alabama Emergency Management Agency (AEMA) reported to [the AORC] Duty Officer a damaged gauge that had been reported from Nucor Steel Tuscaloosa. AEMA stated that the damage was minimal and with no releases to the general public. This information was reported by the Environmentalist with Nucor Steel Tuscaloosa.

"The Duty Officer contacted the Environmentalist and he stated that an over fill had occurred and damaged the locking pin on the shutter of the gauge. Surveys revealed no damage to the shielding of the gauge, but the gauge will be kept secure in the caster mold until Ronan arrives for assessment of damage. The shutter mechanism is functioning, but cannot be locked in the closed position.

"As of today [November 12, 2019], 0730 CST, the gauge is secure, but unlockable. The licensee has contacted the manufacturer for assessment and repair. Ronan is scheduled to arrive on November 14, 2019. The incident remains open until the appropriate repairs are completed."

Alabama Incident 19-32

Agreement State	Event Number: 54383
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: MERCY HEALTH - ST. RITA'S MEDICAL CENTER Region: 3 City: LIMA State: OH County: License #: 02230020000 Agreement: Y Docket: NRC Notified By: MICHAEL RUBADUE HQ OPS Officer: BETHANY CECERE	Notification Date: 11/12/2019 Notification Time: 16:14 [ET] Event Date: 10/30/2019 Event Time: 00:00 [EST] Last Update Date: 11/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANN MARIE STONE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE BY 20 PERCENT OR MORE

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

"On 11/30/2019, the licensee notified the Ohio Department of Heath of a medical event involving a prostate seed implant. The licensee stated that it appears the implant template shifted prior to seed placement and resulted in a 48 percent underdose. The patient and referring physician have been notified."

Isotope: Cs-131, 104.377 MBq
Intended dose: 11000 rad
Given dose: 6820 rad

Item Number: OH190015

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.

Page Last Reviewed/Updated Thursday, March 25, 2021