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Event Notification Report for November 27, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2019 - 11/27/2019

** EVENT NUMBERS **


54165 54334 54393 54394

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Agreement State Event Number: 54165
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: RAYONIER ADVANCED MATERIALS
Region: 1
City: JESUP   State: GA
County:
License #: GA-381-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/16/2019
Notification Time: 13:34 [ET]
Event Date: 07/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOSEPH DEBOER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 11/27/2019

EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER MALFUNCTIONED

The following information was obtained from the state of Georgia via email:

"The shutter on a saltcake density meter was identified as needing attention on the last inventory and Berthold was scheduled to come on the next outage to repair or replace as needed. The outage is scheduled for 7/31/19.

"Today, [the licensee] identified that a saltcake pump near the gauge needs to be replaced and the gauge is listed on the pump's lockout sheet. When IM [instrument maintenance] attempted to lock out the meter as part of the established lock out, the shutter handle broke meaning the gauge cannot be locked out. (Lock out requires all energy sources affecting the pump to be locked out. The gauge is in the line ahead of the pump and about 6 feet away so does not really affect the pump.) Radiation survey at the pump showed 65 microRem/hr radiation. (500 microRem/hr at gauge surface and 134 microRem/hr at one foot)

"Maintenance work at the pump will continue with a lock out variance to cite not being able to close the shutter and a proximity radiation work permit used. Berthold is still scheduled to come in 7/31/19 for gauge shutter repair.

"Source is Cesium-137, 20 mCi, model P-2623-100 in LB7440 holder, serial no. 2104-6-90."

* * * UPDATE FROM ROGER WILSON TO KARL DIEDERICH ON 11/26/19 AT 1:12 PM * * *

The radioactive material was transferred to Berthold for disposal on 11/25/19.

Notified R1DO (Henrion) and NMSS_EVENTS_NOTIFICATION (via e-mail).

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Agreement State Event Number: 54334
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRADY HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/16/2019
Notification Time: 17:20 [ET]
Event Date: 10/15/2019
Event Time: 00:00 [EDT]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 11/27/2019

EN Revision Text: CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE

The following report was received from the Georgia Radioactive Materials Program via email:

"A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks.

"The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area.

"The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water.

"The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event."

* * * UPDATE AT 1733 EST ON 11/26/2019 FROM IRENE BENNETT TO JEFF HERRERA * * *

The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email:

On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident.

The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures.

The physician did not think a bioassay was necessary for the patient as they were not exposed.

Notified the R1DO (Henrion) and NMSS via email.

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Agreement State Event Number: 54393
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EQUISTAR CHEMICAL LP
Region: 4
City: PASADENA   State: TX
County:
License #: L01854
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/18/2019
Notification Time: 16:38 [ET]
Event Date: 11/05/2019
Event Time: 00:00 [CST]
Last Update Date: 11/18/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - GAUGE SHUTTERS STUCK OPEN

The following information was received from the State of Texas via email and phone call:

"On November 18, 2019, the licensee's radiation safety officer (RSO) notified the Agency [Texas Department of State Health Services] that on November 5, 2019, during routine shutter checks on fixed nuclear gauges at their facility, it was discovered that shutters on three Ohmart model SHD-30 gauges and one Ohmart model SHD-45 gauge were stuck in the open position. These gauges normally operate with the shutters in the open position. There is no increased risk of exposure to any individual. The RSO stated the shutter checks were performed on November 5, 2019, but an email was not sent to the RSO until November 8, 2019. The RSO did not see the email until today, November 18, 2019. After seeing the email, the RSO immediately contacted a service company who responded and was onsite during the RSO's call to the Agency.

"Gauge and source information:
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M5149
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M5150
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M6017
Ohmart Model SHD-45 - 375 mCi Cs-137 - SN: M5189

"The RSO also reported that two other gauges, one SHD-30 and one SHD-45, have broken handles that need repair. The shutters on these two gauges can still be operated.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No: 9725

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Agreement State Event Number: 54394
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: ZIRKLE FRUIT COMPANY
Region: 4
City: SELAH   State: WA
County: YAKIMA
License #: WN-I0541-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 11/18/2019
Notification Time: 19:15 [ET]
Event Date: 11/17/2019
Event Time: 00:00 [PST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSC (CANADA) (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 information was received from the State of Washington via email:

"At Selah-Home Ranch, the ranch manager noticed on Sunday morning, November 17, 2019, that someone had broken into the ranch shop building. The doors on the building had been forced open, the locked storage closet inside the building was also forced open, and the lock on a storage locker inside the storage closet was cut. Two CPN International model 503 portable nuclear gauges were stored inside the storage locker in locked storage cases. Both portable nuclear gauges were removed from the ranch shop building by the thief. One CPN International model 503 portable nuclear gauge (serial number H310606212) was found outside the ranch shop building, undamaged and still in its carrying case. The other portable nuclear gauge (believed to be serial number H35066208) is missing and stolen (approximately 50 milliCuries of americium-241/beryllium). The Zirkle Fruit Company is in the process of confirming the serial number of the stolen gauge (Sealed Source and Device Registry Number CA-0208-D-104-S).

"Zirkle Fruit Company has notified the Yakima County Sheriff. The case number is 19C20517."

* * * UPDATE AT 1901 EST ON 11/20/19 FROM JAMES KILLINGBECK TO THOMAS KENDZIA * * *

The following update was received from the State of Washington via email:

"The correct serial number of the CPN International model 503 moisture gauge that was stolen is: H371204057."

Notified via email the R4DO (O'Keefe), ILTAB, NMSS Events, CNSNS (Mexico).

Washington State Event No: WA-19-031

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 Wednesday, November 27, 2019
Wednesday, November 27, 2019