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Event Notification Report for January 23, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/22/2020 - 1/23/2020

** EVENT NUMBERS **


54477 54478 54479 54481 54487 54491 54492

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Agreement State Event Number: 54477
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY
Region: 1
City: LEXINGTON   State: KY
County:
License #: KY-202-049-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: KERBY SCALES
Notification Date: 01/14/2020
Notification Time: 15:52 [ET]
Event Date: 08/20/2019
Event Time: 00:00 [CST]
Last Update Date: 01/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE - LESS THAN PRESCRIBED DOSE RECEIVED

The following was received from the State of Kentucky via e-mail:

"The University of Kentucky reported that a patient received less dose than prescribed on 8/20/2019. The patient was prescribed to receive 429.2 MBq (11.6 mCi) of Y-90 microspheres (Sirtex Medical model SIR- Spheres). A microsphere dose of 425.5 MBq (11.5 mCi) was drawn from the unit vial into the administration vial. However, the patient only received an activity of 316.72 MBq (8.56 mCi), which is 26.2 percent less than prescribed, because some microspheres remained in the administration system. Additionally, it was difficult to draw 429.2 MBq (11.6 mCi) from the 7.13 GBq (192.6 mCi) in the unit vial as it represented only a small portion of the whole. The patient and referring physician were notified. Corrective actions included ordering a dose calibrated to more closely provide the activity needed for the date and time of administration. If the activity to be administered is low, the university will ensure that the activity drawn is 10 percent greater than prescribed. More flushes of the system will also be performed in hopes of pushing more of the residual activity into the patient."

Kentucky Incident Number - 190008.
NMED Item Number - 190442

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: 54478
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON   State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: SZYMON MUDREWICZ
HQ OPS Officer: OSSY FONT
Notification Date: 01/14/2020
Notification Time: 17:56 [ET]
Event Date: 01/14/2020
Event Time: 12:45 [EST]
Last Update Date: 01/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
KEVIN WILLIAMS (NMSS DDD)
WILLIAM GOTT (IRD)
LAURA PEARSON (ILTAB)
ILTAB (EMAIL)
This material event contains a "Category 1" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST CATEGORY 1 SHIPMENT

The following summary was initially reported by the Massachusetts Department of Public Health (DEP) and subsequently reported by the Tennessee Department of Environment and Conservation (DEC), both via phone:

The MA DEP was notified by QSA Global, Inc. that a shipping container containing 12,400 Ci of Ir-192 did not arrive at their facility as expected. The original shipment had six (6) containers but only five (5) arrived at the Burlington, MA location. The last known location of the missing container was at the [Common Carrier] facility in Memphis, TN. QSA Global was in the process of notifying local law enforcement in Tennessee. Massachusetts DPH does not believe this event to be a theft or diversion.

Additionally, TN DEC was notified by [the Common Carrier] of the missing container and that a search was in progress.

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA IOCC, EPA Emergency Ops Center, FDA Emergency Ops Center (email), DHS Nuclear SSA (email), FEMA NWC (email), FEMA NRCC SASC (email), and DNDO-JAC (email).

* * * UPDATE ON 1/15/2020 AT 1035 EST FROM SZYMON MUDREWICZ TO THOMAS KENDZIA * * *

The following was reported by the Massachusetts Department of Public Health (DEP) via phone and email:

"At 1015 EST this morning, MA DEP was notified [by QSA Global] that the package was located by [the Common Carrier] in Memphis, TN last evening. It has been delivered to Burlington this morning, not damaged, and is in the possession of the Licensee, QSA Global, in Burlington, MA. MA DEP will continue to investigate the event."

Notified R1DO (Dentel), NMSS DDD (Williams), IRDM (Grant), ILTAB (Pearson), ILTAB (email), NMSS DAY (Rivera-Capella), INES (Milligan), NMSS Event Notification (email), NMSSDHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA IOCC, EPA Emergency Ops Center, FDA Emergency Ops Center (email), DHS Nuclear SSA (email), FEMA NWC (email), FEMA NRCC SASC (email), and DNDO-JAC (email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 1" LEVEL OF RADIOACTIVE MATERIAL

Category 1 sources, if not safely managed or securely protected would be likely to cause permanent injury to a person who handled them, or were otherwise in contact with them, for more than a few minutes. It would probably be fatal to be close to this amount of unshielded material for a period of a few minutes to an hour. These sources are typically used in practices such as radiothermal generators, irradiators and radiation teletherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 54479
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: COLUMBUS AUTO SHREDDING
Region: 3
City: COLUMBUS   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/15/2020
Notification Time: 11:42 [ET]
Event Date: 01/14/2020
Event Time: 00:00 [EST]
Last Update Date: 01/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - Cs-137 SOURCE FOUND AT A SCRAP YARD

The following information was received via E-mail:

"An unknown device was discovered at a metal scrap yard in Ohio. The device has no markings or labels. A Cs-137 source of unknown activity was identified in the device. No loose contamination was detected. Maximum dose rate on the device is 500 mr/hr and 6 mr/hr at one meter. The device is secure at the facility pending disposal. The Ohio Department of Health will continue to track down the origin of the source."

Ohio Item Number: OH200001

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Agreement State Event Number: 54481
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: PLAQUEMINE   State: LA
County:
License #: LA-2002-L02
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/15/2020
Notification Time: 16:16 [ET]
Event Date: 01/15/2020
Event Time: 00:00 [CST]
Last Update Date: 01/15/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK PROCESS GAUGE SHUTTER

The following information was received via E-mail:

"On January 15, 2020, at 1400 CST, the DOW Chemical Radiation Safety Officer contacted the supervisor of the Louisiana Department of Environmental Quality/ERSD/Radiation Section to report that a shutter failed to shut during routine maintenance. The shutter which failed to shut was found on January 14, 2020, at approximately 1500 CST, at DOW Chemicals Company. The shutter is stuck in the open condition and does not effect operation. The gauge is a Vega Americas model number SHF2B, s/n 38953125, with a 500 mCi Cs-137 sealed source, s/n 0368CR. The licensee has contacted the contractor for repair and is awaiting a date and time for the repair."

Event Report ID No.: LA20200001

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Power Reactor Event Number: 54487
Facility: SEQUOYAH
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN ALEXANDER
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 01/22/2020
Notification Time: 04:34 [ET]
Event Date: 01/21/2020
Event Time: 22:18 [EST]
Last Update Date: 01/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
NICOLE COOVERT (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

CONTAINMENT RELIEF VALVES INOPERABLE

"At 22:18 (EST) on 1/21/20, it was discovered that all Unit 1 containment vacuum relief isolation valves were closed and all vacuum relief lines were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The isolation valves were opened and the vacuum relief valves were restored to operable.

"There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 54491
Facility: HATCH
Region: 2     State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRANDON SHUMAN
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/22/2020
Notification Time: 17:50 [ET]
Event Date: 01/21/2020
Event Time: 20:05 [EST]
Last Update Date: 01/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NICOLE COOVERT (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 90 Power Operation 90 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY (FFD) ISSUE INVOLVING CONTRACT PERSONNEL

"At 2005 EST on January 21, 2020, Hatch Security was informed that a contract worker covered by 10 CFR 26.719(b) had been involved in a legal action as defined in 10 CFR 26.5. The contract worker's plant access has been suspended."

The NRC Resident Inspector has been notified.

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Fuel Cycle Facility Event Number: 54492
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE   State: NM
County: LEA
License #: SNM-2010
Docket: 70-3103
NRC Notified By: WYATT PADGETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/22/2020
Notification Time: 19:00 [ET]
Event Date: 01/22/2020
Event Time: 16:23 [MST]
Last Update Date: 01/22/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
NICOLE COOVERT (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

REQUIRED PROCEDURAL CONTROLS WERE NOT FOLLOWED

"Urenco USA is conservatively reporting a condition in that Uranic bearing material was placed into the Small Component Decontamination Train (SCDT) without meeting all conditions of IROFS54a and IROFS54b.

"IROFS54a and IROFS54b are Mass Controls that ensure the configuration of the SCDT remains sub-critical. Bookkeeping elements of the IROFS were performed correctly and the masses of the components were determined properly. However the visual inspection of the SCDT to ensure it is empty, prior to introducing components, was not performed in accordance with procedure instructions.

"The components were removed and the visual inspection was performed which confirmed the SCDT was in fact empty.

"The facility was and remains in a safe and stable configuration."

The licensee will notify NRC Region 2 tomorrow.


Page Last Reviewed/Updated Thursday, January 23, 2020
Thursday, January 23, 2020