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Event Notification Report for March 09, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/6/2020 - 3/9/2020

** EVENT NUMBERS **


54547 54548 54549 54550 54551 54552 54553 54570

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Non-Agreement State Event Number: 54547
Rep Org: VETERANS HEALTH ADMINISTRATION
Licensee: VETERANS HEALTH ADMINISTRATION
Region: 4
City: NORTH LITTLE ROCK   State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: KIM WIEBECK
HQ OPS Officer: OSSY FONT
Notification Date: 02/27/2020
Notification Time: 10:38 [ET]
Event Date: 02/27/2020
Event Time: 06:10 [CST]
Last Update Date: 02/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
STEVE ORTH (R3DO)
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NON-AGREEMENT STATE REPORT - EXTERNALLY CONTAMINATED PACKAGE

The following was received from the Veterans Health Administration via E-mail:

"Per 10 CFR 20.1906(d), Veterans Health Administration (VHA) National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.

"The package was received Thursday, February 27, 2020, at around 0710 EST by the North Florida/South Georgia Veterans Health System [Permit No.: 0912467-02] in Gainesville, Florida. This facility holds permit number 09-12467-02 under the VHA master materials license.

"The package was checked-in and surveyed upon receipt around 0710 EST. Wipe tests performed on the external surface of the entire package indicated a removable contamination level of around 560 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. Removable contamination level on the bottom surface of the package, indicated a removable contamination level of around 413 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters.

"The package contained three unit doses consisting of a 6 mCi dose of Tc-99m Mebrofenin (calibrated for 1330), a 25 mCi dose of Tc-99m Sestamibi (calibrated for 0930), and a 1 mCi dose of Tc-99m Sulfur Colloid (calibrated for 0800).

"The dosage was shipped from Triad Isotopes, out of Jacksonville, Florida, who was also the delivery carrier. The facility Radiation Safety Officer immediately notified the delivery carrier by phone about the contaminated package around 0730 EST.

"The patient dosages inside the package were not impacted and were able to be used. As corrective actions, the packaging materials were bagged in plastic and set aside in a restricted area at the facility.

"VHA National Health Physics Program, who manages the master materials license, was notified of the incident around 0840 EST.

"In addition, the licensee is notifying their NRC Region III project manager (Parker) of the event by inclusion in this email."

The external contamination was Tc-99m and the package will be held until the isotope has decayed prior to returning it to the pharmacy.


* * * UPDATE FROM THE STATE OF FLORIDA, BUREAU OF RADIATION CONTROL TO DONALD NORWOOD AT 1725 EST ON 2/28/2020 * * *

The following is a synopsis of information received via E-mail:

Reporting Organization: State of Florida Bureau of Radiation Control
NRC Notified By: Matthew Senison
Licensee: Jubilant DraxImage Radiopharmacies, Inc.
City, State: Jacksonville, Florida
License Number: 4587-5

Jubilant, Jacksonville received a call from the VHA in Gainesville, Florida about a delivery bag which had been delivered around 0710 EST that was contaminated on the outside. Jubilant, Jacksonville then notified their RSO who notified Jubilant's corporate RSO. Jubilant, Jacksonville personnel reviewed surveys and DOT documentation and found no removable contamination. They immediately pulled all six carts that are used in the pharmacy and wipe tested and surveyed each cart using a single channel analyzer and found only background. The driver is a third party (MDS) and had just returned. Jubilant, Jacksonville personnel surveyed and wipe tested the entire van and found it to also be at background. The Jubilant, Jacksonville RSO then called the VHA's RSO to relay that three patient doses were in the bag and no removable contamination had been found in the bag nor on the doses. VHA's RSO stated that she was notifying the NRC who would notify BRC. Since the NRC report shows the activity was Tc-99m, and neither party could find the source; at this point greater than five half-lives have passed, so there are no current plans to deploy investigators to either facility at this time.

Florida Incident Number: FL20-023 (2)

Notified R1DO (Ferdas), R3DO (Orth), and the NMSS Events Notification E-mail group.

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Agreement State Event Number: 54548
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON   State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/27/2020
Notification Time: 15:54 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EST]
Last Update Date: 02/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MEDICAL EVENT - HDR UNDERDOSE TO PATIENT

The following information was received from the state of Florida via E-mail:

"[The licensee] reported to the BRC [Bureau of Radiation Control] on 25 Feb 2020, and e-mailed an incident report on 26 Feb 2020 at 1224 EST that on 24 Feb 2020 at 1315 EST an HDR [high dose rate] incident occurred to a patient receiving skin therapy.

"The patient was prescribed 7.5 Gray x 5 fractions, on five different parts of the left hand. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient by 56.25 percent. No Authorized Users were exposed to the source or otherwise contaminated."

Florida Incident Number: FL20-022

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: 54549
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: INTERNATIONAL PAPER
Region: 1
City: SAVANNAH   State: GA
County:
License #: GA 143-1
Agreement: Y
Docket:
NRC Notified By: GREGORY REESE
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2020
Notification Time: 06:54 [ET]
Event Date: 05/02/2019
Event Time: 00:00 [EST]
Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BROKEN DENSITY GAUGE SHUTTER

The following is a summary of emails received from the Georgia Department of Natural Resources (the state):

On 05/02/2019, the licensee discovered a broken shutter on an Ohmart DSGX GEN2000 fixed density gauge during semi-annual leak testing. The gauge is roughly 15 to 20 feet in the air and contained a 20 mCi Cs-137 source (A-2102 source/SN 61798). The source was barricaded and warnings posted. The source was determined not to be leaking.

At the time a reactive inspection was performed.

On 08/01/2019, an update was sent to the state. An offsite authorized technician attempted to repair the shutter but was unsuccessful. The radiation source remained in service and barricaded and the RSO continued to actively monitor the source with no leakage detected. The licensee was obtaining a quote for removal/proper disposal and the purchase of a new radiation source for replacement, but the source continues to be operational with no additional risk to workers.

The incident was closed on 08/01/2019.

Incident Report No.: GA-2019-15


* * * UPDATE ON 2/28/2020 AT 1406 EST FROM GREG REESE TO THOMAS KENDZIA * * *

Gauge was replaced and sent to QSA Global for disposal. Source was received at QSA Global on 01/13/2020 and verified to not be leaking.

Notified R1DO (Ferdas) and NMSS Event Notification (email).

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Agreement State Event Number: 54550
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT FAYETTE HOSPITAL
Region: 1
City: FAYETTEVILLE   State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: GREGORY REESE
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2020
Notification Time: 06:54 [ET]
Event Date: 01/18/2019
Event Time: 00:00 [EST]
Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF I-125 SEED

The following is a summary of emails received from the Georgia Department of Natural Resources (the state):

On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal.

The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital.

On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed.

Corrective actions include to document seeds acquired for implantation on a single sheet of paper.

Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity.

The incident was closed on 03/04 2019.

Incident Report No.: GA-2019-10

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

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Agreement State Event Number: 54551
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BLUES CITY BREWERY, LLC
Region: 1
City: Memphis   State: TN
County:
License #: GL-125
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2020
Notification Time: 10:17 [ET]
Event Date: 02/19/2020
Event Time: 00:00 [EST]
Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF DEVICES CONTAINING AM-241

The following was received from the Tennessee Division of Radiological Health via email:

"During a recent inventory at Blues City Brewery, the environmental health and safety manager discovered that two devices [Industrial Dynamics CI-2GV/3] were missing. Devices had been out of use for 1 - 2 years. Actual activity [of the Am-241 sources] are unknown at this point. The activity will be reported during the follow-up report."

Incident Report No.: TN-20-038

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

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Agreement State Event Number: 54552
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SOURCE PRODUCTION & EQUIPMENT COMPANY, INC
Region: 4
City: SAINT ROSE   State: LA
County:
License #: LA-2966-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 02/28/2020
Notification Time: 15:54 [ET]
Event Date: 02/11/2020
Event Time: 00:00 [CST]
Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TWO PERSONNEL EXCEEDED ANNUAL DOSE LIMIT

The following was received from the state of Louisiana via email:

"On February 11, 2020, Source Production & Equipment Company, Inc. (SPEC) contacted Louisiana Department of Environmental Quality, Emergency & Radiation Services Division, Radiation Section, by email to report that two employees had exceeded their annual five rem limit for the 2019 year. Both employees worked at SPEC in the hot cell room manufacturing Se-75, Ir-192, and Co-60 sources for industrial radiography. Hot Cell employee number 1 received an estimated TEDE of 5,028 mR and Hot Cell Employee number 2 received an estimated TEDE of 5,687 mR for 2019 year."

Event Report ID No.: LA20200003

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Agreement State Event Number: 54553
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC dba SHAWCOR
Region: 4
City: ABILENE   State: TX
County:
License #: LO6462
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/01/2020
Notification Time: 13:52 [ET]
Event Date: 03/01/2020
Event Time: 00:00 [CST]
Last Update Date: 03/01/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following information was received via E-mail:

This event occurred in Austin, Texas.

"On March 1, 2020, one of the licensee's technicians had pulled off the road and was parked in a parking area, sleeping, when local law enforcement pulled up. Local law enforcement wanted to take the technician in for suspicion of DWI. At approximately 0800 CST the technician called the site radiation safety officer and told him of the situation.

"Law enforcement stayed with the technician until the tow truck came and took the vehicle to impound at approximately 0830 CST. The vehicle was locked, the alarm on the dark room was activated and the technician took all the keys to the dark room and camera with him. The vehicle was carrying a radiography camera (Spec 150) containing an 80 Curie Iridium-192 source.

"The licensee dispatched employees to the impound yard and they arrived at approximately 1015 CST and provided surveillance of the vehicle until it was released to them. They verified that the alarm system on the dark room was still armed and that the camera was present. The truck is being returned to the licensee's facility.

"At last report from the licensee, law enforcement had not performed any testing to determine if the technician was under-the-influence. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: Not Yet Assigned

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Power Reactor Event Number: 54570
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: LORRAINE WEAVER
HQ OPS Officer: RICHARD SMITH
Notification Date: 03/06/2020
Notification Time: 14:19 [ET]
Event Date: 03/06/2020
Event Time: 07:30 [MST]
Last Update Date: 03/06/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RICK DEESE (R4DO)
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 N 0 Startup 0 Startup
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY - CONTRACT SUPERVISOR VIOLATED THE FFD POLICY

A non-licensed contract supervisor had a confirmed positive for a controlled substance during an initial Fitness For Duty screening test. The individuals plant access has been terminated.

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Monday, March 09, 2020
Monday, March 09, 2020