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Event Notification Report for March 13, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/12/2020 - 3/13/2020

** EVENT NUMBERS **


54563 54564 54565 54566 54568 54584

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Agreement State Event Number: 54563
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PHOENIX TECHNOLOGIES
Region: 1
City: ALPHARETTA   State: GA
County:
License #: 1616-1
Agreement: Y
Docket:
NRC Notified By: JOHN HAYS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/05/2020
Notification Time: 11:08 [ET]
Event Date: 11/06/2017
Event Time: 00:00 [EST]
Last Update Date: 03/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING CESIUM-137 SOURCE

The following information was received from the State of Georgia via email:

"[The Radiation Safety Officer] of Phoenix Technology reported a leaking cesium-137 source from one of their clients (Myers Cardiology). During a source change out on November 6, 2017, it was noted that the old source was leaking. The activity of the leaking source is 203 microCuries, and the leak test results are 26 nanoCuries. The leaking source was placed inside a protective pig and inside a plastic bag labeled as a damaged source. The source has been sent to Pinestar Technologies in Pennsylvania for proper disposal."

Source Manufacturer: IPL
Source Model No.: MED-3550
Source Serial No.: 986-15-17

Georgia Item Number: GA170001

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Agreement State Event Number: 54564
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRADY MEMORIAL HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: JOHN HAYS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/05/2020
Notification Time: 11:08 [ET]
Event Date: 08/09/2016
Event Time: 00:00 [EST]
Last Update Date: 03/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (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 - LOST I-125 SOURCE

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

"The Georgia Radiation Materials Program received a call from the [Radiation Safety Officer] RSO from Grady Memorial Hospital on August 12, 2016, stating the [200 microCurie] I-125 seed used for localization of non-palpable lesions was lost. The doctor performing the procedure stated the seed went into the tube of the suction tank. A survey of the suction tank, hallways and operating room did not uncover the lost source. The tissue, removed from the patient, which was transferred to pathology, also did not contain the source. The surveys of the hallway and operating room were performed after the hospital was notified. The RSO recommends bringing the patient back in the hospital to be surveyed to verify if the source was ever removed from the patient. At the time of the call, the RSO has been unable to speak to the doctor. The doctor is a surgeon and not an authorized user. The RSO stated the tube to the suction tank cannot be found and it may have made its way into the biohazard container. The RSO will follow-up with the biohazard department to see if the tube can be traced down so the tube can be surveyed to determine if the source became lodged within it. The RSO is also trying to follow-up with the doctor for more information."

NMED Report ID: 160362

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: 54565
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: JOHN HAYS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/05/2020
Notification Time: 11:41 [ET]
Event Date: 06/29/2018
Event Time: 00:00 [EST]
Last Update Date: 03/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (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 - LOST IODINE-125 SEED

The following information was received from the State of Georgia via email:

"On June 29, 2018, it was brought to the [Piedmont Fayette Hospital Radiation Safety Officer's] RSO's attention that a radioactive seed containing 62 microCuries of Iodine-125 was unaccounted for and could not be located. The seed was manufactured by Best Medical International, Inc., Model 2301. The physical form is a double wall titanium tube containing a tungsten x-ray marker that is coated with I-125. The source serial/lot number is 45876A-26. The source was calibrated at 100 microCuries on 5/11/2018. On the morning of the seed implantation procedure, 6/27/2018, the source measured at 62 microCuries in the dose calibrator in the hot lab.

"The seed had been used for localization of a breast lesion. Tissue was extracted from the patient and the specimen was reported to have contained the seed at the time of specimen radiography. Following this radiography procedure, the seed appears to have been lost. All efforts were made by staff on-site to locate and search for the seed in all possible locations, with no success. The patient was brought back in for radiology procedures to ensure that the seed was not still contained in the patient. Results of x-rays showed that the seed was not present in the patient. According to the RSO, it is likely that the seed was disposed of along with the trash collected after the procedure, or possibly washed down the floor drain in the specimen radiography room.

"According to the RSO, this is a best guess as to the fate of the seed. No individual members of the public or staff were likely to have been exposed to significant doses of radiation, based on the available information submitted to EPD [Georgia Environmental Protection Division]."


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: 54566
Rep Org: COLORADO DEPT OF HEALTH
Licensee: RODEWAY INN
Region: 4
City: COLORADO SPRINGS   State: CO
County:
License #: GL000551
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/05/2020
Notification Time: 11:42 [ET]
Event Date: 07/29/2019
Event Time: 00:00 [MST]
Last Update Date: 03/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received from the State of Colorado via email:

"The current manager of Rodeway Inn reported 7 lost tritium exit signs when conducting the annual reconciliation."

The exit signs have an activity of 7.5 Ci each.

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: 54568
Rep Org: COLORADO DEPT OF HEALTH
Licensee: RADIUS UPTOWN APARTMENTS
Region: 4
City: DENVER   State: CO
County:
License #: GL002506
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/05/2020
Notification Time: 17:11 [ET]
Event Date: 08/30/2019
Event Time: 00:00 [MST]
Last Update Date: 03/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information is a synopsis of an email received from the state of Colorado:

The licensee has reported that they are unable to locate three tritium exit signs. Each exit sign has an activity of 10 Ci. The current service manager states that it is possible the previous owner may have taken the signs.

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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Part 21 Event Number: 54584
Rep Org: FLOWSERVE
Licensee: FLOWSERVE
Region: 1
City: RALEIGH   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MATT HOBBS
HQ OPS Officer: SILAS KENNEDY
Notification Date: 03/12/2020
Notification Time: 17:08 [ET]
Event Date: 03/12/2020
Event Time: 00:00 [EDT]
Last Update Date: 03/12/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
PATRICK FINNEY (R1DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

INTERIM PART 21 NOTIFICATION - DEFECTIVE SOLENOID VALVES

The following is a summary of information that was obtained from Flowserve via facsimile:

On January 13, 2020, and January 14, 2020, two Flowserve Model 38878-8, 3-way, 2-postion solenoids valves supplied to Seabrook Station for use on the feed water isolation valve actuator failed bench testing. The failed solenoid valves were returned to Flowserve for evaluation. The evaluation of these solenoid valves will be completed by June 11, 2020.

Point of Contact: Matt Hobbs, PE Engineering Manager Office: 919-334-7127 MHobbs@flowserve.com


Page Last Reviewed/Updated Friday, March 13, 2020
Friday, March 13, 2020