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Event Notification Report for April 22, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/21/2020 - 4/22/2020

** EVENT NUMBERS **


54662 54665 54674

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Agreement State Event Number: 54662
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT FAYETTE HOSPITAL
Region: 1
City: FAYETTEVILLE   State: GA
County:
License #: 1340-1
Agreement: Y
Docket:
NRC Notified By: STACY ALLMAN
HQ OPS Officer: OSSY FONT
Notification Date: 04/13/2020
Notification Time: 12:21 [ET]
Event Date: 03/31/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/13/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (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 IODINE-125 SEED

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

"An Iodine-125 seed [assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)] used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure.

"The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus [in a bag of solid waste] and transported to the [Pine Ridge Regional Landfill] by the waste disposal company's normal procedure on or around April 2, 2020.

"[The Radiation Safety Officer (RSO)] was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location.

"The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus.

"In [the RSO's] estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit.

"All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees."

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: 54665
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LA QUINTA INN
Region: 4
City: LOUISVILLE   State: CO
County:
License #: GL000263
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/14/2020
Notification Time: 17:29 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY JOSEY (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 via E-mail:

21 tritium exit signs, each containing 9.21 Ci, are unaccounted for. There has been no response for annual general license registrations since 2015.

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: 54674
Rep Org: CURTISS WRIGHT FLOW CONTROL CO.
Licensee: CURTISS WRIGHT FLOW CONTROL CO.
Region: 4
City: IDAHO FALLS   State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: BART HUMBLE
HQ OPS Officer: OSSY FONT
Notification Date: 04/21/2020
Notification Time: 17:18 [ET]
Event Date: 04/20/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/21/2020
Emergency Class:
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
FRANK ARNER (R1DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - DEFECT IN THERMOCOUPLE LOW LEVEL AMPLIFIER MODULES

The following is a summary of information received from Curtiss-Wright, Nuclear Division:

Three RTL modules [thermocouple low level amplifiers] have been delivered to clients that may have included faulty resistors that could have remained undetected during functional testing and will eventually malfunction with time in service.

MAY/MCY resistors are precision, low temperature coefficient, metal foil technology resistors used in circuits where stability with time and temperature is required. The RTL module uses this style of resistor to achieve its accuracy and variable temperature effects specifications. The symptoms exhibited by faulty resistors were open circuit or changes in value in response to physical or thermal stress. Faulty resistors were sent to the manufacturer for failure analysis. Cracks were discovered in the bond wires that connected the resistor leads to the resistor chip inside the resistor package.

The failure rate of resistors manufactured in 2017 and 2018 was significantly greater than resistors manufactured in earlier years. A search of the build records during that time interval resulted in three units. These three modules contain 10 kilo-ohm resistors with date codes from 2017. There are two 10 kilo-ohm resistors in an RTL module, R8 and R17, on the main circuit board assembly. Configured for an RTD input, only R8 is active. R8 sets the 1 milli-ampere excitation current for the RTD element. R17 is used in a voltage offset circuit that is only used in thermocouple and low level amplifier configurations.

If the module has been in service for any significant amount of time with no problems, 12 weeks or more, then it is probable that R8, the only suspect resistor in the default configuration, is not affected by this phenomenon. However, if the module has not seen significant service, then the module should be considered suspect. Additionally, if the module has been or could in the future be reconfigured to a low level amplifier or thermocouple application, then the same situation exists with R17, which is not used in the default configuration.

Affected Plant - Part Number (Serial Numbers):
Beaver Valley - NUS-A135PA-1/3 (s/n: 1800083)
Indian Point 3 - NUS-A138PA-3/13/W (s/n: 1800334)
Ginna - NUS-A138PA-1/4 (s/n: 1800666)

Contact Scientech-I&C-Repair@curtisswright.com to return these modules for further testing and rework, if necessary.

Should you have any questions regarding this matter, please contact:
Shanen Onken
Scientech Business Segment Manager
Curtiss-Wright Nuclear Division
sonken@curtisswright.com
Tel 208-497-3410, Cell 208-821-4054


Page Last Reviewed/Updated Wednesday, April 22, 2020
Wednesday, April 22, 2020