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Event Notification Report for June 30, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/29/2020 - 6/30/2020

** EVENT NUMBERS **


54750 54751 54754 54758

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Non-Agreement State Event Number: 54750
Rep Org: Monongalia County General Hospital
Licensee: Monongalia County General Hospital
Region: 1
City: Morgantown   State: WV
County:
License #: 47-16259-01
Agreement: N
Docket:
NRC Notified By: Mark Perna
HQ OPS Officer: Bethany Cecere
Notification Date: 06/19/2020
Notification Time: 09:28 [ET]
Event Date: 06/15/2020
Event Time: 00:00 [EDT]
Last Update Date: 06/22/2020
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen Lnm>10x
Person (Organization):
DONNA JANDA (R1DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

MISSING BRACHYTHERAPY SEEDS

"[The licensed material lost is] Palladium-103, 3.56 mCi in a solid brachytherapy seed form.

"Forty-nine Pd-103 seeds were ordered from the local radiopharmacy, Pharmalogic in Bridgeport, WV. The order was for three cartridges of 15 seeds and one cartridge of four seeds. The package containing the seeds was received in Nuclear Medicine on 6/12/20. As per procedure, the package was checked in and surveyed and checked against the manifest. Four cartridges were locked inside the container which matched the manifest. The individual seeds were not counted. To count the individual seeds requires opening the entire package and unscrewing the cartridges from the container and then inspecting each cartridge carefully. That same afternoon, the package was transferred to Sterilization. [The RSO] interviewed the director of Sterilization and [they] confirmed that the container was not opened except to crack it to insert a tag indicating that the package had completed sterilization. The package, now wrapped in sterile cloth, was returned to Nuclear Medicine for storage until Monday, 6/15/20, when it was transferred to the Operating Room (OR) for implantation into the patient.

"In the OR on 6/15/20, the Authorized User (AU) unwrapped the sterile cloth around the package and began to prepare the seeds for implantation. The AU immediately noticed that something wasn't right. The cartridge that was supposed to contain 4 seeds was empty. The AU stopped the procedure and a survey of the OR and the container was undertaken. No loose seeds were found. The AU determined that 45 seeds was sufficient to complete the procedure, amended the Written Directive to indicate such and completed the procedure.

"Immediately following the procedure, Sterilization, Nuclear Medicine and the trash were surveyed with no seeds found. Pharmalogic was notified and they surveyed their preparation areas, packaging/shipping materials which had, by this time, been returned and the truck that made the delivery on 6/12/20. No seeds were found.

"[The licensee doesn't] know what happened to the seeds. After careful evaluation, [they] can find no breakdown in our process that would have allowed an opportunity for the seeds to disappear. [The cartridges] were screwed to the inside of the canister and were not removed until they were in the OR in preparation for implantation. It appears from [the licensee's] end that the four seeds were never in the cartridge that was screwed into the canister. The pharmacy insists that they were.

"Given the extremely small size of the seeds, the small number of seeds and their very low external dose rate, even if the seeds were lost on [hospital] premises, it is unlikely to produce any meaningful external exposure to anyone."

* * * UPDATE ON 6/22/20 AT 0911 EDT FROM MARK PERNA TO THOMAS KENDZIA * * *

The following update was received via telephone:

The pharmacy determined that they had not put the four seeds in the canister and that they had possession of the seeds. The seeds were not lost.

Notified R1DO (Janda), ILTAB (email) and NMSS Event Notifications (email).

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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Fuel Cycle Facility Event Number: 54751
Facility: Bwx Technologies, Inc.
RX Type: Uranium Fuel Fabrication
Comments: Heu Fabrication & Scrap
Region: 2
City: Lynchburg   State: VA
County: Campbell
License #: SNM-42
Docket: 070-27
NRC Notified By: Chris Terry
HQ OPS Officer: Brian P. Smith
Notification Date: 06/19/2020
Notification Time: 13:02 [ET]
Event Date: 06/19/2020
Event Time: 10:30 [EDT]
Last Update Date: 06/19/2020
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
MARK MILLER (R2DO)
SILAS KENNEDY (IRD)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- FUELS GROUP (EMAIL)

Event Text

ONSITE FATALITY

The following was received via email:

"At approximately 1030 EDT on Friday, June 19, 2020, a BWXT NOG-L employee lost his life due to a fire incident. There were no eye witnesses, but workers in the area reported hearing a pop and then found the victim on the floor in the Supercompactor Room (an intermediate controlled work area). At this time the investigation has not determined what caused the event. The fire did not continue and was out before the Emergency Team could respond to the incident. There was no release of radioactive material above 1 DAC [Derived-Air-Concentration]. The victim was pronounced dead at the scene by paramedics on the Emergency Team. The Campbell County Sheriff's Department and the VA OSHA [Virginia Occupational Safety and Health Administration] were contacted at 1140. A message was left with the Federal OSHA. At approximately 1415, NOG-L was contacted by John Ratcliffe from Federal OSHA. The local Fire Marshall and Campbell County Sheriff's department are completing their investigation and the body has been removed from the scene of the incident."

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Agreement State Event Number: 54754
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HKH Engineering, Inc. dba: Earthspectives
Region: 4
City: Santa Ana   State: CA
County:
License #: 6518-30
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Kerby Scales
Notification Date: 06/22/2020
Notification Time: 15:43 [ET]
Event Date: 06/18/2020
Event Time: 00:00 [PDT]
Last Update Date: 06/22/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

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

"The Radiologic Health Branch was notified by the facility RSO [Radiation Safety Officer] that he detected radiation levels approximately 20 times background on a small subassembly piece that he had replaced for his Mount Sopris Instrument Co, Model HLP-2375 logging tool. The Mt. Sopris supplied sub-assembly contains an Isotope Products Lab model HEG series Cs-137 sealed source # B2-951 (100 mCi on ref. date 7/1/2003).

"On June 19, 2020, a wipe from the subassembly piece was measured using a pancake GM (with 15 percent efficiency for Cs-137), and showed approximately 1 microCi activity."

California Event ID Number: 061820

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Part 21 Event Number: 54758
Rep Org: UNITED CONTROLS INTERNATIONAL
Licensee: United Controls International
Region: 1
City: Norcross   State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Rob Hale
HQ OPS Officer: Thomas Herrity
Notification Date: 06/29/2020
Notification Time: 12:04 [ET]
Event Date: 05/01/2020
Event Time: 00:00 [EDT]
Last Update Date: 06/29/2020
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
DAVE WERKHEISER (R1DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 - ABB/THOMAS & BETTS/CYBEREX PRINTED CIRCUIT BOARD SHORTS TO GROUND WHEN INSTALLED IN HOST BATTERY CHARGER

The following is a summary of information received from United Controls International:

On May 1, 2020, Peach Bottom Atomic Power Station notified United Controls International (UCI) that a printed circuit board (PCB) in a station battery charger was shorting to ground. UCI has determined that an energized trace was too close to the mounting screw/washer causing the short. The trace was too close because the mounting holes were modified at the time of installation prior to commercial grade dedication. The modification was not documented. However, this modification was made to subsequent Time Delay Oscillator PCBs.

UCI has determined that in this application the energized trace is not used and can be removed from the board without affecting the function. The subject boards should be returned to UCI for this additional modification. UCI will remove the trace and inspect to ensure sufficient clearance exists.

The component is used in ABB/Thomas & Betts/Cyberex P/N: 93-41-119385. The subject board was supplied to Peach Bottom Generating Station in May, 2009.

CONTACT:
Wesley Hickle
Engineering Manager
whickle@unitedcontrols.com
770-496-1406 x 165


Page Last Reviewed/Updated Tuesday, June 30, 2020
Tuesday, June 30, 2020