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Event Notification Report for July 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/23/2020 - 7/24/2020

** EVENT NUMBERS **


54779 54780 54782 54783 54784 54785

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Agreement State Event Number: 54779
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: Neel-Schaffer, Inc.
Region: 1
City: Columbia   State: SC
County:
License #: SC-970
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Ossy Font
Notification Date: 07/15/2020
Notification Time: 10:22 [ET]
Event Date: 07/15/2020
Event Time: 09:45 [EDT]
Last Update Date: 07/15/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (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 - STOLEN MOISTURE DENSITY GAUGES

The following is a summary from the South Carolina Department of Public Health received via phone:

At 0945 EDT on 07/15/2020, the licensee's Radiation Safety Officer (RSO) notified the State that two Troxler moisture density gauges (model 3430P, serial #'s 72756 and 75041), each containing 8 mCi of Cs-137 and 40 mCi of Am-241, were stolen from their Ballentine, SC storage facility. The devices had not been used in a few days, so it is unknown when they were stolen. The RSO reports that the job box containing the travel cases were taken, but the locks were not cut. Additionally, the roll up gate was closed but not secured. The RSO believes it could be an inside job. The RSO was in the process of calling the police.

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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Non-Agreement State Event Number: 54780
Rep Org: Billings Clinic
Licensee: Billings Clinic
Region: 4
City: Billings   State: MT
County:
License #: 25-01051-01
Agreement: N
Docket:
NRC Notified By: Mariah White
HQ OPS Officer: Donald Norwood
Notification Date: 07/15/2020
Notification Time: 12:25 [ET]
Event Date: 07/14/2020
Event Time: 11:15 [MDT]
Last Update Date: 07/15/2020
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(1) - Unplanned Contamination
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNAUTHORIZED USE OF A RESTRICTED RADIATION ROOM AS A TOUCHDOWN SPACE

"On July 14, 2020, at approximately 1115 MDT, the Radiation Safety Officer was notified that a restricted radiation room was used intermittently for 30-45 minute periods as a touchdown space for Billings Clinic's Internal Medicine residents. The room had not been decommissioned.

"The restricted radiation room being used was the Billings Clinic Hospital I-131 Inpatient Therapy Room (room 3501; general inpatient medical floor). This room was last used for [a 153 mCi I-131 Sodium Iodine] radiation treatment on June 21, 2017. Beginning June 4, 2020, the room began being used as a touchdown space for Internal Medicine residents. Surveys were performed on July 14, 2020 using survey meters. Wipes for removable contamination were performed on a table, two computers, phone, and the floor around the area where staff were working. All items had activity levels indistinguishable from background readings. The items were removed from the room. The room has been secured with a new lock and radiation warning signs have been reposted. The radiation signs had been removed at an unknown time between June 4, 2020 and July 14, 2020.

"The licensee is not aware of any radiation exposure as a result of this reported event."

The licensee is making this report as a deviation from 10 CFR 35.13(f) as required by reporting requirement 10 CFR 30.50(b)(1)(iii).

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Agreement State Event Number: 54782
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: AdventHealth - Altamonte Springs
Region: 1
City: AltamonteSprings   State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Donald Norwood
Notification Date: 07/15/2020
Notification Time: 14:35 [ET]
Event Date: 07/14/2020
Event Time: 09:15 [EDT]
Last Update Date: 07/15/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - THERASPHERE PROCEDURE UNDERDOSE

The following information was received via E-mail:

"On 7/15/2020, at 1340 EDT, the licensee reported that yesterday, 7/14/2020, sometime between 0915 and 0930 EDT, a male patient receiving TheraSphere treatment was underdosed by approximately 30 percent due to a leak in the delivery assembly. This was discovered around half-way through the procedure. No exposure to anyone other than the patient occurred. Contamination has been contained and removed. The prescribed activity was 5.7 GBq and dose was 150 Gy. The actual activity delivered is estimated to be 3.99 GBq and dose was 105 Gy. The patient is scheduled to return next week for follow-up treatment."

Florida Incident Number: FL20-080

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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Non-Agreement State Event Number: 54783
Rep Org: NASA MICHOUD ASSEMBLY FACILITY
Licensee: NASA MICHOUD ASSEMBLY FACILITY
Region: 4
City: New Orleans   State: LA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Keith Savoy
HQ OPS Officer: Brian Lin
Notification Date: 07/15/2020
Notification Time: 15:15 [ET]
Event Date: 07/06/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/15/2020
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen Lnm>1000x
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOSS TRITIUM EXIT SIGN

The following information was received via email:

"The Michoud Assembly Facility [(MAF)] operates under an NRC general license. The MAF currently has a project being performed by a subcontractor to replace approximately 28 Tritium exit signs. On 7/6/2020, an employee noticed that one Tritium exit sign [source activity of 3.0 Curies] was not in the location of its last inventory. Further investigation into the incident and discussions with the project manager indicated that the exit sign was most likely removed by the subcontractor performing the demolition work on-site. The project manager notified the subcontractor to investigate the incident further, at which time the subcontractor reported the Tritium exit sign had been disposed of at the Construction and Debris (C&D) waste [facility] in the Gentilly Landfill LCC 1 located at 10200 Almonaster Blvd. in New Orleans, LA 70127."

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: 54784
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Construction & Geotechnical Material Testing, Inc.
Region: 3
City: Bensenville   State: IL
County:
License #: IL-02179-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ossy Font
Notification Date: 07/16/2020
Notification Time: 10:48 [ET]
Event Date: 07/14/2020
Event Time: 15:30 [CDT]
Last Update Date: 07/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE CRUSHED WITH SOURCE ROD EXTENDED

The following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email:

"At approximately 1530 CDT on July 14, 2020, the Agency was contacted by the RSO [(Radiation Safety Officer)] /owner of Construction & Geotechnical Material Testing (IL-02179-01) regarding a Troxler 3440 gauge [s/n: 24805; containing 8 mCi of Cs-137 and 40 mCi of Am-241] that was run over and crushed by an operator running a roller on a construction site at 1514 Main Street in Lombard. The RSO reported that operations had stopped and that he needed guidance to get the source rod out. At 1550 CDT, the Agency contacted the licensee for details and to provide guidance.

"The gauge user was uninjured but the gauge was run over and destroyed. At the time of the incident it was confirmed that the source rod was extended into the ground and a measurement was in process. The gauge user immediately notified personnel in the area and cordoned off the area. The gauge user then notified his RSO, who then notified Troxler (their emergency contact) and IEMA as per their emergency procedures. The RSO immediately went to the scene. He stated that he verified the security of the scene. He did not believe that the source rod was bent. The RSO stated that he was headed back to his office for a survey meter.

"Agency inspectors reviewed concerns regarding exposure from the Cs-137 source and the possibility of a leaking source with the RSO. Procedures were reviewed for surveys of the area once the gauge was removed to ensure the Cs-137 source had not become dislodged and that the source was not leaking. The Agency offered to dispatch inspectors to assist; however, the licensee had the gauge manufacturer engaged and able to respond.

"The gauge manufacturer responded to the scene at approximately 1700 CDT and confirmed the source rod was unbent and able to be shielded. Both the Am-241 and the Cs-137 sources were confirmed as present and intact. The gauge was safely repackaged into the Troxler case by Troxler personnel and the TI [Transport Index] confirmed as 0.3. This information was confirmed with pictures sent to the Agency. Troxler personnel performed surveys of the area to confirm the source was removed and that there was no contamination/leakage. Both sources (Cs-137 and Am-241) were placed into the Troxler transport container without incident. Both Troxler and the licensee performed surveys of the site prior to departing and after packaging the damaged source. At 1830, the licensee confirmed background readings at the site and the gauge was transported back to Troxler. The gauge will be leak tested and then shipped to Troxler in North Carolina for disposal.

"This matter will remain open pending receipt of leak tests, additional gauge information, documentation of disposal, and required written reports."

Illinois Item Number: IL200011

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Agreement State Event Number: 54785
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: Syngenta Crop Protection, LLC
Region: 4
City: St. Gabriel   State: LA
County:
License #: LA-2219-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Donald Norwood
Notification Date: 07/16/2020
Notification Time: 13:09 [ET]
Event Date: 07/15/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK FIXED GAUGE SHUTTER

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

On July 15, 2020, at 1445 CDT, the Radiation Safety Officer (RSO) for Syngenta Crop Protection, LLC contacted the Louisiana Department of Environmental Quality / Emergency and Radiological Services Division / Radiation Section to report that shutters had failed to close on two fixed density gauges during routine maintenance. The shutters are stuck in the open position and do not affect operation. The gauges are Ronan Engineering Model SAI, s/n's 5832GK and 5835GK, each with a 50 mCi Cs-137 sealed source, at the time of installation. The licensee contacted the contractor, BBP Sales, LLC, to determine whether the gauges should be disposed of or repaired. The decision will be made on July 16, 2020 on how to deal with the stuck shutters. Repair or disposal of the gauges should be accomplished by July 20, 2020.

Louisiana Event Report ID No.: LA20200005


Page Last Reviewed/Updated Friday, July 24, 2020
Friday, July 24, 2020