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Event Notification Report for July 27, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/24/2020 - 7/27/2020

** EVENT NUMBERS **


54784 54785 54786 54787 54788 54790 54791 54800

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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

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Agreement State Event Number: 54786
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UF Health Jacksonville, Shands
Region: 1
City: Jacksonville   State: FL
County:
License #: 3157-1
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Ossy Font
Notification Date: 07/17/2020
Notification Time: 09:49 [ET]
Event Date: 07/16/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received from the Florida Bureau of Radiation Control (BRC) via email:

"On July 16, 2020, a 54 year old man was mistakenly provided two doses of Tc-99 Sestamibi for heart stress test. Two doses were administered with a total activity of 41.6 mCi, estimated dose of 7.49 R, to the intestinal wall. The RSO [(Radiation Safety Officer]) reports that standard verification process for patient identification prior to dosage was not followed. Patient and patient's cardiologist have both been notified, no effects of the mis-dose are expected.

"The RSO will provide additional info in the 15 day letter to BRC. Licensing and Technology will be tasked to investigate."

Florida Incident Number FL20-081

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: 54787
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: Alpha-Omega Services, Inc.
Region: 4
City: Vinton,   State: LA
County:
License #: LA-10025-L01, Amedment 33, AI30898
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 10:48 [ET]
Event Date: 07/12/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SOURCE DAMAGED IN SHIPMENT

The following was received from the Louisiana Department of Environmental Quality via email:

"On July 12, 2020, the Radiation Safety Officer (RSO) contacted the state by voice mail to the Louisiana Department of Environmental Quality/Emergency Response Services Division/Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was damaged in transit with the shipper. The source was being shipped to Providence Regional Cancer Partnership, Rad Oncology Department, 1717 13th Street, Everett, WA 98201. The source serial number is 02-01-2499-001-062320-11518-64. The activity of the Ir-192 source was 11.189 Ci on June 26, 2020 when it was shipped. The source was returned back to Alpha-Omega Services because the HDR drive cable was found damaged and twisted. The transport container had been damaged. The source was found to be one inch high from its designated shielding transportation position. The return survey found the exposure to be 80 mR.hr at surface and 4.0 mR/hr TI. The container had been shipped at a surface reading of 31 mR/hr and a TI of 0.9 mR/hr at one meter."

LA Report Number: LA20200006

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Agreement State Event Number: 54788
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Mayo Clinic Jacksonville
Region: 1
City: Jacksonville   State: FL
County:
License #: 1812-3
Agreement: Y
Docket:
NRC Notified By: John Williamson
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 17:20 [ET]
Event Date: 07/17/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTERED TO PATIENT

The following was reported by the Florida Bureau of Radiation Control:

"On 7/17/2020 during ablative treatment with Y-90 TheraSpheres to the male patient, it was discovered that only a partial treatment was administered to the patient. 511.6 Gy was prescribed, 358.9 Gy was delivered, for a 70% delivery rate. The event was discovered during a routine check of waste activity. The Radiation Safety Officer (RSO) reports that from initial information from the tech, all procedures were followed. No abnormal events were noted during the procedure. The prescribing physician and patient have been notified. Clinical outcome is expected to be ok. The RSO will phone in more details on Monday as he was working remotely on Friday. A fifteen day letter will follow. Licensing and Technology will be tasked to investigate."

FL incident number: FL20-082

Notified RI and NMSS Events Notification.

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: 54790
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UTAH CANCER SPECIALISTS
Region: 4
City: Salt Lake City   State: UT
County:
License #: UT 1800491
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Thomas Herrity
Notification Date: 07/17/2020
Notification Time: 20:05 [ET]
Event Date: 07/16/2020
Event Time: 00:00 [MDT]
Last Update Date: 07/17/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINSTRATION OF MEDICAL TREATMENT

The following was received from the State of Utah, Department of Environmental Quality, Division of Waste Management and Radiation Control:

"Misadministration with external beam radiation therapy, the licensee (Utah Cancer Specialists) delivered 300 cGy per site, per day, over two treatments, as follows: Two sites were treated incorrectly at 1000 MDT on July 16, 2020 in the 3rd lumbar area and the right kidney. One site was treated incorrectly at 1530 MDT on July 17, 2020 in the 3rd lumbar area while the right kidney was treated correctly.

"It was discovered by way of a cone beam CT in preparation for the kidney treatment where the misalignment was observed. The misalignment was made due to setting up at incorrect tattoos."

Utah Event Number will be provided in a later report.

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: 54791
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: J.D. Hynes and Associates
Region: 1
City: Princess Anne   State: MD
County:
License #: 45-011-01
Agreement: Y
Docket:
NRC Notified By: Charles Cox
HQ OPS Officer: Kerby Scales
Notification Date: 07/18/2020
Notification Time: 11:17 [ET]
Event Date: 07/17/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/20/2020
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 - LOST TROXLER GAUGE

The following was received by the state of Maryland via email:

"On July 17, 2020 at 2115 EDT the Maryland Radiological Health Program was notified of a lost or stolen portable moisture density gauge. A technician for J. D. Hynes and Associates was at a job site at the University of Maryland Eastern Shore, 30610 College Backbone Road, Princess Anne Maryland. The technician completed the job and was preparing to store the gauge in the transportation case when he was distracted. He then drove the truck approximately 16 miles back to the office at 32185 Beaver Run Drive, Salisbury, MD 21804. The technician discovered the gauge was not in the case. The technician contacted his supervisor and the owner at 1730 EDT and then returned to the job site at approximately 1800 EDT to search for the gauge and discovered the site was locked. The project superintendent was contacted and a key for entry was obtained by the licensee supervisor. Both the licensee supervisor and technician entered the jobsite and searched for the missing gauge and did not locate it there. Then they searched along the travel route independently from each other to try and locate the missing gauge. Both employees searched until approximately 2100 EDT when it got too dark to see. The licensee contacted Wicomico County Police Department and Somerset County Police department and both county fire departments. The gauge was a Troxler 3400 series with 9 mCi Cs-137 and 44 mCi AmBe sources. The serial number is 75791. A reactive inspection will be conducted on Monday July 20, 2020."

* * * UPDATE ON 7/2/2020 AT 1724 EDT FROM ATNATIWOS MESHESHA TO THOMAS KENDZIA * * *

The following update was received via email:

"A portable density gauge was lost from the J.D. Hynes and Associates, Inc. on July 17, 2020 between approximately 14:45 EDT to 15:20 hours EDT. The gauge was identified as Troxler, model 3440P, serial number 75791 with nominal activities of 8 mCi of Cs-137 (on 1/7/2019) and 40 mCi of Am-241:Be (on 2/11/2019). The last leak test was performed on March 6, 2020. The gauge was lost while returning to office from the job-site.

"On July 17, 2020, at approximately 10:00 hours EDT, the density gauge was placed in the tailgate of a pick-up truck by the gauge operator after warm up and daily calibration, and waiting for the day's work at a building construction in the University of Maryland Eastern Shore Campus located at 30610 Collage Backbone Road; Princess Anne, Maryland 25813; in Somerset County. Work was suspended at about 14:45 hours EDT due to water leakages in the underground pipes. The gauge operator proceeded to drive back to the licensee's office located at 32185 Beaver Run Drive, Salisbury, MD 21804, in Wicomico County. After driving for about 25 minutes (about 18 miles) and arriving at the office parking lot the gauge operator realized that the gauge was not placed in its transportation case. The gauge was missing from the bed of the open tailgate of the pick-up truck.

"The event has been reported to the Maryland State Police, in Salisbury; the Incident Number is: 2020-00322775.

"Maryland Department of Environment, Radiological material Division will conduct a reactive investigation.

Notified R1DO (Carfang), NMSS Event Notifications (email) and ILTAB (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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Power Reactor Event Number: 54800
Facility: Sequoyah
Region: 2     State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Cal Atchley
HQ OPS Officer: Bethany Cecere
Notification Date: 07/24/2020
Notification Time: 09:00 [ET]
Event Date: 07/24/2020
Event Time: 01:05 [EDT]
Last Update Date: 07/24/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

ICE BED INOPERABLE

"At 0105 [EDT] on 7/24/20 it was discovered Unit 2 Ice Bed was INOPERABLE. Therefore, since this is a single train system the requirements of 50.72 (b)(3)(v)(C) and (D) have been met. This condition is being reported as an 8-hour non-emergency NRC Notification.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

This condition put the unit in a 48-hour LCO. The old chillers were put into service to bring the temperature of the ICE bed down. At 0833 EDT, the technical specification limit was no longer exceeded and the unit exited the LCO.


Page Last Reviewed/Updated Monday, July 27, 2020
Monday, July 27, 2020