Event Notification Report for September 09, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/08/2020 - 09/09/2020
EVENT NUMBERS
54896548925489354894
Agreement State
Event Number: 54896
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: Becton Dickinson Infusion Therapy Systems Inc
Region: 4
City: Broken Bow State: NE
County: Custer
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: Brian Miller
HQ OPS Officer: Thomas Herrity
Licensee: Becton Dickinson Infusion Therapy Systems Inc
Region: 4
City: Broken Bow State: NE
County: Custer
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: Brian Miller
HQ OPS Officer: Thomas Herrity
Notification Date: 09/11/2020
Notification Time: 13:56 [ET]
Event Date: 09/09/2020
Event Time: 16:29 [CDT]
Last Update Date: 09/11/2020
Notification Time: 13:56 [ET]
Event Date: 09/09/2020
Event Time: 16:29 [CDT]
Last Update Date: 09/11/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GREG WARNICK (R4DO)
SILAS KENNEDY (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG WARNICK (R4DO)
SILAS KENNEDY (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - WATER LOSS FROM SOURCE STORAGE POOL
The following is a synopsis of the report received from the State of Nebraska Division of Radioactive Materials via phone:
The licensee reported that while they were responding to a product jam alarm they discovered some water on the floor by the source storage pool. In reviewing the control system operation log, the operators found the system had responded to a low water level by opening the make-up water valve. This is a normal system occurrence due to evaporation from the pool. The make-up valve did not close upon reaching the normal water level, so level in the pool continued to rise. Level reached the high water alarm point which is at the top of the pool. The drain valve opened at the high water alarm point causing level to drop, but some water had already overflowed from the pool onto the surrounding floor. Level continued to lower and upon reaching the low level setpoint the system correctly responded by closing the drain valve and reopening the make-up valve. The level control system then responded correctly and the make-up valve closed when water level returned to normal.
The irradiator facility has replaced the level switches and updated the preventative maintenance frequency for the valves and switches to prevent a repeat of this event.
The source was never uncovered. No release or personnel exposure occurred.
The following is a synopsis of the report received from the State of Nebraska Division of Radioactive Materials via phone:
The licensee reported that while they were responding to a product jam alarm they discovered some water on the floor by the source storage pool. In reviewing the control system operation log, the operators found the system had responded to a low water level by opening the make-up water valve. This is a normal system occurrence due to evaporation from the pool. The make-up valve did not close upon reaching the normal water level, so level in the pool continued to rise. Level reached the high water alarm point which is at the top of the pool. The drain valve opened at the high water alarm point causing level to drop, but some water had already overflowed from the pool onto the surrounding floor. Level continued to lower and upon reaching the low level setpoint the system correctly responded by closing the drain valve and reopening the make-up valve. The level control system then responded correctly and the make-up valve closed when water level returned to normal.
The irradiator facility has replaced the level switches and updated the preventative maintenance frequency for the valves and switches to prevent a repeat of this event.
The source was never uncovered. No release or personnel exposure occurred.
Agreement State
Event Number: 54892
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: Mid American Energy - Lousia Generating Station
Region: 3
City: Muscatine State: IA
County:
License #: 0040-1-70-FG
Agreement: Y
Docket:
NRC Notified By: Randal S. Dahlin
HQ OPS Officer: Thomas Herrity
Licensee: Mid American Energy - Lousia Generating Station
Region: 3
City: Muscatine State: IA
County:
License #: 0040-1-70-FG
Agreement: Y
Docket:
NRC Notified By: Randal S. Dahlin
HQ OPS Officer: Thomas Herrity
Notification Date: 09/09/2020
Notification Time: 12:17 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2020
Notification Time: 12:17 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date : 9/25/2020
EN Revision Text: AGREEMENT STATE REPORT - BROKEN SHUTTER MECHANISM ON FIXED GAUGE
The following was received from Iowa Department of Public Health via email:
"The licensee reported today that during a routine shutter check it was discovered that a shutter on a fixed gauging device had come off of its hinge. The device is located on coal silo 106 outlet at the 163 foot elevation. Due to the location of the device, no personnel can be exposed to the beam. The licensee has contacted a vendor to repair the shutter. This event will be updated once the Agency (Iowa Department of Public Health) receives the written report."
The gauge was a Kay-Ray Sensall model 7700-C containing 50 milliCuries of Cs-137.
Iowa NMED Number: IA200003
* * * UPDATE ON 9/24/20 AT 1119 EDT FROM RANDAL DAHLIN TO SOLOMON SAHLE* * *
The following information was received from the State of Iowa Department of Public Health via email:
"The outside vendor arrived on-site September 16, 2020 and found that the right end mounting bracket for the shaft was bent and the shaft was no longer in the mounting bracket. The vendor removed the device and repaired the shutter. The apparent cause of the shutter failure was the source was swung out to where it completely cleared the calibration blocks and then swung back into place. The state considers this event be closed."
Notified R3DO (Cameron) and NMSS Events Notifications (email).
Agreement State
Event Number: 54893
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: Medical College of Wisconsin
Region: 3
City: Milwaukee State: WI
County:
License #: 079-1104-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Caty Nolan
Licensee: Medical College of Wisconsin
Region: 3
City: Milwaukee State: WI
County:
License #: 079-1104-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Caty Nolan
Notification Date: 09/09/2020
Notification Time: 16:28 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2020
Notification Time: 16:28 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST AND FOUND MO-99/TC-99M GENERATOR
The following was received from the State of Wisconsin Department of Health Services (the Department) via email:
"On September 9, 2020, the licensee reported a missing 7.5 Ci Mo-99/Tc-99m generator, which was subsequently found, to the Department. The facility receives a generator every Sunday evening. On September 8, the licensee became aware that this week's generator was missing and initiated search efforts. The licensee confirmed with the generator supplier that a generator was delivered on September 6. The licensee reviewed security footage and determined that the generator was delivered at 2115 CDT on September 6. The licensee reviewed additional camera footage and determined that a different courier service requested access to the nuclear medicine hot lab about an hour later and took the package that had been delivered at 2115 CDT. The licensee contacted the second courier service and determined that the missing generator was found in the courier's warehouse on September 9. The generator has been returned to the licensee.
"The licensee is evaluating potential dose to members of the public. The Department will perform a follow-up investigation."
Event Report No.: WI200006
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
The following was received from the State of Wisconsin Department of Health Services (the Department) via email:
"On September 9, 2020, the licensee reported a missing 7.5 Ci Mo-99/Tc-99m generator, which was subsequently found, to the Department. The facility receives a generator every Sunday evening. On September 8, the licensee became aware that this week's generator was missing and initiated search efforts. The licensee confirmed with the generator supplier that a generator was delivered on September 6. The licensee reviewed security footage and determined that the generator was delivered at 2115 CDT on September 6. The licensee reviewed additional camera footage and determined that a different courier service requested access to the nuclear medicine hot lab about an hour later and took the package that had been delivered at 2115 CDT. The licensee contacted the second courier service and determined that the missing generator was found in the courier's warehouse on September 9. The generator has been returned to the licensee.
"The licensee is evaluating potential dose to members of the public. The Department will perform a follow-up investigation."
Event Report No.: WI200006
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
Agreement State
Event Number: 54894
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Not Provided
Region: 1
City: State: NY
County:
License #: Not Provided
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Thomas Herrity
Licensee: Not Provided
Region: 1
City: State: NY
County:
License #: Not Provided
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Thomas Herrity
Notification Date: 09/09/2020
Notification Time: 16:29 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2020
Notification Time: 16:29 [ET]
Event Date: 09/09/2020
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE
The following was received from the New York State Department of Health via fax:
"A medical licensee reported that only 30.3 mCi of a prescribed dose of 45.1 mCi of SIRTEX SIR-Spheres was delivered to a patient. The microspheres apparently became clogged in the applicator. A written report is forthcoming."
Event Report ID No.: NYDOH-20-03
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.
The following was received from the New York State Department of Health via fax:
"A medical licensee reported that only 30.3 mCi of a prescribed dose of 45.1 mCi of SIRTEX SIR-Spheres was delivered to a patient. The microspheres apparently became clogged in the applicator. A written report is forthcoming."
Event Report ID No.: NYDOH-20-03
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.