Event Notification Report for September 11, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/10/2020 - 9/11/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54861
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: Mistras Group, Inc. Region: 4 City: Torrance State: CA County: License #: 4832-19 Agreement: Y Docket: NRC Notified By: Robert Greger HQ OPS Officer: Donald Norwood	Notification Date: 08/26/2020 Notification Time: 23:49 [ET] Event Date: 07/07/2020 Event Time: 00:00 [PDT] Last Update Date: 08/27/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE RETRACTION FAILURE

The following information was received via E-mail:

"The Radiation Safety Officer with Mistras Group, Inc. contacted the Radiologic Health Branch regarding an incident with an Ir-192 radiography source that was determined to be locked out of its exposure device. The source was an Industrial Nuclear Model 32 Ir-192 source, Serial Number 550F, with an activity of 63.4 Curies. The device was an Industrial Nuclear Ir-100, Serial Number 4358. The incident occurred during radiography operations at a refinery in El Segundo.

"After a routine exposure, the radiographer retracted the source. The radiographer then proceeded with the radiation survey that showed a dose rate of 80 mR/hr approximately 2 feet from the exposure device, indicating that the source was not in the locked and shielded position. The radiographer contacted the RSO who instructed them to readjust the restricted area boundary to maintain 2 mR/hr dose rate.

"After the RSO arrived at the site, they placed shielding to reduce the dose rate while performing retrieval and returning the source to the locked and secured position. The device was then red tagged and placed out of service until it could be evaluated by the manufacturer. The highest dose received by Mistras Personnel (RSO) was 20 mrem, as read by a self-reading pocket dosimeter. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

California 5010 Number: 070820

Fuel Cycle Facility	Event Number: 54875
Facility: Global Nuclear Fuel - Americas RX Type: Uranium Fuel Fabrication Comments: Leu Conversion (Uf6 To Uo2) Leu Fabrication Lwr Commerical Fuel Region: 2 City: Wilmington State: NC County: New Hanover License #: SNM-1097 Docket: 07001113 NRC Notified By: Phillip Ollis HQ OPS Officer: Donald Norwood	Notification Date: 09/02/2020 Notification Time: 16:52 [ET] Event Date: 09/02/2020 Event Time: 10:27 [EDT] Last Update Date: 09/02/2020
Emergency Class: Non Emergency 10 CFR Section: PART 70 APP A (c) - Offsite Notification/News Rel	Person (Organization): MARK MILLER (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT REPORT FOR OFFSITE NOTIFICATION

"At approximately 1027 EDT on September 2, 2020, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing a part of the Fuel Manufacturing Operation (FMO) was impaired due to planned sprinkler head modifications. Additional compensatory measures were enacted. The system was restored at approximately 1300 EDT today (9/2/2020) and the Deputy Fire Marshall informed of restoration. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will notify Region 2.

Agreement State	Event Number: 54876
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: University Hospitals of Cleveland Region: 3 City: Cleveland State: OH County: License #: 02110180077 Agreement: Y Docket: NRC Notified By: Michael J. Rubadue HQ OPS Officer: Thomas Herrity	Notification Date: 09/03/2020 Notification Time: 11:13 [ET] Event Date: 08/27/2020 Event Time: 00:00 [EDT] Last Update Date: 09/03/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): DAVID HILLS (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE DELIVERED TO PATIENT

The following was received from the Ohio Department of Health:

"The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver.

"The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. The posterior was treated first and then the catheter was moved to the anterior position. Post treatment scans of the patient indicated the posterior received 20 mCi (35 Gy) and the anterior received 100 mCi (180 Gy). The physician believes the catheter slipped after initial placement, resulting in an overdose to the anterior and underdose to the posterior.

"The licensee will no longer conduct spilt dose procedures."

Ohio Item Number: OH200006

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.

Agreement State	Event Number: 54878
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: Home Depot #3210 Region: 4 City: Scottsbluff State: NE County: License #: GL0644 Agreement: Y Docket: NRC Notified By: Deb Wilson HQ OPS Officer: Thomas Herrity	Notification Date: 09/03/2020 Notification Time: 16:17 [ET] Event Date: 05/31/2012 Event Time: 00:00 [CDT] Last Update Date: 09/03/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): RICK DEESE (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

This is information received from the state of Nebraska via email:

"In conducting a search for records for NRC Event #54500, it was determined that Home Depot #3210 was remodeled at the same time as Home Depot #3208 in Grand Island, NE and all (16) tritium exit signs were exchanged for LED in May 2012. Disposal records are unavailable due to Staybright Electric, the contractor in charge of replacement and disposal, going out of business. Home Depot was unable to produce disposal records but it is there belief that the signs were disposed of properly as Staybright conducted tritium exit sign removals for other Home Depots in the region prior to their closing for which records of disposal were obtained, demonstrating knowledge of proper procedure.

"The State of Nebraska also checked with Tritiumdisposal.com and SRBT in attempt to locate records as the outlets of disposal for Staybright, but no records were found.

"Home Depot currently has a plan in place that was submitted to the NRC in July of 2009 for facility management to reiterate tritium exit sign management requirements to existing vendors to ensure signs are managed within NRC requirements. As part of ongoing tritium exit sign servicing it is very reasonable to believe that Staybright transferred and disposed of tritium exit sign inventory properly. Home Depot continues to proactively address and replace (as appropriate) its remaining tritium exit sign inventories through the use of professional, third party vendors and continues to responsibly manage its existing inventories at current stores throughout the United States.

"A Home Depot corporate representative will track all purchases and returned signs to ensure accurate inventory and disposal.

"All Tritium Exit Signs have been replaced with LED.

"Home Depot will no longer install tritium exit signs within newly constructed locations."

Nebraska Item Number: NE200006

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: 54879
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: Grady Memorial Hospital Region: 1 City: Atlanta State: GA County: License #: GA 258-2 Agreement: Y Docket: NRC Notified By: Leslines Leveque HQ OPS Officer: Thomas Herrity	Notification Date: 09/03/2020 Notification Time: 17:27 [ET] Event Date: 08/27/2020 Event Time: 00:00 [EDT] Last Update Date: 09/03/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): JOSEPHINE AMBROSINI (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 MEDICAL SEED AFTER REMOVAL FROM PATIENT

The following is a synopsis of the event received from the Georgia Radioactive Materials Program:

On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted.

On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020.

The seeds were I-125 encapsulated in titanium. Model IAI-125A. Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts.

The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds.

Incident #: 29

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

Power Reactor	Event Number: 54895
Facility: Pilgrim Region: 1 State: MA Unit: [1] [] [] RX Type: [1] GE-3 NRC Notified By: Stan Paul HQ OPS Officer: Kerby Scales	Notification Date: 09/10/2020 Notification Time: 16:09 [ET] Event Date: 09/10/2020 Event Time: 10:02 [EDT] Last Update Date: 09/10/2020
Emergency Class: Non Emergency 10 CFR Section: 26.719 - Fitness For Duty	Person (Organization): ANNE DeFRANCISCO (R1DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Defueled

Event Text

FITNESS FOR DUTY (FFD) POLICY VIOLATION

A contract employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's rights to access the plant have been suspended.

The licensee notified the NRC Region I Decommissioning Lead Inspector.

Page Last Reviewed/Updated Wednesday, March 24, 2021