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Event Notification Report for September 25, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/24/2020 - 9/25/2020

** EVENT NUMBERS **


54892 54900 54902 54903 54904 54908

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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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



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).

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Agreement State Event Number: 54900
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Pavetex Engineering LLC
Region: 4
City: Pottsboro   State: TX
County:
License #: L 06407
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian Lin
Notification Date: 09/16/2020
Notification Time: 07:40 [ET]
Event Date: 09/14/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOST AND FOUND DEVICE

The following information was submitted by the Texas Department of Health Services (the Agency) via email:

"On September 15, 2020, at 1700 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that one of their technicians had left a Troxler model 4640B density gauges at a job site overnight. The technician had completed their work on September 14, 2020, and left the job site after completing their paperwork, but failed to store the device into their truck. The RSO stated the gauge handle was locked and did not believe any individual would receive an exposure. The RSO stated the device contains two cesium-137 sources, but did not know the activities. The manufacturer's website states the activity to be 8 (+ or - 1) milliCuries. The licensee's license states a device source cannot exceed 9 milliCuries. The RSO stated they had technicians out searching for the gauge. At 1736 CDT, on September 15, 2020, the RSO contacted the Agency and reported the gauge had been recovered. He could not provide any additional information. Additional information has been requested. If during the investigation of this event it is determined that an individual could have been exposed, the Agency will submit an update to this report. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 9797

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Agreement State Event Number: 54902
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo   State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel J. Samson
HQ OPS Officer: Howie Crouch
Notification Date: 09/16/2020
Notification Time: 17:16 [ET]
Event Date: 08/11/2020
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSC (CANADA) (FAX)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was obtained from the state of New York via facsimile:

"On September 9, 2020, the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO [radiation safety officer] when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered.

"In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered.

"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."

New York Event Report ID No.: NYDOH-20-04

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: 54903
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: St. Mark's Hospital
Region: 4
City: Salt Lake City   State: UT
County:
License #: UT 1800253
Agreement: Y
Docket:
NRC Notified By: Phil Goble
HQ OPS Officer: Thomas Herrity
Notification Date: 09/16/2020
Notification Time: 18:00 [ET]
Event Date: 09/16/2020
Event Time: 13:00 [MDT]
Last Update Date: 09/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT RADIONUCLIDE ADMINISTERED TO A PATIENT

The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email:

"At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient."

State Event Report No.: Will be provided in a follow up 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: 54904
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Geotek Operations Limited
Region: 4
City: Phoenix   State: AZ
County:
License #: 07-495
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Thomas Herrity
Notification Date: 09/16/2020
Notification Time: 18:48 [ET]
Event Date: 09/16/2020
Event Time: 00:00 [MST]
Last Update Date: 09/16/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CONSTRUCTION GAUGE RUN OVER BY CONSTRUCTION VAN

The following was received from the Arizona Department of Health Services (The Department) via email:

"The Department received notification from the licensee that a construction vehicle ran over a portable gauge. The gauge is a Troxler 3430, Serial Number 21871, containing approximately 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241:Beryllium. The Department has requested additional information and continues to investigate the event."

Arizona Event No. 20-018.

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Power Reactor Event Number: 54908
Facility: Grand Gulf
Region: 4     State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Leroy Purdy
HQ OPS Officer: Brian P. Smith
Notification Date: 09/24/2020
Notification Time: 06:31 [ET]
Event Date: 09/24/2020
Event Time: 02:58 [CDT]
Last Update Date: 09/24/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
RICK DEESE (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 83 Power Operation 83 Power Operation

Event Text

EMERGENCY SIREN INADVERTENTLY ACTUATED

"On September 24, 2020, at 0258 CDT, Grand Gulf Nuclear Station (GGNS) was notified that one Emergency Notification Siren located on US Hwy 61 had actuated. Claiborne County was informed that no emergency exists at GGNS. The alarming siren has since been secured. Notification is being provided to the NRC in regards to the potential for media inquiry.

"The licensee informed the NRC Resident Inspector."


Page Last Reviewed/Updated Friday, September 25, 2020
Friday, September 25, 2020