United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2020 > October 02

Event Notification Report for October 02, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/1/2020 - 10/2/2020

** EVENT NUMBERS **


54878 54906 54909 54910

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 10/01/2020
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



EN Revision Imported Date : 10/2/2020

EN Revision 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 their 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

* * * RETRACTION ON 10/1/2020 AT 1020 EDT FROM DEB WILSON TO ANDREW WAUGH * * *

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

"While the Home Depots were remodeled at similar times, it was found that the tritium exit signs at Store 3210 in Scottsbluff were kept in service until the end of their useful life. Records were recovered showing all signs being disposed of by Curie Environmental Services in Albuquerque, NM on 9/20/2019."

Notified R4DO (Silva), NMSS Events (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

To top of page
Agreement State Event Number: 54906
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Western Illinois Cancer Treatment Center
Region: 3
City: Galesburg   State: IL
County:
License #: IL-01902-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Brian Lin
Notification Date: 09/23/2020
Notification Time: 14:58 [ET]
Event Date: 09/22/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/23/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The Agency was notified on 9/23/20 that a high dose rate afterloader (HDR) administration resulted in a medical event on 9/22/20 at the Western Illinois Cancer Treatment Center in Galesburg, IL. The licensee states no untoward effects are expected of the patient. Agency staff will respond and evaluate on 9/24/20. The Agency was contacted by an authorized medical physicist and radiation safety officer for Western Illinois Cancer Treatment Center in Galesburg (RML IL-01902-01), to report a medical event that occurred the previous day on September 22, 2020. Reportedly, a patient was prescribed a 30 Gy therapeutic dose to the vaginal cuff, to be delivered over a series of (5) fractionated 6 Gy administrations. Two of the 6 Gy administrations had already been performed on 9/15/20 and 9/18/20 without issue. The patient arrived for the third fractionated dose of 6 Gy on 9/22/20. An unnamed nurse was present as well. It is unclear if an authorized medical physicist was physically present at time of administration. Rather than delivering the dose through the vaginal cavity, the HDR applicator was inserted into the rectal cavity. This was not noticed until after the treatment was delivered. Based on the information currently available, the written directive specified a 6 Gy fraction to be delivered to the vaginal treatment area. The dose delivered was 1.46 Gy. This meets the reportable criteria in 32 Ill. Adm. Code 335.1080(a)(1) for an underdose. Additionally, had the administration gone as prescribed; the rectum would have only received (for 50% of the volume) 1.53 Gy per fraction. In this administration, the dose to the rectum (50% of volume) was 3.94 Gy. This also meets the reportable criteria for an overexposure. The format of this report provides data in the context of an overexposure. The language in the written directive will be reviewed, as well as procedures, personnel present, treatment plan and post-plan calculations on September 24, 2020. Reporting timeliness appears appropriate at this time. A written report will be required to the Agency by October 7, 2020. The referring physician has been notified. The patient is being advised today, which at this time appears to be in accordance with applicable regulations. This report will be updated as additional information becomes available."

Illinois Item Number: IL200017.

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.

To top of page
Agreement State Event Number: 54909
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Terracon Consultants
Region: 1
City: Sarasota   State: FL
County:
License #: 3817-13
Agreement: Y
Docket:
NRC Notified By: Mark Seidensticker
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2020
Notification Time: 12:41 [ET]
Event Date: 09/24/2020
Event Time: 09:30 [EDT]
Last Update Date: 09/24/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DONNA JANDA (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/STOLEN TROXLER GAUGE

The following is a summary of information reported by the Florida Department of Health via email:

Terracon Consultants reported a Troxler 2440 gauge was stolen from a truck while the truck was parked at a residence in Brandenton, Florida. The gauge was stolen around 0930 EDT on 9/24/2020. The gauge was secured with two chains and two locks by the driver of the truck. The local police department has been notified. The gauge contained a 8 mCi Cs-137 source (S/N: 75-1841) and a 40 mCi Am241:Be source (S/N: 47-15958).

Florida Incident Number: FL20-109

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

To top of page
Agreement State Event Number: 54910
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MISTRAS Group, Inc.
Region: 1
City: Midlothian   State: VA
County:
License #: 041-498-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2020
Notification Time: 12:57 [ET]
Event Date: 07/31/2019
Event Time: 10:28 [EDT]
Last Update Date: 09/24/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - CAMERA SOURCE UNABLE TO RETRACT

The following was reported by the Virginia Office of Radiological Health, via email:

"On August 26, 2019, the Virginia Office of Radiological Health (ORH) received an incident report from the licensee, MISTRAS GROUP, Inc. The source, 66 curies of Ir-192, could not be retracted to its shielded position during radiographic work. The radiographic work involved inspecting a water tank located in an open space. The incident occurred on July 31, 2019, at about 1028 EDT at a temporary jobsite located in White Post, Virginia. The incident occurred because a magnetic stand that was utilized to support the source tube fell during an exposure, creating a kink in the source tube and preventing full retraction back to the shielded position. The radiography crew immediately established a new boundary, notified the Radiation Safety Officer (RSO) and customer, and relocated all workers outside the boundary area. A radiation survey was performed immediately at the new boundary and the measurement did not exceed 2 mR in any one hour. The site was supervised by the radiography crew until the RSO arrived at the scene and repositioned the source back to its shielding position safely. The pocket dosimeters indicated that the RSO, the radiographer, and assistant radiographer received 28 mrem, 20 mrem, and 10 mrem, respectively. In addition, the whole body dosimeters were sent to Landauer for analysis and no significant radiation exposures were reported to the RSO, Radiographer, and Assistant Radiographer.

"On August 28, 2019, the ORH inspector conducted a reactive inspection and it was found that the root causes of the incident were identified properly by the licensee and corrective actions, including training on procedures, on radiographic techniques, and on set up for that particular type of radiography work were discussed with the radiographer. The ORH determined that this incident is closed."

The report from Virginia also stated:

"This incident was reported to the NRC through NMED on August 29, 2019 as if it was a 30-day notification requirement. However, the 2020 Virginia IMPEP review team discovered that it should have been classified as a 24-hour notification requirement. Accordingly, this report is being sent to correct the error."

Event Report ID No: VA-19004


Page Last Reviewed/Updated Friday, October 02, 2020
Friday, October 02, 2020