Event Notification Report for September 27, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/26/2021 - 09/27/2021
Agreement State
Event Number: 55470
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Cheddars Casual Caf‚
Region: 4
City: Colorado Springs State: CO
County:
License #: GL002038
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Cheddars Casual Caf‚
Region: 4
City: Colorado Springs State: CO
County:
License #: GL002038
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/06/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/06/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 7.09 Ci of tritium each, were reported as lost during annual registration. The owner recalled that the signs had been removed many years ago."
NMED No.: CO210020
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
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 7.09 Ci of tritium each, were reported as lost during annual registration. The owner recalled that the signs had been removed many years ago."
NMED No.: CO210020
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: 55471
Rep Org: COLORADO DEPT OF HEALTH
Licensee: T-Mobile - Greeley
Region: 4
City: Greeley State: CO
County:
License #: GL002207
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: T-Mobile - Greeley
Region: 4
City: Greeley State: CO
County:
License #: GL002207
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 08/04/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 08/04/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - FOUR LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Four exit signs, each containing 6.2 Ci of tritium, were reported as lost during annual registration. New owner as of 04/01/2021. Upon inspecting the property, unable to locate signs registered with the State."
NMED No.: CO210029
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
EN Revision Text: AGREEMENT STATE REPORT - FOUR LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Four exit signs, each containing 6.2 Ci of tritium, were reported as lost during annual registration. New owner as of 04/01/2021. Upon inspecting the property, unable to locate signs registered with the State."
NMED No.: CO210029
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: 55472
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Davis Partnership Architects PC
Region: 4
City: Denver State: CO
County:
License #: GL000674
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: Davis Partnership Architects PC
Region: 4
City: Denver State: CO
County:
License #: GL000674
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/16/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/16/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration."
NMED No.: CO210028
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration."
NMED No.: CO210028
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: 55473
Rep Org: COLORADO DEPT OF HEALTH
Licensee: University of Colorado - Denver
Region: 4
City: Denver State: CO
County:
License #: GL002538
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: University of Colorado - Denver
Region: 4
City: Denver State: CO
County:
License #: GL002538
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/30/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/30/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 17.5 Ci of tritium, was reported as lost during annual registration. An exhaustive search resulted in the belief that the contractor never installed the sign."
NMED No.: CO210027
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 17.5 Ci of tritium, was reported as lost during annual registration. An exhaustive search resulted in the belief that the contractor never installed the sign."
NMED No.: CO210027
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: 55474
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Westin Hotel - Wildwood Lodge
Region: 4
City: Snowmass Village State: CO
County:
License #: GL002217
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: Westin Hotel - Wildwood Lodge
Region: 4
City: Snowmass Village State: CO
County:
License #: GL002217
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/27/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/27/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 9.2 Ci of Tritium, was reported as lost during annual registration. The owner was not able to locate the sign on the property and the owner was unsure of when the sign was removed."
NMED No.: CO210026
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 9.2 Ci of Tritium, was reported as lost during annual registration. The owner was not able to locate the sign on the property and the owner was unsure of when the sign was removed."
NMED No.: CO210026
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: 55475
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Brodie Management
Region: 4
City: Westminster State: CO
County:
License #: GL002447
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: Brodie Management
Region: 4
City: Westminster State: CO
County:
License #: GL002447
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration. There was a change of ownership in 2019. The sign was lost or replaced prior to new ownership."
NMED No.: CO210025
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration. There was a change of ownership in 2019. The sign was lost or replaced prior to new ownership."
NMED No.: CO210025
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: 55476
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Town of Lyons
Region: 4
City: Lyons State: CO
County:
License #: GL002040
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Town of Lyons
Region: 4
City: Lyons State: CO
County:
License #: GL002040
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/09/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.03 Ci of tritium, reported as lost during annual registration. The business moved to a new location. It was most likely disposed of with other demolition debris when vacated."
NMED No.: CO210021
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the Colorado Department of Health via email:
"One exit sign, containing 7.03 Ci of tritium, reported as lost during annual registration. The business moved to a new location. It was most likely disposed of with other demolition debris when vacated."
NMED No.: CO210021
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: 55477
Rep Org: COLORADO DEPT OF HEALTH
Licensee: One Renaissance LLC
Region: 4
City: Denver State: CO
County:
License #: GL002564
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Licensee: One Renaissance LLC
Region: 4
City: Denver State: CO
County:
License #: GL002564
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Donald Norwood
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 07/01/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following information was received via email:
"One exit sign, containing 12.57 Ci of tritium, was reported as lost during annual registration. The location of the sign is unknown."
NMED No.: CO210024
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
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following information was received via email:
"One exit sign, containing 12.57 Ci of tritium, was reported as lost during annual registration. The location of the sign is unknown."
NMED No.: CO210024
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: 55478
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Rocky Mountain Bottling Co.
Region: 4
City: Wheat Ridge State: CO
County:
License #: GL000979
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Rocky Mountain Bottling Co.
Region: 4
City: Wheat Ridge State: CO
County:
License #: GL000979
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 9.2 Ci and 10 Ci of tritium, reported as lost during the annual registration. The timeframe of removal is unknown."
NMED No.: CO210022
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
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 9.2 Ci and 10 Ci of tritium, reported as lost during the annual registration. The timeframe of removal is unknown."
NMED No.: CO210022
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: 55479
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Five Rivers Cattle Feeding
Region: 4
City: LaSalle State: CO
County:
License #: GL002226
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Five Rivers Cattle Feeding
Region: 4
City: LaSalle State: CO
County:
License #: GL002226
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/30/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/30/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 6.2 Ci of tritium each, reported as lost during the annual registration. Licensee is unable to locate."
NMED No.: CO210023
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
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 6.2 Ci of tritium each, reported as lost during the annual registration. Licensee is unable to locate."
NMED No.: CO210023
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
Fuel Cycle Facility
Event Number: 55480
Facility: Louisiana Energy Services
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: Blake Bixenman
HQ OPS Officer: Ossy Font
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: Blake Bixenman
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 16:55 [ET]
Event Date: 07/20/2021
Event Time: 14:01 [MDT]
Last Update Date: 09/17/2021
Notification Time: 16:55 [ET]
Event Date: 07/20/2021
Event Time: 14:01 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
EN Revision Imported Date: 9/27/2021
EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE
During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.
On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).
The licensee will notify the NRC Region 2.
EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE
During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.
On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).
The licensee will notify the NRC Region 2.
Agreement State
Event Number: 55481
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: T S I Laboratories INC
Region: 4
City: Victoria State: TX
County:
License #: L 04767
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ossy Font
Licensee: T S I Laboratories INC
Region: 4
City: Victoria State: TX
County:
License #: L 04767
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 22:14 [ET]
Event Date: 09/17/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/20/2021
Notification Time: 22:14 [ET]
Event Date: 09/17/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/20/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/27/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On September 17, 2021, the Agency was notified by the licensee that a Troxler 3411 moisture density gauge containing a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source was damaged at a temporary job site. The licensee reported that while the gauge was sitting on the ground and not being used it was run over by a bulldozer, snapping the operating arm of the cesium source. The source was in the shielded position when the event occurred and a radiation survey of the gauge after the event verified it was still fully shielded. The licensee stated the gauge would be returned to its storage location and arrangements would be made to have the gauge disposed of. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 9885
* * * UPDATE FROM ART TUCKER TO THOMAS HERRITY AT 11:23 ON 09/20/21 * * *
The following information was received via e-mail:
"Received pictures of the gauge. Pictures show the rod for the cesium source was bent. The dose rate meter appears to be reading 0.8 millirem per hour."
Notified R4DO (YOUNG) and NMSS Events Notification group.
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On September 17, 2021, the Agency was notified by the licensee that a Troxler 3411 moisture density gauge containing a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source was damaged at a temporary job site. The licensee reported that while the gauge was sitting on the ground and not being used it was run over by a bulldozer, snapping the operating arm of the cesium source. The source was in the shielded position when the event occurred and a radiation survey of the gauge after the event verified it was still fully shielded. The licensee stated the gauge would be returned to its storage location and arrangements would be made to have the gauge disposed of. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 9885
* * * UPDATE FROM ART TUCKER TO THOMAS HERRITY AT 11:23 ON 09/20/21 * * *
The following information was received via e-mail:
"Received pictures of the gauge. Pictures show the rod for the cesium source was bent. The dose rate meter appears to be reading 0.8 millirem per hour."
Notified R4DO (YOUNG) and NMSS Events Notification group.
Power Reactor
Event Number: 55484
Facility: Limerick
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kris Strausser
HQ OPS Officer: Howie Crouch
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Kris Strausser
HQ OPS Officer: Howie Crouch
Notification Date: 09/23/2021
Notification Time: 18:46 [ET]
Event Date: 09/23/2021
Event Time: 14:43 [EDT]
Last Update Date: 09/23/2021
Notification Time: 18:46 [ET]
Event Date: 09/23/2021
Event Time: 14:43 [EDT]
Last Update Date: 09/23/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
LALLY, CHRISTOPHER (R1)
LALLY, CHRISTOPHER (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 9/27/2021
EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE
"During planned testing of the Unit 1 HPCI [high pressure coolant injection] system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable."
HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done.
The licensee has notified the NRC Resident Inspector.
EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE
"During planned testing of the Unit 1 HPCI [high pressure coolant injection] system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable."
HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done.
The licensee has notified the NRC Resident Inspector.
Part 21
Event Number: 55490
Rep Org: Southern Nuclear, Fleet Regulatory
Licensee: Joseph M. Farley Nuclear Plant (FNP)
Region: 1
City: Birmingham State: AL
County:
License #:
Agreement: N
Docket:
NRC Notified By: Cheryl Gayheart
HQ OPS Officer: Thomas Herrity
Licensee: Joseph M. Farley Nuclear Plant (FNP)
Region: 1
City: Birmingham State: AL
County:
License #:
Agreement: N
Docket:
NRC Notified By: Cheryl Gayheart
HQ OPS Officer: Thomas Herrity
Notification Date: 09/24/2021
Notification Time: 17:27 [ET]
Event Date: 09/24/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Notification Time: 17:27 [ET]
Event Date: 09/24/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
MILLER, MARK (R2DO)
PART 21/50.55 REACTORS, - (EMAIL)
MILLER, MARK (R2DO)
PART 21/50.55 REACTORS, - (EMAIL)
GENERAL ELECTRIC HITACHI TRIP UNITS RIVETS POPPING OFF
"Based upon a 10 CFR 21.21(b) transfer notification from General Electric Hitachi (GEH), Southern Nuclear Operating Company's (SNC) Joseph M. Farley Nuclear Plant (FNP) has determined there is evidence a Substantial Safety Hazard could have been created by the failure of the rivets installed on certain EC Trip Units if they were left uncorrected. These EC Trip Units are a subcomponent of all five (5) emergency diesel generator control panel supply breakers at FNP.
"This defect was identified and the components were repaired by GEH before being installed in the plant. These defective EC Trip Units never posed a challenge to the safe operation of FNP.
"The NRC Senior Resident Inspector at FNP has been notified."
"Based upon a 10 CFR 21.21(b) transfer notification from General Electric Hitachi (GEH), Southern Nuclear Operating Company's (SNC) Joseph M. Farley Nuclear Plant (FNP) has determined there is evidence a Substantial Safety Hazard could have been created by the failure of the rivets installed on certain EC Trip Units if they were left uncorrected. These EC Trip Units are a subcomponent of all five (5) emergency diesel generator control panel supply breakers at FNP.
"This defect was identified and the components were repaired by GEH before being installed in the plant. These defective EC Trip Units never posed a challenge to the safe operation of FNP.
"The NRC Senior Resident Inspector at FNP has been notified."
Power Reactor
Event Number: 55492
Facility: Nine Mile Point
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Amanda Tetro
HQ OPS Officer: Donald Norwood
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Amanda Tetro
HQ OPS Officer: Donald Norwood
Notification Date: 09/25/2021
Notification Time: 09:16 [ET]
Event Date: 09/25/2021
Event Time: 03:42 [EDT]
Last Update Date: 09/25/2021
Notification Time: 09:16 [ET]
Event Date: 09/25/2021
Event Time: 03:42 [EDT]
Last Update Date: 09/25/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
Person (Organization):
LALLY, CHRISTOPHER (R1)
LALLY, CHRISTOPHER (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF UNINTERRUPTIBLE POWER SUPPLY RESULTED IN ISOLATION OF TWO EMERGENCY CONDENSERS
"On 9/25/2021 at 0342 EDT, Nine Mile Point Nuclear Station Unit 1 experienced a loss of the Uninterruptible Power Supply (UPS), UPS 162A, which resulted in a loss of Reactor Protection System (RPS) Bus 11. This resulted in an isolation of both No. 11 and No. 12 Emergency Condensers. Emergency Condenser No. 11 was returned to standby on 9/25/2021 at 0420 EDT and Emergency Condenser No. 12 was returned to standby on 9/25/2021 at 0429 EDT.
"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(v)(B) which states: 'Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (B) remove residual heat.'
"The NRC Senior Resident was informed."
"On 9/25/2021 at 0342 EDT, Nine Mile Point Nuclear Station Unit 1 experienced a loss of the Uninterruptible Power Supply (UPS), UPS 162A, which resulted in a loss of Reactor Protection System (RPS) Bus 11. This resulted in an isolation of both No. 11 and No. 12 Emergency Condensers. Emergency Condenser No. 11 was returned to standby on 9/25/2021 at 0420 EDT and Emergency Condenser No. 12 was returned to standby on 9/25/2021 at 0429 EDT.
"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(v)(B) which states: 'Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (B) remove residual heat.'
"The NRC Senior Resident was informed."
Agreement State
Event Number: 55386
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Notification Date: 07/30/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/28/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
* * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *
The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital:
The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study.
The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward.
Notified R1DO (SCHROEDER) and NMSS Events Notification group.
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
* * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *
The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital:
The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study.
The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward.
Notified R1DO (SCHROEDER) and NMSS Events Notification group.
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: 55482
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: University of Utah
Region: 4
City: Salt Lake City State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: Tim Butler
HQ OPS Officer: Mike Stafford
Licensee: University of Utah
Region: 4
City: Salt Lake City State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: Tim Butler
HQ OPS Officer: Mike Stafford
Notification Date: 09/21/2021
Notification Time: 10:35 [ET]
Event Date: 09/09/2021
Event Time: 12:00 [MDT]
Last Update Date: 09/21/2021
Notification Time: 10:35 [ET]
Event Date: 09/09/2021
Event Time: 12:00 [MDT]
Last Update Date: 09/21/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/28/2021
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL
The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:
"On August 27, 2021, local heavy rain infiltrated the Merrill Engineering Building, causing flooding on the first and third floors. The first floor also included some radioactive materials labs. While stripping the labs on September 9, 2021, in preparation for repair, the contractor violated policy and failed to notify the lab owners before moving material from the lab. Included in the material removed from the lab was a safe containing 13 exempt calibration sources and one 0.006 milliCurie U-235 ceramic source. The safe was moved to an onsite trailer that was under control of the contractor and not the University. When the lab owner returned to the lab later in the day they immediately reported the sources missing. Investigation by licensee personnel lead them to where the sources were being stored. The sources were out of the licensee's exclusive control for 1 to 3 hours. The sources were re-secured and placed under the licensee's exclusive control closing the incident. The report was not determined to be reportable until the Division was able to conduct its on site investigation on September 20, 2021."
Utah Event Report ID Number: UT 210005
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
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL
The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:
"On August 27, 2021, local heavy rain infiltrated the Merrill Engineering Building, causing flooding on the first and third floors. The first floor also included some radioactive materials labs. While stripping the labs on September 9, 2021, in preparation for repair, the contractor violated policy and failed to notify the lab owners before moving material from the lab. Included in the material removed from the lab was a safe containing 13 exempt calibration sources and one 0.006 milliCurie U-235 ceramic source. The safe was moved to an onsite trailer that was under control of the contractor and not the University. When the lab owner returned to the lab later in the day they immediately reported the sources missing. Investigation by licensee personnel lead them to where the sources were being stored. The sources were out of the licensee's exclusive control for 1 to 3 hours. The sources were re-secured and placed under the licensee's exclusive control closing the incident. The report was not determined to be reportable until the Division was able to conduct its on site investigation on September 20, 2021."
Utah Event Report ID Number: UT 210005
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