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: 55495
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Turner Specialty Services
Region: 4
City: Nederland State: TX
County:
License #: L 05417
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Kerby Scales
Licensee: Turner Specialty Services
Region: 4
City: Nederland State: TX
County:
License #: L 05417
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Kerby Scales
Notification Date: 09/28/2021
Notification Time: 13:50 [ET]
Event Date: 09/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/28/2021
Notification Time: 13:50 [ET]
Event Date: 09/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/28/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: AGREEMENT STATE REPORT - UNRETRACTABLE SOURCE
The following was received from the state of Texas (the Agency) via email:
"On September 27, 2021, the licensee notified the Agency that one of its industrial radiography crews working at a temporary job site had been unable to retract the source. The crew was using a QSA 880D exposure device, containing a 35 curie iridium-192 source, and they had placed it on pipe approximately two feet off the ground so the guide tube/collimator would reach where the shot was to be taken. After cranking out the source, they recognized the drive cable was not straight and when they pulled back to straighten it, the device fell and bent the guide tube and the source could not be retracted. The source was cranked into the collimator and the radiographers stayed outside their barricade until an authorized person arrived to retrieve the source. The authorized person pulled back on the camera and the guide tube straightened enough so they could retract the source into the fully shielded/locked position. No one received an overexposure as a result of this event. The camera was taken to the manufacturer and the inspection found no issues. The guide tube was removed from service and will be disposed. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9887
EN Revision Text: AGREEMENT STATE REPORT - UNRETRACTABLE SOURCE
The following was received from the state of Texas (the Agency) via email:
"On September 27, 2021, the licensee notified the Agency that one of its industrial radiography crews working at a temporary job site had been unable to retract the source. The crew was using a QSA 880D exposure device, containing a 35 curie iridium-192 source, and they had placed it on pipe approximately two feet off the ground so the guide tube/collimator would reach where the shot was to be taken. After cranking out the source, they recognized the drive cable was not straight and when they pulled back to straighten it, the device fell and bent the guide tube and the source could not be retracted. The source was cranked into the collimator and the radiographers stayed outside their barricade until an authorized person arrived to retrieve the source. The authorized person pulled back on the camera and the guide tube straightened enough so they could retract the source into the fully shielded/locked position. No one received an overexposure as a result of this event. The camera was taken to the manufacturer and the inspection found no issues. The guide tube was removed from service and will be disposed. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 9887
Agreement State
Event Number: 55554
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: University of Illinois - Chicago
Region: 3
City: Chicago State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Licensee: University of Illinois - Chicago
Region: 3
City: Chicago State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: Robin Muzzalupo
HQ OPS Officer: Thomas Kendzia
Notification Date: 11/02/2021
Notification Time: 18:08 [ET]
Event Date: 09/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 11/02/2021
Notification Time: 18:08 [ET]
Event Date: 09/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 11/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
McCraw, Aaron (R3DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/2/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today.
"The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021.
"The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time."
Illinois Item Number: IL210035
EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today.
"The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021.
"The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time."
Illinois Item Number: IL210035