Event Notification Report for January 06, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
01/05/2022 - 01/06/2022

EVENT NUMBERS
55643 55678 55680 55681 55686 55690
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 55643
Rep Org: Monument Health
Licensee: Monument Health
Region: 4
City: Rapid City   State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Notification Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 01/05/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following is a summary of a phone call with the licensee:

A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.

* * * RETRACTION ON 01/05/2022 AT 1854 EST FROM JIM McKEE TO JEFFREY WHITED * * *

The following is a summary of a phone call with the licensee:

Following discussions with an NRC inspector, the licensee determined that the correct activity had been implanted into the correct area. As such, a medical event did not need to be reported and the licensee retracted the event.

Notified R4DO (Roldan-Otero) and NMSS Event Notification.

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: 55678
Rep Org: Colorado Dept of Health
Licensee: Saint Mary Corwin Hospital
Region: 4
City: Pueblo   State: CO
County:
License #: CO 235-02
Agreement: Y
Docket:
NRC Notified By: Derek Bailey
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/29/2021
Notification Time: 11:34 [ET]
Event Date: 12/20/2021
Event Time: 00:00 [MST]
Last Update Date: 12/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - MISSING/UNACCOUNTED FOR IODINE-125 SEED

The following was sent by the state of Colorado Health Department (Division) via e-mail:

"On Tuesday December 28, 2021, the Division received an email from St. Mary Corwin Hospital, indicating an unaccounted for iodine-125 seed. The seed was discovered missing on December 20, 2021.

"An internal investigation by St. Mary Corwin Hospital verified that all patients that had an iodine-125 seed implanted had their seeds removed. Additionally, the physics and pathology area and equipment were surveyed by two physicists. The investigation by St. Mary Corwin Hospital concluded the seed was likely disposed of in the municipal waste stream.

"Estimated dose to any worker: St. Mary Corwin Hospital concluded that due to the high likelihood the seed was in a trash bin, no person would've come within a meter of the seed for any extended period. At [when measured by] a meter, any of these seeds would be at or below background, so most likely the exposure to an individual would be indistinguishable from background."

Colorado Event Report No. CO 210046

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.

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: 55680
Rep Org: Texas Dept of State Health Services
Licensee: ECS Southwest LLP
Region: 4
City: Austin   State: TX
County:
License #: L 05319
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/30/2021
Notification Time: 14:37 [ET]
Event Date: 12/29/2021
Event Time: 00:00 [CST]
Last Update Date: 12/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - CESIUM SOURCE UNABLE TO FULLY RETRACT

The state of Texas (the Agency) reported the following via phone and email:

"On December 30, 2021, the Agency was notified by the licensee that on December 29, 2021, one of its technicians was unable to fully retract a 10 millicurie cesium-137 source to its fully shielded position. The source is installed in a Humboldt 5001EZ moisture density gauge. The technician had performed 3 samples that morning and the failure came at the end of the [fourth] exposure. The technician placed the gauge into its transport container and returned the gauge to the shop. The radiation safety officer (RSO) performed a survey of the gauge and found the highest reading 1 meter from the gauge was 0.4 millirem per hour. The RSO stated the transport index for the gauge measured that morning was 0.2. The RSO stated that the source was stuck about 2 inches outside from the fully shielded [position]. The RSO stated they used a hammer and anchor bolt and drove the source back into the shielded position. The RSO stated they noticed wet clay material oozing out of the area between the source shaft and the gauge case. The RSO believes the clay is what was preventing the source from fully retracting. The RSO stated they were taking a leak test of the cesium source. The RSO was instructed to isolate the hammer and bolt used to drive the source to the shielded position. The Agency went to the licensee's location and performed fixed and removable contamination survey on the hammer and anchor bolt used to drive the source back to the shielded position. No contamination was detected. The RSO's hands and clothing was surveyed for contamination. No contamination was detected. The RSO stated the gauge will be sent to the service company after the results of the leak test are received. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9905


Agreement State
Event Number: 55681
Rep Org: Nevada Radiological Health
Licensee: Universal Engineering Sciences
Region: 4
City: North Las Vegas   State: NV
County:
License #: 00-11-14073-01
Agreement: Y
Docket:
NRC Notified By: Haley Brown
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/30/2021
Notification Time: 18:36 [ET]
Event Date: 12/29/2021
Event Time: 00:00 [PST]
Last Update Date: 12/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED GAUGE

The state of Nevada reported the following via email:

"On 12/29/21 an Authorized User failed to secure a portable nuclear gauge in its type A shipping container and transported the nuclear device from one work site to another. The unsecured gauge fell off the back of the truck's tailgate and was missing from approximately [1545 PST] until it was located at a nearby gas station at [1625 PST]. It had been placed next to an air pump refill station and left there by an unknown person. The Authorized User recovered the gauge and returned it to the licensee's use location.

"The RSO performed leak test sampling on 12/29/21 at [1900 PST] and the tests were sent to lnstroTek 's California testing facility for analysis on 12/30/21 at [0930 PST]. The gauge has been properly secured with 2 tangible barriers and isolated from use by other employees. The Radiation Control Program performed surveys and swipe testing of the damaged gauge and all results were within twice background. As soon as the licensee receives leak test results, the gauge will be prepared and shipped to the lnstroTek - California for disposal. Licensee will provide the RCP [Radiation Control Program] with additional results and information as it becomes available.

"Troxler Model 3440 S/N 23813 Americium-241/Be 40 mCi and Cesium-137 8 mCi. Last periodic leak test performed 12/14/21 - Passed"

Nevada Item Number: NV210022

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: 55686
Facility: Framatome ANP Richland
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
Region: 2
City: Richland   State: WA
County: Benton
License #: SNM-1227
Docket: 07001257
NRC Notified By: Calvin Manning
HQ OPS Officer: Bethany Cecere
Notification Date: 01/04/2022
Notification Time: 10:42 [ET]
Event Date: 01/03/2022
Event Time: 16:15 [PST]
Last Update Date: 01/04/2022
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: OFFSITE NOTIFICATION

The following information was provided by the licensee email:

"RCW 49.17.062 (1)(a) requires an employer report 'within 24 hours. that 10 or more of their employees at the workplace or worksite in this State have tested positive for the infectious or contagious disease that is the subject of the public health emergency, must report the positive tests to the department in a form prescribed by the department.'

"On 1/03/2022, at 1615 PST, the Framatome Horn Rapids Road human resources manager notified Washington State Division of Occupational Safety and Health that the Richland Fuel Fabrication site hit that threshold of 10 COVID-19 positive cases.

"These cases do not appear to be worker-to-worker transmissions of the virus.

"This notification is being made under the concurrent reporting requirement of 10CFR70 Appendix A concurrent reporting."


Power Reactor
Event Number: 55690
Facility: Ft Calhoun
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: Kelly Daughenbaugh
HQ OPS Officer: Jeffrey Whited
Notification Date: 01/05/2022
Notification Time: 13:36 [ET]
Event Date: 01/05/2022
Event Time: 09:09 [CST]
Last Update Date: 01/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Roldan-Otero, Lizette (R4DO) (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled
Event Text
EN Revision Imported Date: 1/6/2022

EN Revision Text: OFFSITE NOTIFICATION DUE TO ONSITE FIRE

The following information was provided by the licensee via email:

"At 0907 CST, a small fire was reported in the Intake Structure at Fort Calhoun Station. Offsite fire departments were notified at 0909 CST and responded at 0922 CST. Fire was confirmed extinguished at 0949 CST. Fire was extinguished using offsite resources per the Station Fire Plan. There were no injuries reported. The fire occurred in the Non-Radiological area of the plant and there was no release of radioactivity or hazardous materials."

Page Last Reviewed/Updated Thursday, January 06, 2022