Event Notification Report for March 02, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/01/2022 - 03/02/2022
Agreement State
Event Number: 55724
Rep Org: MA Radiation Control Program
Licensee: Atlas ATC
Region: 1
City: East Hartford State: CT
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Joshua Daehler
HQ OPS Officer: Nestor Makris
Licensee: Atlas ATC
Region: 1
City: East Hartford State: CT
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Joshua Daehler
HQ OPS Officer: Nestor Makris
Notification Date: 02/02/2022
Notification Time: 13:25 [ET]
Event Date: 02/01/2022
Event Time: 09:54 [EST]
Last Update Date: 03/01/2022
Notification Time: 13:25 [ET]
Event Date: 02/01/2022
Event Time: 09:54 [EST]
Last Update Date: 03/01/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
Lilliendahl, Jon (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/2/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST X-RAY FLUORESCENCE INSTRUMENT
The following was received via email from the Massachusetts Radiation Control Program:
"Atlas ATC of East Hartford, Connecticut (ATC) reported on February 2, 2022, that a Protec LPA-1 x-ray fluorescence instrument, serial number 1331, containing a cobalt-57 sealed source of up to 12 millicuries, was mistakenly transported by an employee from their East Hartford, Connecticut storage location to an asbestos work site, on February 1, 2022, located in Springfield, Massachusetts and that the instrument is missing.
"ATC explained that the instrument was mistakenly transported to and not used at the Springfield, Massachusetts site because the site work was for asbestos analysis and not for lead paint analysis, and however may have somehow become missing at or near the Springfield, Massachusetts site, and that they will be searching the site for the missing instrument.
"ATC further explained that they thought that the instrument may somehow be registered with state of Connecticut and however that they were not familiar with any general or specific license that may have been issued by U.S. Nuclear Regulatory Commission regarding use or storage of the instrument, containing cobalt-57, in Connecticut.
"The reporting requirement is a 30-day telephone report and is of 105 CMR 120.281(A)(2), stolen, lost, or missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
This event has been reported by the licensee as EN 55760.
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 X-RAY FLUORESCENCE INSTRUMENT
The following was received via email from the Massachusetts Radiation Control Program:
"Atlas ATC of East Hartford, Connecticut (ATC) reported on February 2, 2022, that a Protec LPA-1 x-ray fluorescence instrument, serial number 1331, containing a cobalt-57 sealed source of up to 12 millicuries, was mistakenly transported by an employee from their East Hartford, Connecticut storage location to an asbestos work site, on February 1, 2022, located in Springfield, Massachusetts and that the instrument is missing.
"ATC explained that the instrument was mistakenly transported to and not used at the Springfield, Massachusetts site because the site work was for asbestos analysis and not for lead paint analysis, and however may have somehow become missing at or near the Springfield, Massachusetts site, and that they will be searching the site for the missing instrument.
"ATC further explained that they thought that the instrument may somehow be registered with state of Connecticut and however that they were not familiar with any general or specific license that may have been issued by U.S. Nuclear Regulatory Commission regarding use or storage of the instrument, containing cobalt-57, in Connecticut.
"The reporting requirement is a 30-day telephone report and is of 105 CMR 120.281(A)(2), stolen, lost, or missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open."
This event has been reported by the licensee as EN 55760.
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: 55751
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: The Carle Foundation
Region: 3
City: Urbana State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Karen Cotton-Gross
Licensee: The Carle Foundation
Region: 3
City: Urbana State: IL
County:
License #: IL-01156-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/22/2022
Notification Time: 13:00 [ET]
Event Date: 12/28/2016
Event Time: 00:00 [CST]
Last Update Date: 02/22/2022
Notification Time: 13:00 [ET]
Event Date: 12/28/2016
Event Time: 00:00 [CST]
Last Update Date: 02/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dickson, Billy (R3)
NMSS_Events_Notification, (EMAIL)
Dickson, Billy (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/2/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following information was provided by the Illinois Emergency Management Agency (Agency) via email:
"At 1400 CST on February 21, 2022, The Carle Foundation notified the Agency to advise of an unreported medical event that occurred on December 28, 2016. No adverse patient impact reported. This will be reported to the NRC this morning.
"Following a comprehensive review of Y-90 Therasphere procedures performed over the last several years, The Carle Foundation d/b/a The Carle Foundation Hospital identified an additional medical event in addition to the one identified during a recent Agency inspection on 2/16/22, that was not reported as required. On 12/28/2016, a written directive to deliver 0.51 GBq Y-90 Theraspheres to the Superior Branch of Segment 3 (liver) was prepared; however, only 0.16 GBq (31.4%) was delivered. The licensee was under the impression that this was not a reportable medical event since they revised the treatment plan and written directive after the procedure. Although still under investigation, the root cause appears to be the use of a smaller microcatheter than recommended. No further treatment to the patient is planned. The authorized user advised that the dose delivered to the critical mass of the segment treated was medically satisfactory for this case."
Illinois Report # IL220006
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 - UNDERDOSE TO PATIENT
The following information was provided by the Illinois Emergency Management Agency (Agency) via email:
"At 1400 CST on February 21, 2022, The Carle Foundation notified the Agency to advise of an unreported medical event that occurred on December 28, 2016. No adverse patient impact reported. This will be reported to the NRC this morning.
"Following a comprehensive review of Y-90 Therasphere procedures performed over the last several years, The Carle Foundation d/b/a The Carle Foundation Hospital identified an additional medical event in addition to the one identified during a recent Agency inspection on 2/16/22, that was not reported as required. On 12/28/2016, a written directive to deliver 0.51 GBq Y-90 Theraspheres to the Superior Branch of Segment 3 (liver) was prepared; however, only 0.16 GBq (31.4%) was delivered. The licensee was under the impression that this was not a reportable medical event since they revised the treatment plan and written directive after the procedure. Although still under investigation, the root cause appears to be the use of a smaller microcatheter than recommended. No further treatment to the patient is planned. The authorized user advised that the dose delivered to the critical mass of the segment treated was medically satisfactory for this case."
Illinois Report # IL220006
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: 55752
Rep Org: California Radiation Control Prgm
Licensee: G3 Quality, Inc
Region: 4
City: Cerritos State: CA
County:
License #: 7986-19
Agreement: Y
Docket:
NRC Notified By: Don Oesterle
HQ OPS Officer: Lloyd Desotell
Licensee: G3 Quality, Inc
Region: 4
City: Cerritos State: CA
County:
License #: 7986-19
Agreement: Y
Docket:
NRC Notified By: Don Oesterle
HQ OPS Officer: Lloyd Desotell
Notification Date: 02/22/2022
Notification Time: 19:03 [ET]
Event Date: 02/21/2022
Event Time: 00:00 [PST]
Last Update Date: 02/22/2022
Notification Time: 19:03 [ET]
Event Date: 02/21/2022
Event Time: 00:00 [PST]
Last Update Date: 02/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), (EMAIL)
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), (EMAIL)
EN Revision Imported Date: 3/2/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following report was received from the California Department of Public Health via email:
"On February 21, 2022, the alternate Radiation Safety Officer of G3 Quality, Inc. contacted the California Office of Emergency Services to report a stolen moisture density gauge. The gauge was a CPN model MC-3 S/N M370108596 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was discovered stolen, along with other equipment, from a locked temporary storage container in a fenced (also locked) area of a construction site at the northwest corner of Interstate 10 and Interstate 15. The theft likely occurred sometime between Friday, February 19 and Monday, February 21. The storage container and fence locks were cut. A police report was given to the Ontario Police Department. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."
California Event Number: 022122
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 - STOLEN MOISTURE DENSITY GAUGE
The following report was received from the California Department of Public Health via email:
"On February 21, 2022, the alternate Radiation Safety Officer of G3 Quality, Inc. contacted the California Office of Emergency Services to report a stolen moisture density gauge. The gauge was a CPN model MC-3 S/N M370108596 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was discovered stolen, along with other equipment, from a locked temporary storage container in a fenced (also locked) area of a construction site at the northwest corner of Interstate 10 and Interstate 15. The theft likely occurred sometime between Friday, February 19 and Monday, February 21. The storage container and fence locks were cut. A police report was given to the Ontario Police Department. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."
California Event Number: 022122
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: 55753
Rep Org: California Radiation Control Prgm
Licensee: Ninyo and Moore
Region: 4
City: Irvine State: CA
County:
License #: 7633-30
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Karen Cotton-Gross
Licensee: Ninyo and Moore
Region: 4
City: Irvine State: CA
County:
License #: 7633-30
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/23/2022
Notification Time: 15:27 [ET]
Event Date: 02/20/2022
Event Time: 00:00 [PST]
Last Update Date: 02/23/2022
Notification Time: 15:27 [ET]
Event Date: 02/20/2022
Event Time: 00:00 [PST]
Last Update Date: 02/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), (EMAIL)
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), (EMAIL)
EN Revision Imported Date: 3/3/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the California Department of Public Health via email:
"Ninyo and Moore, a geotechnical and environmental sciences firm reported the theft of a Troxler 3430 moisture density gauge No. 38218, containing a Cs-137 sealed source of 0.3 GBq (8 mCi) and Am-241 sealed source of 1.48 GBq (40 mCi). The theft occurred from a temporary job site in Visalia, CA, The locked 10' X 20' Conex job box had the locks cut off and the entire secured Knack box containing the Type A transport container and gauge was taken. Construction tools totaling approximately $12,000 were stolen. Visalia Police Department was notified and an officer took a theft report and is looking for video surveillance in the area. Site security was not at the location at the time of the Sunday night theft."
California 5010 Number: 022222
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 - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the California Department of Public Health via email:
"Ninyo and Moore, a geotechnical and environmental sciences firm reported the theft of a Troxler 3430 moisture density gauge No. 38218, containing a Cs-137 sealed source of 0.3 GBq (8 mCi) and Am-241 sealed source of 1.48 GBq (40 mCi). The theft occurred from a temporary job site in Visalia, CA, The locked 10' X 20' Conex job box had the locks cut off and the entire secured Knack box containing the Type A transport container and gauge was taken. Construction tools totaling approximately $12,000 were stolen. Visalia Police Department was notified and an officer took a theft report and is looking for video surveillance in the area. Site security was not at the location at the time of the Sunday night theft."
California 5010 Number: 022222
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: 55754
Rep Org: Louisiana DEQ
Licensee: Equistar Chemicals, LP
Region: 4
City: Lake Charles State: LA
County:
License #: LA-2663-L01
Agreement: Y
Docket:
NRC Notified By: James M. Pate III
HQ OPS Officer: Karen Cotton-Gross
Licensee: Equistar Chemicals, LP
Region: 4
City: Lake Charles State: LA
County:
License #: LA-2663-L01
Agreement: Y
Docket:
NRC Notified By: James M. Pate III
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/24/2022
Notification Time: 10:11 [ET]
Event Date: 02/23/2022
Event Time: 18:00 [CST]
Last Update Date: 02/24/2022
Notification Time: 10:11 [ET]
Event Date: 02/23/2022
Event Time: 18:00 [CST]
Last Update Date: 02/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/3/2022
EN Revision Text: AGREEMENT STATE REPORT - BROKEN SOURCE CABLE
The following information was provided by the state of Louisiana via email:
"On February 24, 2022, at 0759 CST, the Louisiana Department of Environmental Quality received this event notification. The facility involved was Louisiana Integrated Polyethylene JV, LLC. On February 23, 2022, at 1800 CST, a Berthold device cable broke or disconnected in a vessel. The source cannot be retrieved back into a shielded condition. The gauge is a Berthold Model: SSC-200, source holder: LB 300 IRL, source S/N: 1405-11-16, 1000 mCi of Cs-137. Survey meter readings at the vessel are 400 mR/hr and 2 mR/hr at fifteen (15) feet.
"The facility has contacted the manufacturer to come assist in source retrieval within the pipe inside the vessel."
Louisiana Event Report ID No.: LA 20220003
EN Revision Text: AGREEMENT STATE REPORT - BROKEN SOURCE CABLE
The following information was provided by the state of Louisiana via email:
"On February 24, 2022, at 0759 CST, the Louisiana Department of Environmental Quality received this event notification. The facility involved was Louisiana Integrated Polyethylene JV, LLC. On February 23, 2022, at 1800 CST, a Berthold device cable broke or disconnected in a vessel. The source cannot be retrieved back into a shielded condition. The gauge is a Berthold Model: SSC-200, source holder: LB 300 IRL, source S/N: 1405-11-16, 1000 mCi of Cs-137. Survey meter readings at the vessel are 400 mR/hr and 2 mR/hr at fifteen (15) feet.
"The facility has contacted the manufacturer to come assist in source retrieval within the pipe inside the vessel."
Louisiana Event Report ID No.: LA 20220003
Agreement State
Event Number: 55755
Rep Org: Texas Dept of State Health Services
Licensee: Universal Pressure Pumping, Inc.
Region: 4
City: Cleburne State: TX
County:
License #: L 06871
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Karen Cotton-Gross
Licensee: Universal Pressure Pumping, Inc.
Region: 4
City: Cleburne State: TX
County:
License #: L 06871
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/24/2022
Notification Time: 12:19 [ET]
Event Date: 02/22/2022
Event Time: 00:00 [CST]
Last Update Date: 02/24/2022
Notification Time: 12:19 [ET]
Event Date: 02/22/2022
Event Time: 00:00 [CST]
Last Update Date: 02/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
O'Keefe, Neil (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 3/3/2022
EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER FAILURE
The following information was provided by the Texas Department of State Health Services (Agency) via email:
"On February 23, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews had a failure of a shutter device on a Thermo Fisher Model 5190 density gauge containing a 20 millicurie (original activity) cesium - 137 source. The RSO stated that the shutter is a lead sheet that slides in a channel in front of the source. The RSO stated that the channel the sheet of lead slides through was damaged and the lead sheet will not stay in place if the gauge is moved (jiggled). It cannot be locked in the shield (closed) position. The workers removed the gauge and the pipe it was installed on and placed them both in storage. The RSO stated they were going to contact the manufacturer to have the gauge repaired.
"No individual received any significant exposure from this event.
"Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: 9918
EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGE SHUTTER FAILURE
The following information was provided by the Texas Department of State Health Services (Agency) via email:
"On February 23, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews had a failure of a shutter device on a Thermo Fisher Model 5190 density gauge containing a 20 millicurie (original activity) cesium - 137 source. The RSO stated that the shutter is a lead sheet that slides in a channel in front of the source. The RSO stated that the channel the sheet of lead slides through was damaged and the lead sheet will not stay in place if the gauge is moved (jiggled). It cannot be locked in the shield (closed) position. The workers removed the gauge and the pipe it was installed on and placed them both in storage. The RSO stated they were going to contact the manufacturer to have the gauge repaired.
"No individual received any significant exposure from this event.
"Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: 9918