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: 55793
Rep Org: Arkansas Department of Health
Licensee: Anchor Packaging Company
Region: 4
City: Paragould State: AR
County:
License #: GL-0010
Agreement: Y
Docket:
NRC Notified By: Christy Steward
HQ OPS Officer: Donald Norwood
Licensee: Anchor Packaging Company
Region: 4
City: Paragould State: AR
County:
License #: GL-0010
Agreement: Y
Docket:
NRC Notified By: Christy Steward
HQ OPS Officer: Donald Norwood
Notification Date: 03/17/2022
Notification Time: 11:30 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CST]
Last Update Date: 03/22/2022
Notification Time: 11:30 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CST]
Last Update Date: 03/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - FOUND AM-241 SOURCE
The following information was received via E-mail from the Arkansas Department of Health (ADH):
"WW Recycling in Marmaduke, Arkansas, reported to Arkansas Radiation Control Program on March 2, 2022, that they believed a source had been found in scrap metal unloaded at their facility. At the time of the report, they were unable to identify the customer from whom the scrap metal was purchased.
"Intact labeling provided general license information, Am-241, manufactured by NDC in California, source SN 7090AR, Model 103, 5.55 GBq (150 mCi) in April 2011. The device manufacturer identified the device and tracked its shipment to Arkansas' GL-0010, Anchor Packaging Company located in Paragould, Arkansas.
"Radiation surveys conducted by recycling facility personnel indicated a reading of 10 microR/hr at approximately three feet from the item.
"Health Physicists from the Arkansas Radiation Control Program responded to WW Recycling on the morning of March 3, 2022.
"A metal drum container clearly labeled with a radioactive material sign, observed to be closed, in good repair was surveyed by ADH personnel. The top of the metal drum registered 185 microR/hr. The reading at the bottom sealed edge of the drum reached 85 milliR/hr. The shutter appears to be missing. There are no known exposures.
"The device remains secured at the recycling center and this event remains open while Anchor GL-0010 pursues disposal through a specific licensee authorized to perform this sort of activity/retrieval.
"Reporting Requirement: Arkansas State Board of Health Rules for Control of Sources of Ionizing Radiation RH-402.c.5. and 10 CFR Part 31.5(c)(5)."
State Event Report ID No.: AR-2022-04
* * * UPDATE ON 3/22/2022 AT 1534 EDT FROM CHRISTY STEWARD TO BRIAN LIN * * *
"On March 17, 2022, WW Recycling in Marmaduke, Arkansas, contacted the Arkansas Department of Health - Radiation Control Section to report the discovery of a second gauge. Photos received March 18, 2022, confirm this gauge to be similar to the generally licensed fixed gauge discovered then reported to the Department on March 2, 2022 (NDC model 103X, SN 13629, Am-241, 5.55 GBq). SN 13629 was once registered to Anchor Packaging Company in Paragould, Arkansas, and later documented as disposed. The gauge was found in the remnants of the original load where the first gauge was found. The gauge was placed into a radioactive material - labeled small drum and secured in the remote storage building where the initial gauge is being stored (also in a small drum).
"WW Recycling personnel measured 40 microR/hr, via their Ludlum 193-6, on contact with the outside of the wall closest to the two drums. Inside the building, about 7 feet away from the drums, radiation levels begin increasing above background. The photo indicates the shutter to be attached but not closed. There are no known exposures.
"Reporting requirements: Arkansas State Board of Health Rules for Control of Sources of Ionizing Radiation - RH-1501.a.1.A. and RH-1501.b. pursuant to RH-409.c.10. "
Notified R4DO (Taylor), and NMSS Events Notification via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf.
EN Revision Text: AGREEMENT STATE REPORT - FOUND AM-241 SOURCE
The following information was received via E-mail from the Arkansas Department of Health (ADH):
"WW Recycling in Marmaduke, Arkansas, reported to Arkansas Radiation Control Program on March 2, 2022, that they believed a source had been found in scrap metal unloaded at their facility. At the time of the report, they were unable to identify the customer from whom the scrap metal was purchased.
"Intact labeling provided general license information, Am-241, manufactured by NDC in California, source SN 7090AR, Model 103, 5.55 GBq (150 mCi) in April 2011. The device manufacturer identified the device and tracked its shipment to Arkansas' GL-0010, Anchor Packaging Company located in Paragould, Arkansas.
"Radiation surveys conducted by recycling facility personnel indicated a reading of 10 microR/hr at approximately three feet from the item.
"Health Physicists from the Arkansas Radiation Control Program responded to WW Recycling on the morning of March 3, 2022.
"A metal drum container clearly labeled with a radioactive material sign, observed to be closed, in good repair was surveyed by ADH personnel. The top of the metal drum registered 185 microR/hr. The reading at the bottom sealed edge of the drum reached 85 milliR/hr. The shutter appears to be missing. There are no known exposures.
"The device remains secured at the recycling center and this event remains open while Anchor GL-0010 pursues disposal through a specific licensee authorized to perform this sort of activity/retrieval.
"Reporting Requirement: Arkansas State Board of Health Rules for Control of Sources of Ionizing Radiation RH-402.c.5. and 10 CFR Part 31.5(c)(5)."
State Event Report ID No.: AR-2022-04
* * * UPDATE ON 3/22/2022 AT 1534 EDT FROM CHRISTY STEWARD TO BRIAN LIN * * *
"On March 17, 2022, WW Recycling in Marmaduke, Arkansas, contacted the Arkansas Department of Health - Radiation Control Section to report the discovery of a second gauge. Photos received March 18, 2022, confirm this gauge to be similar to the generally licensed fixed gauge discovered then reported to the Department on March 2, 2022 (NDC model 103X, SN 13629, Am-241, 5.55 GBq). SN 13629 was once registered to Anchor Packaging Company in Paragould, Arkansas, and later documented as disposed. The gauge was found in the remnants of the original load where the first gauge was found. The gauge was placed into a radioactive material - labeled small drum and secured in the remote storage building where the initial gauge is being stored (also in a small drum).
"WW Recycling personnel measured 40 microR/hr, via their Ludlum 193-6, on contact with the outside of the wall closest to the two drums. Inside the building, about 7 feet away from the drums, radiation levels begin increasing above background. The photo indicates the shutter to be attached but not closed. There are no known exposures.
"Reporting requirements: Arkansas State Board of Health Rules for Control of Sources of Ionizing Radiation - RH-1501.a.1.A. and RH-1501.b. pursuant to RH-409.c.10. "
Notified R4DO (Taylor), and NMSS Events Notification via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf.
Agreement State
Event Number: 55762
Rep Org: Colorado Dept of Health
Licensee: Avago Tech
Region: 4
City: Fort Collins State: CO
County:
License #: GL002495
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Gerond George
Licensee: Avago Tech
Region: 4
City: Fort Collins State: CO
County:
License #: GL002495
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Gerond George
Notification Date: 03/02/2022
Notification Time: 12:04 [ET]
Event Date: 03/02/2022
Event Time: 12:04 [MST]
Last Update Date: 03/02/2022
Notification Time: 12:04 [ET]
Event Date: 03/02/2022
Event Time: 12:04 [MST]
Last Update Date: 03/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Agrawal, Ami (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Agrawal, Ami (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/1/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following information was received via E-mail:
On 01/27/22, Avago Tech reported four tritium exit signs (2.3 Ci each) as lost during their final wrap up shipment for disposal.
NMED No.: CO220005
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 SIGNS
The following information was received via E-mail:
On 01/27/22, Avago Tech reported four tritium exit signs (2.3 Ci each) as lost during their final wrap up shipment for disposal.
NMED No.: CO220005
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: 55763
Rep Org: Iowa Department of Public Health
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendoff State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Dahlin Randal
HQ OPS Officer: Karen Cotton-Gross
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendoff State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Dahlin Randal
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 03/03/2022
Notification Time: 09:57 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CST]
Last Update Date: 03/03/2022
Notification Time: 09:57 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CST]
Last Update Date: 03/03/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Feliz-Adorno, Nestor (R3)
NMSS_Events_Notification, (EMAIL)
Feliz-Adorno, Nestor (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 4/1/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER GAUGE
The following information was provided by the Iowa Department of Public Health via email:
"A stuck shutter was discovered Wednesday, March 2nd on the B-gauge, shutter 1. Entry to the gauge house has been prohibited per protocol. Measurements indicate an increase dose rate relative to background at the south side adjacent to the gauge and shutter 1 position, with a maximum reading of 0.11 mR/hr. The licensee's service provider, SenTek, has been requested to perform emergency repair work. The B-Gauge was repaired last night around 1900 CST. The shutter failed to close due to the solenoid valve that opens and closes the shutter, which would not vent pressure. The failed solenoid valve was replaced by a new valve. The project to replace these gauges with x-ray technology is ongoing and on track to be replaced by first quarter, 2023."
"Source/Radioactive Material: SEALED SOURCE GAUGE
Manufacturer: Isotope Measuring Systems, Inc.
Model Number: NOT KNOWN IAEA Category: 3
Serial Number: 2332-2336L
Radionuclide: AM-241
Activity: 5 Ci (185 GBq)"
Iowa Event Number: IA220001
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER GAUGE
The following information was provided by the Iowa Department of Public Health via email:
"A stuck shutter was discovered Wednesday, March 2nd on the B-gauge, shutter 1. Entry to the gauge house has been prohibited per protocol. Measurements indicate an increase dose rate relative to background at the south side adjacent to the gauge and shutter 1 position, with a maximum reading of 0.11 mR/hr. The licensee's service provider, SenTek, has been requested to perform emergency repair work. The B-Gauge was repaired last night around 1900 CST. The shutter failed to close due to the solenoid valve that opens and closes the shutter, which would not vent pressure. The failed solenoid valve was replaced by a new valve. The project to replace these gauges with x-ray technology is ongoing and on track to be replaced by first quarter, 2023."
"Source/Radioactive Material: SEALED SOURCE GAUGE
Manufacturer: Isotope Measuring Systems, Inc.
Model Number: NOT KNOWN IAEA Category: 3
Serial Number: 2332-2336L
Radionuclide: AM-241
Activity: 5 Ci (185 GBq)"
Iowa Event Number: IA220001
Agreement State
Event Number: 55920
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwest Community Hospital
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01094-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ossy Font
Licensee: Northwest Community Hospital
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01094-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ossy Font
Notification Date: 05/31/2022
Notification Time: 17:10 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2022
Notification Time: 17:10 [ET]
Event Date: 03/02/2022
Event Time: 00:00 [CDT]
Last Update Date: 06/16/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
EN Revision Imported Date: 6/17/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO EMBRYO/FETUS
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"The RSO [(Radiation Safety Officer)] for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate.
"The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads)."
Illinois Item Number: IL220018
* * * UPDATE FROM GARY FORESEE TO BRIAN PARKS AT 1526 EDT ON 6/16/2022 * * *
The following was received from the Illinois Emergency Management Agency (IMEA) via email:
"A reactionary inspection was performed 6/2/22. The required 15-day report was received on 6/12/22 and put forward root cause and corrective action. The cause of the event was determined to be the ineffectiveness of the pregnancy testing policy to account for very early stage (i.e., first week of gestation) pregnancies that standard pregnancy tests cannot detect. The licensee revised its pregnancy testing policy to include patient instruction to abstain from intercourse for at least ten days prior to the administration of the dose. The licensee will be cited for failing to provide timely notification and corrective action to prevent a recurrence sought in the response. Pending no further developments and resolution of appropriate enforcement action, this matter is considered closed."
Notified R3DO (Feliz-Adorno) and NMSS Events Notification E-mail Group.
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO EMBRYO/FETUS
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"The RSO [(Radiation Safety Officer)] for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate.
"The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads)."
Illinois Item Number: IL220018
* * * UPDATE FROM GARY FORESEE TO BRIAN PARKS AT 1526 EDT ON 6/16/2022 * * *
The following was received from the Illinois Emergency Management Agency (IMEA) via email:
"A reactionary inspection was performed 6/2/22. The required 15-day report was received on 6/12/22 and put forward root cause and corrective action. The cause of the event was determined to be the ineffectiveness of the pregnancy testing policy to account for very early stage (i.e., first week of gestation) pregnancies that standard pregnancy tests cannot detect. The licensee revised its pregnancy testing policy to include patient instruction to abstain from intercourse for at least ten days prior to the administration of the dose. The licensee will be cited for failing to provide timely notification and corrective action to prevent a recurrence sought in the response. Pending no further developments and resolution of appropriate enforcement action, this matter is considered closed."
Notified R3DO (Feliz-Adorno) and NMSS Events Notification E-mail Group.