Event Notification Report for September 01, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/31/2022 - 09/01/2022
Agreement State
Event Number: 56063
Rep Org: Texas Dept of State Health Services
Licensee: Recon Petrotechnologies Inc.
Region: 4
City: Alvarado State: TX
County:
License #: L 06839
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Mike Stafford
Notification Date: 08/23/2022
Notification Time: 18:32 [ET]
Event Date: 08/23/2022
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE
The following report was received via email from the Texas Department of State Health Services (the Agency):
"On August 23, 2022, the licensee notified the Agency that a string of well logging tools containing a 1.5 curie cesium-137 source and a 15 curie americium-241 source was lodged downhole in a well in Starr County, Texas. The sources are at 8,772 foot depth. Efforts to remove approximately 1,800 feet of wireline cable from above the tool were unsuccessful. The abandonment plan has been submitted to the Agency and to the Texas Railroad Commission for review. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: I-9950
Agreement State
Event Number: 56064
Rep Org: MA Radiation Control Program
Licensee: Dana Farber Cancer Institute
Region: 1
City: Boston State: MA
County:
License #: 60-0037
Agreement: Y
Docket:
NRC Notified By: Joshua E. Daehler
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/24/2022
Notification Time: 11:09 [ET]
Event Date: 08/22/2022
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNINTENDED DOSE TO FETUS
The following information was provided by the Massachusetts Radiation Control Program (The Agency) via email:
"The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure.
"The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report.
"The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant.
"The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received.
"The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4).
"The Agency considers this event to be open."
Massachusetts Event Number: 20-5109
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: 56065
Rep Org: Georgia Radioactive Material Pgm
Licensee:
Region: 1
City: State: GA
County: Macon
License #: 1392
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 12:51 [ET]
Event Date: 08/23/2022
Event Time: 12:00 [EDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST RADIOACTIVE PORTABLE GAUGE
The following information was received via email:
"The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to [Environmental Protection Division] (EPD) at [1530 EDT]. The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. [The driver was unable to locate the gauge]. We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss."
The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance:
The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241).
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: 56066
Rep Org: Texas Dept of State Health Services
Licensee: Propetro Services Inc
Region: 4
City: Midland State: TX
County:
License #: G 02571
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 16:36 [ET]
Event Date: 08/23/2022
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - BROKEN SHUTTER
The following information was received from the Texas Department of State Health Services (the Agency) via email:
"On August 24, 2022 the Agency received a report of an equipment failure from a general license acknowledgement (GLA) licensee. A lead plate on the shutter was found to no longer be attached to the shutter. An initial possible cause is that vibrations allowed the lead to go through the screws and become detached. The shutter was removed from service and placed into storage. A lead blanket is covering the gauge and a survey found no elevated readings. The device is approximately 8.5 years old and contains a 200 milli-Curie Cs-137 source. Nobody was believed to have received a significant dose from this issue. The licensee is taking pictures and will try to better determine the cause. The device will be repaired by a service company on August 26, 2022. An investigation is ongoing and further information will be provided per SA-300."
Texas Reference Number: 9951
Agreement State
Event Number: 56067
Rep Org: California Radiation Control Prgm
Licensee: CA Department of Transportation - Engineering Services
Region: 4
City: Santa Ana State: CA
County:
License #: 8131-30
Agreement: Y
Docket:
NRC Notified By: John Fassel
HQ OPS Officer: Ian Howard
Notification Date: 08/24/2022
Notification Time: 17:57 [ET]
Event Date: 08/24/2022
Event Time: 06:00 [PDT]
Last Update Date: 08/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST/RECOVERED RADIOACTIVE SOURCE
The following was provided by the California Department of Public Health (CDPH)/Radiation Health Branch (RHP) via email:
"On August 24, 2022, the Caltrans [California Department of Transportation] RSO [Radiation Safety Officer] notified CDPH/RHB of the theft ( Loss of control) and subsequent recovery of a Caltrans vehicle that contained a locked and shielded Cs-137 sealed source. The 3.7 GBq (100 mCi) Cs-137 sealed source is manufactured by Gammatron, Inc. - model GT-GHP. The sealed source is a component of a Mount Sopris Instrument Company gamma probe logging tool.
"The Caltrans vehicle was parked at [1800 PDT] on August 23, 2022, at a Doubletree hotel in Santa Ana and discovered stolen at [0600 PDT] on August 24, 2022, from the hotel parking lot. The RSO was immediately notified. California Highway Patrol was able to track the vehicle's GPS [Global Positioning System] locator signal to a nearby address where the Santa Ana Police located the abandoned vehicle with the sealed source locked inside. Many other items were stolen from the vehicle. There is an ongoing police investigation."
California Reference Number: 082422
Agreement State
Event Number: 56068
Rep Org: SC Dept of Health & Env Control
Licensee: Lowcountry Medical Group
Region: 1
City: Port Royal State: SC
County:
License #: 648
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Ian Howard
Notification Date: 08/25/2022
Notification Time: 15:14 [ET]
Event Date: 08/12/2022
Event Time: 08:30 [EDT]
Last Update Date: 08/25/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION
The following information was received from the South Carolina Department of Health and Environmental Control [the Department] via email:
"At 0905 [EDT] on August 12, 2022, the Department received a call from a representative of the Lowcountry Medical Group to report a contamination event. At about 0830 that same day, the certified nuclear medicine technician (CNMT) prepared to administer a dose to a patient on a treadmill to perform a stress test. While inserting the dose into the IV [intravenous], the cap loosened and the dose was sprayed onto the CNMT. Drops were released onto the treadmill handrails, track, and side. The CNMT decided to complete the treatment rather than to stop the treatment and perform radiation cleanup procedures as listed for the office. The CNMT, while still contaminated, left the room, went down the hall, and grabbed a replacement dose for the patient. This contaminated a hallway that was otherwise an unrestricted area. The CNMT successfully injected the patient with the second dose and completed the test then put the patient on a table to measure his shoes. The CNMT put booties on the patient and released them to go home. The CNMT changed clothes, went home, showered, and returned to the office afterward. The other CNMT remained at the office and cancelled the remaining patients.
"Inspectors from the Department arrived at the location at approximately 1215 to investigate the situation. At the time the inspectors arrived, no cleanup had begun and the contaminated hallway had not been blocked off. The inspectors surveyed the hallway and instructed the CNMTs to block the hallway and begin cleanup procedures. They reviewed the procedures with the staff and made sure that they had the right equipment to perform the cleanup.
"The radioactive material used was Tc-99m [technetium-99m]. The amount of material was 30.7 mCi. The treatment being performed was a nuclear stress test. The office reported that both CNMTs were 0.03 mR/hr (background) after the event. The results of the surveys pre-cleanup were as follows: Treadmill: 20 mR/hr, Floor: 20 mR/hr, Floor behind treadmill: 20 mR/hr."
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: 56069
Rep Org: OK Deq Rad Management
Licensee: Western Farmers Electric Coop
Region: 4
City: Hugo State: OK
County: Choctaw
License #: OK-19428-01
Agreement: Y
Docket:
NRC Notified By: Anna Farnow
HQ OPS Officer: Thomas Herrity
Notification Date: 08/25/2022
Notification Time: 15:38 [ET]
Event Date: 08/05/2022
Event Time: 22:40 [CDT]
Last Update Date: 08/25/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - GAUGE SOURCE EXPOSED TO FIRE
The following information was provided by the Oklahoma Department of Environmental Quality via email:
"On August 5, 2022, at 2240 [CDT] smoke was reported in Coal Bunker D [at the Hugo Plant]. Staff immediately began procedures to extinguish the fire. Coal Bunker D is located directly below Coal Feeder D and this caused thermal heat around the piping which feeds Coal Feeder D. A plug detector, which is a RA-226 source, is mounted around this pipe. By 0600 on August 6, 2022, the Coal Bunker D was down to 120 degrees. The plant staff notified, the WFEC [Western Farmers Electric Cooperative] Radiation Safety Officer (RSO), at 0640 to check the nuclear gauging device (D FDR Top, serial #SE2562, source amount is 2 mCi).
"Upon arriving at the plant, the RSO surveyed the area around the gauge and determined the area was safe. The gauge had received radiant heat from the fire causing the paint to be removed from the gauge. The survey meter read 0.7 mR/hr to 1.0 mR/hr around the gauge which is normal. The RSO also conducted an inhouse leak test check with the survey meter. The background was 0.1 mR/hr and sample was 0.2 mR/hr. WFEC is contacting the manufacturer to determine if further inspection is needed.
"At the time of this notification WFEC believes that no radiation exposure or leaks have occurred."