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Current Event Notification Report for May 21, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/20/2019 - 5/21/2019

** EVENT NUMBERS **


54042 54058 54059 54063 54073

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Non-Agreement State Event Number: 54042
Rep Org: INTERNATIONAL ISOTOPES, INC.
Licensee: INTERNATIONAL ISOTOPES, INC.
Region: 4
City: IDAHO FALLS   State: ID
County:
License #: 11-27680-01MD
Agreement: N
Docket:
NRC Notified By: JOHN MILLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/03/2019
Notification Time: 01:02 [ET]
Event Date: 05/02/2019
Event Time: 21:30 [MDT]
Last Update Date: 05/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
WILLIAM GOTT (IRD)
ANDREA KOCK (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 5/21/2019

EN Revision Text: UNPLANNED CONTAMINATION EVENT DUE TO BREACHED CS-137 SOURCE

The Radiation Safety Officer (RSO) at International Isotopes, Inc. reported that at 2130 PDT on 5/2/19, while changing out the Cs-137 source on a research irradiator, they breached the source which resulted in widespread contamination and a possible uptake event. The irradiator is a JL Shepard Mark 168A and is located at the Harborview Research and Training Facility at the University of Washington in Seattle, WA. International Isotopes, Inc. is an NRC licensee working under reciprocity in the State of Washington (an agreement state).

After discovery of the breach, the immediate area was isolated, the building was ordered evacuated, and the ventilation was secured. Indications are that the seven members of the source retrieval team were externally and potentially internally contaminated.

The State of Washington was notified. The University of Washington RSO was sending response teams to the area. A local hazardous material team is on site.

The source was reported to be 2800 Ci.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATE ON 05/03/2019 AT 1545 EDT FROM TRISTAN HAY TO JEFFREY WHITED * * *

The following update was received via E-mail from the Washington State Department of Health:

"University of Washington (UW) was having their research irradiator (Mark-1 SERIES / Cs-137) disposed of by International Isotopes (NRC License 11-27680-01MD). The Agreement state regulators were present to verify dose measurements and observe ALARA practices. During the source removal and transfer into the transport shielded cask, there was a breach of the sealed source and a small portion of the source was released into the working area. The working area was comprised of the irradiator unit, the shielded containment rig, the loading dock, a 100 feet radius around the loading dock, and the Harborview Research and Technology Center floors 1-3 and stair well. The source was encapsulated with International Isotopes' source housing capsule. A breach was identified during the precursor wipe survey performed prior to putting it into the source housing unit. Once contamination was identified, all personnel performed area contamination surveys and secured and taped off the work space area. All personnel who were present at some point during the transfer were notified of the potential contamination and were given special instructions to return to the Harborview Medical Center area for decontamination.

"Simultaneously the NRC, Washington Radiation Emergency Hotline, and the [National Materials Event Database] NMED were notified of the situation by International Isotopes immediately after the incident occurred. Seattle Fire and Seattle Hazmat units were dispatched to the scene to assess the situation and begin decontamination protocols. The International Isotope workers, UW RSO, FBI agent, and other present workers were decontaminated and placed in a contained area of the Harborview Medical Center Emergency Room. Bioassay samples were collected from urine and blood from the contaminated individuals."

Additionally, employees from the State of Washington who responded to the event were surveyed, with the highest level of contamination being 300 cpm on the individual's shoes.

Washington State Licensee: University of Washington
Washington Agreement State License No. C001
Event Report ID No.: WA-19-015

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATE ON 05/04/2019 AT 2136 EDT FROM JOHN MILLER TO JEFFREY WHITED * * *

The following update is a synopsis of information received via E-mail from International Isotopes:

In its E-mail, the licensee provided an initial incident report regarding the breached Cs-137 source incident that occurred during the removal of the source from the Research Irradiator at the Harborview Training and Research Building. The licensee provided a summary of planned work, a summary of the incident, a summary of the whole-body exposures received by International Isotopes and contractor employees, a summary of initial personnel skin contamination results, a summary of post-decontamination personnel skin contamination results, and a summary of recovery actions taken to date.

According to its assessment, the licensee indicated that the highest whole-body exposure to any one individual was 55 mrem. The majority of surveys taken at the loading dock level indicated that surfaces were contaminated in the 50,000 - 300,000 cpm range.

The summary of recovery actions taken to date are as follows:

International Isotopes hired a contractor to perform decontamination and remediation of the affected areas. The Department of Energy, Region 8, Radiological Assistance Program team surveyed the building floors. International Isotopes employees surveyed the parking lot area where emergency response operations took place reducing the size of the controlled area, marking spots with identified levels. The loading dock area was further isolated from the building by covering outdoor louvers and double door between corridor and loading dock with heavy plastic. International Isotopes remains on-site to support the contractor and the University of Washington by performing assessment surveys and development of the decontamination and recovery plan.

Notified R4DO (Werner), IRD MOC (Gott), NMSS (Kock), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE AT 1648 EDT ON 05/16/2019 FROM JOHN MILLER TO JEFF HERRERA * * *

"This report provides an update to the May 2, 2019 incident involving the breached Cs-137 source.

"International Isotopes Inc. (INIS) performed dose estimates based on 24 hour urine samples collected from the INIS employees that were involved in the incident.

"There were seven INIS individuals involved, the INIS estimates are provided in the table below. Note that individuals 6 and 7 are not included in the LANL Report as their urine sample results were released later. These sample results have since been provided to LANL.

"Name; Time Between intake and sample (days); Concentration (pCi/L); Modeled Intake (uCi); Percent ALI; CED (mRem)

"Individual 1: 1.625; 15,700; 2.284; 1.142 Percent; 57.1
Individual 2: 1.396; 6,100; 1.235; 0.618 Percent; 30.9
Individual 3: 1.698; 1,280; 0.186; 0.093 Percent; 4.7
Individual 4: 1.665; 8,540; 1.242; 0.621 Percent; 31.1
Individual 5: 1.697; 19,800; 2.880; 1.440 Percent; 72.0

"Individual 6: 1.687; 5,540; 0.806; 0.403 Percent; 20.1
Individual 7: 1.437; 4,110; 0.624; 0.312 Percent; 15.6"

Notified R4DO (Proulx), IRD MOC (Kennedy), NMSS (Rivera Capella), and NMSS Events Notification via e-mail, DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 05/20/2019 AT 1050 FROM INTERNATIONAL ISOTOPES TO KENDZIA * * *

The following update is a synopsis of information received via E-mail from International Isotopes:

International Isotopes provided a detailed update on internal and whole body doses, skin contamination and decontaminated results for the affected seven individuals. The highest internal dose was 57.1 mrem for individual 1, the highest whole body dose was 55 mrem for individual 7, and the highest dose to the skin from skin contamination was 36 mrem to individuals 3 and 4. Blood sampling of the individuals showed no changes due to radiation.

Facility decontamination continues. International Isotope management is in the process of conducting a detailed investigation in order to determine the direct, contributing, and root causes of this event.

Notified R4DO (Gepford) IRD MOC (Kennedy), and NMSS Events Notification via e-mail.

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Agreement State Event Number: 54058
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NASA - MICHOUD ASSEMBLY FACILITY
Region: 4
City: NEW ORLEANS   State: LA
County:
License #: LA-2319-L01A, AI # 9145
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 05/10/2019
Notification Time: 14:44 [ET]
Event Date: 09/26/2013
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL

The following information was excerpted from an email received from the State of Louisiana:

On 8/15/2018, the radiation safety officer (RSO) at NASA's Michoud Assembly Facility (NASA-M) discovered a dew point device containing a radioactive source was sent to a recycling center for disposal. The recycler was UNICOR Recycling Factory (UCF) in Marinna, FL. UCF was not licensed to receive radioactive material. The dew point device with the source was sent to UCF for disposal on 9/26/2013. The RSO reported the disposal to the Louisiana Department of Environmental Quality, as a lost source and unreported release of radioactive material, on 5/9/2019. UCF was contacted my NASA-M for records and documentation, but UCF stated they did not have any records/documentation for that device disposal.

The device was an Alnor Instrument Co.; Type 7000U Dew Point Determination device with a 35 microCi Am-241 source (serial number 25829).

Louisiana Event Report ID No.: LA-190007

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

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Agreement State Event Number: 54059
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY MEDICAL CENTER
Region: 1
City: LEXINGTON   State: KY
County:
License #: 20204922
Agreement: Y
Docket:
NRC Notified By: ANJAN BHATTACHARYYA
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/10/2019
Notification Time: 14:55 [ET]
Event Date: 05/07/2019
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDER ADMINISTRATION OF PRESCRIBED DOSE DURING MEDICAL PROCEDURE

The following was received via a telephone report from the Kentucky Department of Radiation Control:

The Kentucky Department of Radiation Control was notified by the University of Kentucky Medical Center in Lexington, Kentucky, that on 05-07-2019 they had a medical event. During a Sirtex Therapy procedure, which uses Y-90 microspheres, less than 20 percent of the prescribed dose was delivered. Investigation continues.

Kentucky Event Report ID No.: KY190004

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.

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Agreement State Event Number: 54063
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: TC TRANSCONTINENTAL
Region: 3
City: MENASHA   State: WI
County:
License #: 139-1408-01
Agreement: Y
Docket:
NRC Notified By: JERRY LEE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/13/2019
Notification Time: 13:40 [ET]
Event Date: 05/10/2019
Event Time: 16:00 [CDT]
Last Update Date: 05/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SHUTTER STUCK IN OPEN POSITION

The following was received via e-mail:

"On May 13, 2019, the Wisconsin Department of Health Services (DHS) was notified by the licensee TC Transcontinental that at around 1600 CDT on Friday, May 10, 2019, a shutter got stuck in the open position. A ThermoFisher technician was on site doing regular maintenance checks on a Kr-85 Thermo EGS Gauging Model TFC-185 when the shutter got stuck in the open position. The licensee cordoned off the area to prevent unauthorized access to the vicinity.

"ThermoFisher was on site Saturday, May 11, 2019 and repaired the stuck shutter. The shutter now opens and closes as expected.

"The Wisconsin DHS will perform a reactive inspection with the licensee."

Event Report ID No.: WI 190004

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Power Reactor Event Number: 54073
Facility: ARKANSAS NUCLEAR
Region: 4     State: AR
Unit: [1] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: KEVIN PARKS
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/20/2019
Notification Time: 00:02 [ET]
Event Date: 05/19/2019
Event Time: 18:09 [CDT]
Last Update Date: 05/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID PROULX (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 91 Power Operation

Event Text

LOSS OF THE SAFETY PARAMETER DISPLAY SYSTEM DUE TO INVERTER FAILURE

"On May 19, 2019, at 1809 CDT, the Safety Parameter Display System (SPDS) was lost to both Arkansas Nuclear One Units 1 and 2 due to the SPDS Inverter (2Y-26) failure. The SPDS Inverter is the power supply to both units' SPDS. The Unit 2 Control Room dispatched operators in response to a smoke alarm received from the 2Y-26 Inverter room. Upon arrival, smoke was reported emanating from 2Y-26. There was no report of fire at any time. Field operators de-energized 2Y-26 and the smoke ceased. The loss of SPDS also caused the Power Operating Limits (POL) function of the Unit 2 Core Operating Limits Supervisory System (COLSS) to be lost, so Unit 2 reduced power to 91 [percent] in accordance with Technical Specifications. Both units are at power and stable.

"The NRC Resident has been notified.

"This is reportable per 10 CFR 50.72(b)(3)(xiii)."


Page Last Reviewed/Updated Tuesday, May 21, 2019
Tuesday, May 21, 2019