Alert

The NRC is shutdown due to the lapse in appropriations. Exempted activities to maintain critical health and safety activities and progress on critical activities, including activities outlined in Executive Order 14300, as described in the OMB Approved NRC Lapse Plan will continue.

Event Notification Report for July 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/24/2019 - 7/25/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54164
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: PROFESSIONAL SERVICES INDUSTRIES, INC. Region: 3 City: DAYTON State: OH County: License #: 31261310039 Agreement: Y Docket: NRC Notified By: STEPHEN JAMES HQ OPS Officer: JEFF HERRERA	Notification Date: 07/16/2019 Notification Time: 12:48 [ET] Event Date: 07/15/2019 Event Time: 00:00 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RHEX EDWARDS (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE DUE TO TRUCK FIRE

The following report was received from the Ohio Bureau of Environmental Health and Radiation Protection via email:

"The licensee [Professional Service Industries, Inc.] experienced a vehicle fire today (7/15/19) involving a Troxler 3430P gauge, S/N 70185, containing a double-encapsulated sealed source of Cs-137 (8 mCi [0.30 GBq]) plus a double-encapsulated sealed source of Am-241 (40 mCi [1.48 GBq]).

"The vehicle driver pulled over on the shoulder of the interstate when he noticed smoke [coming] from the bed of the truck. The licensee believes that the cause of the fire may have been as a result of vandalism that ruptured the fuel tank. The licensee reported that such activities have occurred in the past. No one was injured.

"After the fire was extinguished, the device was surveyed using a calibrated NDS Model ND-500A survey meter. The measured radiation levels of the device were 20 mR/hr at the surface, and 0.9 mR/hr at 1 meter, without the transport case. The device has been leak tested pending results and Troxler has been contacted for disposal."

Item Number: OH190011

Agreement State	Event Number: 54165
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: RAYONIER ADVANCED MATERIALS Region: 1 City: JESUP State: GA County: License #: GA-381-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/16/2019 Notification Time: 13:34 [ET] Event Date: 07/16/2019 Event Time: 00:00 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER MALFUNCTIONED

The following information was obtained from the state of Georgia via email:

"The shutter on a saltcake density meter was identified as needing attention on the last inventory and Berthold was scheduled to come on the next outage to repair or replace as needed. The outage is scheduled for 7/31/19.

"Today, [the licensee] identified that a saltcake pump near the gauge needs to be replaced and the gauge is listed on the pump's lockout sheet. When IM [instrument maintenance] attempted to lock out the meter as part of the established lock out, the shutter handle broke meaning the gauge cannot be locked out. (Lock out requires all energy sources affecting the pump to be locked out. The gauge is in the line ahead of the pump and about 6 feet away so does not really affect the pump.) Radiation survey at the pump showed 65 microRem/hr radiation. (500 microRem/hr at gauge surface and 134 microRem/hr at one foot)

"Maintenance work at the pump will continue with a lock out variance to cite not being able to close the shutter and a proximity radiation work permit used. Berthold is still scheduled to come in 7/31/19 for gauge shutter repair.

"Source is Cesium-137, 20 mCi, model P-2623-100 in LB7440 holder, serial no. 2104-6-90."

Fuel Cycle Facility	Event Number: 54166
Facility: GLOBAL NUCLEAR FUEL - AMERICAS RX Type: URANIUM FUEL FABRICATION Comments: LEU CONVERSION (UF6 TO UO2) LEU FABRICATION LWR COMMERICAL FUEL Region: 2 City: WILMINGTON State: NC County: NEW HANOVER License #: SNM-1097 Docket: 07001113 NRC Notified By: PHILLIP OLLIS HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/16/2019 Notification Time: 14:42 [ET] Event Date: 07/16/2019 Event Time: 11:33 [EDT] Last Update Date: 07/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL	Person (Organization): FRANK EHRHARDT (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT NOTIFICATION DUE TO SPRINKLER MAINTENANCE

"At 1133 EDT on July 16, 2019, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system for the Fuel Manufacturing Operation Shop Support Areas was taken offline for planned maintenance to modify sprinkler piping. Compensatory measures were enacted. The system was taken offline at approximately 0800 EDT and was returned to service at approximately 1400. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will be notifying the North Carolina Emergency Management Agency and NRC Region 2.

Agreement State	Event Number: 54169
Rep Org: TENNESSEE DIV OF RAD HEALTH Licensee: VANDERBILT UNIVERSITY MEDICAL CENTER Region: 1 City: NASHVILLE State: TN County: License #: R-19266-A26 Agreement: Y Docket: NRC Notified By: RUBEN CROSSLIN HQ OPS Officer: CATY NOLAN	Notification Date: 07/17/2019 Notification Time: 10:24 [ET] Event Date: 07/16/2019 Event Time: 00:00 [EDT] Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

"Vanderbilt University Medical Center had a misadministration on 7/16/19. A patient was supposed to receive 14 mCi of I-131 NaI, but the technologist administered 33 mCi of I-131 NaI. The technologist will send a written report within the 15 day requirement."

Item Number: TN-19-098

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: 54170
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: PERKINELMER, INC. Region: 1 City: BILLERICA State: MA County: License #: 00-3200 Agreement: Y Docket: NRC Notified By: KENATH TRAEGDE HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/17/2019 Notification Time: 15:11 [ET] Event Date: 07/12/2019 Event Time: 00:00 [EDT] Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOST THEN FOUND SHIPMENT OF RADIOACTIVE IODINE-125

The following information was received from the Commonwealth of Massachusetts via email:

"Two shipments of licensed material in the form of Iodine-125 saline, one with an activity of 1.75 Curies and the other, 1.25 Curies, were discovered not to be delivered by [a common carrier] to the licensee's authorized use site at 331 Treble Cove Road, Billerica, MA, on Friday, July 12, 2019. PerkinElmer leases authorized use space from another Massachusetts licensee, Lantheus Medical Imaging, Inc., at the same street address. PerkinElmer subsequently contacted Lantheus and [the common carrier] on 7/12/19 at approximately 1416 EDT to report the missing packages.

"On Monday, July 15, [the package] containing 1.25 curies of I-125 was delivered by [the common carrier] to the PerkinElmer shipping department. [The licensee] subsequently reported to [the common carrier] that one of the packages was delivered; however, the second package containing 1.75 curies of I-125 was not. On Tuesday, July 16, [the common carrier] contacted PerkinElmer to report that both packages were delivered and that the case was closed.

"On Wednesday, July 17, at 1054 EDT, [the common carrier] delivered the second package to the PerkinElmer shipping department and stated that it was just picked up from Lantheus a short time before. It had apparently been in Lantheus's possession since Monday, July 15.

"An investigation of the incident is underway."

Agreement State	Event Number: 54171
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT Licensee: SAINT AGNES HOSPITAL Region: 1 City: BALTIMORE State: MD County: BALTIMORE License #: MD-07-010-01 Agreement: Y Docket: NRC Notified By: ALAN GOLDEY HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/17/2019 Notification Time: 15:35 [ET] Event Date: 07/17/2019 Event Time: 00:00 [EDT] Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TWO RADIOPHARMACEUTICAL PACKAGES HAD HIGH SURFACE CONTAMINATION LEVELS WHEN DELIVERED

The following information was received from the state of Maryland via email:

"On July 10, 2019, a health physics consultant contacted the Maryland Department of the Environment Radiological Health Program (MDE/RHP) concerning a discovery during a routine audit conducted on July 10, 2019 at a licensed medical facility.

"A review of incoming Department of Transportation wipe/survey listing reports at the licensed facility [St. Agnes Hospital in Baltimore, MD] indicated that two packages received on June 12, 2019 from the radiopharmacy had high wipe test values recorded at 400,000 dpm per 100 cm2. These values were documented for surface and contents of the packages. Both packages were labeled as White I and had no abnormal outer package surface exposure rate readings. The computer record contained a note stating that, 'dpm verified and Cardinal [Health] notified. Case stored for decay.'

"The technologists did not notify the Radiation Safety Officer or MDE/RHP. The cases were opened, the doses unpacked, and used. The computer record indicated good condition for each box. One box contained one syringe of Tc-99m Ceretec at 17.25 mCi. The other box contained one vial of Tc-99m sodium pertechnetate at 104.22 mCi, one syringe of Tc-99m macro aggregated albumin at 10.61 mCi, and one syringe Tc-99m Sestamibi at 30.41 mCi.

"A reactive inspection is planned [by the state of Maryland]."

Cardinal Health was the radiopharmaceutical provider. The delivery vehicle and the driver were both surveyed on June 12, 2019, with negative results. No other contaminations or any overexposures were identified when the hospital performed surveys of the facility.

Page Last Reviewed/Updated Wednesday, March 24, 2021