Event Notification Report for December 20, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/19/2021 - 12/20/2021
Agreement State
Event Number: 55678
Rep Org: Colorado Dept of Health
Licensee: Saint Mary Corwin Hospital
Region: 4
City: Pueblo State: CO
County:
License #: CO 235-02
Agreement: Y
Docket:
NRC Notified By: Derek Bailey
HQ OPS Officer: Karen Cotton-Gross
Licensee: Saint Mary Corwin Hospital
Region: 4
City: Pueblo State: CO
County:
License #: CO 235-02
Agreement: Y
Docket:
NRC Notified By: Derek Bailey
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/29/2021
Notification Time: 11:34 [ET]
Event Date: 12/20/2021
Event Time: 00:00 [MST]
Last Update Date: 12/29/2021
Notification Time: 11:34 [ET]
Event Date: 12/20/2021
Event Time: 00:00 [MST]
Last Update Date: 12/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Werner, Greg (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 1/28/2022
EN Revision Text: AGREEMENT STATE REPORT - MISSING/UNACCOUNTED FOR IODINE-125 SEED
The following was sent by the state of Colorado Health Department (Division) via e-mail:
"On Tuesday December 28, 2021, the Division received an email from St. Mary Corwin Hospital, indicating an unaccounted for iodine-125 seed. The seed was discovered missing on December 20, 2021.
"An internal investigation by St. Mary Corwin Hospital verified that all patients that had an iodine-125 seed implanted had their seeds removed. Additionally, the physics and pathology area and equipment were surveyed by two physicists. The investigation by St. Mary Corwin Hospital concluded the seed was likely disposed of in the municipal waste stream.
"Estimated dose to any worker: St. Mary Corwin Hospital concluded that due to the high likelihood the seed was in a trash bin, no person would've come within a meter of the seed for any extended period. At [when measured by] a meter, any of these seeds would be at or below background, so most likely the exposure to an individual would be indistinguishable from background."
Colorado Event Report No. CO 210046
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.
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 - MISSING/UNACCOUNTED FOR IODINE-125 SEED
The following was sent by the state of Colorado Health Department (Division) via e-mail:
"On Tuesday December 28, 2021, the Division received an email from St. Mary Corwin Hospital, indicating an unaccounted for iodine-125 seed. The seed was discovered missing on December 20, 2021.
"An internal investigation by St. Mary Corwin Hospital verified that all patients that had an iodine-125 seed implanted had their seeds removed. Additionally, the physics and pathology area and equipment were surveyed by two physicists. The investigation by St. Mary Corwin Hospital concluded the seed was likely disposed of in the municipal waste stream.
"Estimated dose to any worker: St. Mary Corwin Hospital concluded that due to the high likelihood the seed was in a trash bin, no person would've come within a meter of the seed for any extended period. At [when measured by] a meter, any of these seeds would be at or below background, so most likely the exposure to an individual would be indistinguishable from background."
Colorado Event Report No. CO 210046
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.
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
Fuel Cycle Facility
Event Number: 55666
Facility: Framatome ANP Richland
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Notification Date: 12/20/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/21/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/21/2021
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel Agreement State
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
EN Revision Imported Date: 1/21/2022
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.
* * * UPDATE FROM JAMES KILLINGBECK TO THOMAS KENDZIA AT 1136 EST ON 12/21/21 * * *
The following information is a synopsis of information received from the Washington State Department of Health, Office of Radiation Protection (Agency) via e-mail and phone:
The Agency was notified of this event yesterday as it is stated above with the following additional information. The Washington State license for Framatone, Inc. is WN-I0612, Qal-Tek Associates, LLC NRC license is 11-27610-01, cesium-137 source current activity is about 0.0022 curies (2.2 millicuries).
The Agency submitted an NRC NMED report for this event yesterday. The Agency was determining if the event met reporting requirements for notification of the NRC Headquarters Operations Center (HOC). Today the Agency determined this event was reportable to the NRC HOC as an Agreement State report since it met the criteria of 10 CFR 30.50(b)(2).
Washington state incident number WA-21-026
Notified R4DO (O'Keefe), and NMSS Events Notification group (email).
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.
* * * UPDATE FROM JAMES KILLINGBECK TO THOMAS KENDZIA AT 1136 EST ON 12/21/21 * * *
The following information is a synopsis of information received from the Washington State Department of Health, Office of Radiation Protection (Agency) via e-mail and phone:
The Agency was notified of this event yesterday as it is stated above with the following additional information. The Washington State license for Framatone, Inc. is WN-I0612, Qal-Tek Associates, LLC NRC license is 11-27610-01, cesium-137 source current activity is about 0.0022 curies (2.2 millicuries).
The Agency submitted an NRC NMED report for this event yesterday. The Agency was determining if the event met reporting requirements for notification of the NRC Headquarters Operations Center (HOC). Today the Agency determined this event was reportable to the NRC HOC as an Agreement State report since it met the criteria of 10 CFR 30.50(b)(2).
Washington state incident number WA-21-026
Notified R4DO (O'Keefe), and NMSS Events Notification group (email).
Agreement State
Event Number: 55668
Rep Org: Louisiana DEQ
Licensee: Rubicon, LLC
Region: 4
City: Geismar State: LA
County:
License #: LA-2232-L01, Amend. No. 47
Agreement: Y
Docket:
NRC Notified By: Russell S. Clark II
HQ OPS Officer: Ossy Font
Licensee: Rubicon, LLC
Region: 4
City: Geismar State: LA
County:
License #: LA-2232-L01, Amend. No. 47
Agreement: Y
Docket:
NRC Notified By: Russell S. Clark II
HQ OPS Officer: Ossy Font
Notification Date: 12/21/2021
Notification Time: 11:13 [ET]
Event Date: 12/20/2021
Event Time: 13:55 [CST]
Last Update Date: 12/21/2021
Notification Time: 11:13 [ET]
Event Date: 12/20/2021
Event Time: 13:55 [CST]
Last Update Date: 12/21/2021
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: 1/21/2022
EN Revision Text: AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION
The following was received from the Louisiana Department of Environmental Quality (LDEQ) via e-mail:
"On December 20, 2021, at approximately 1:55 pm, Central Standard Time, [the] Radiation Safety Officer for Rubicon, LLC, notified LDEQ of equipment malfunctions. Three Ohmart Model SH-F1 level/density gauges experienced shutter malfunctions, two installed on a vessel within the MDI-III process unit and one Model SH-F1 gauge installed on a vessel in the MDI-I processing unit. The gauges in the MDI-III unit possess two nominally 20 mCi sealed sources of Cs-137 and the gauge in MDI-I possesses a nominally 70 mCi sealed source of Cs-137. The above gauges were undergoing routine annual shutter tests when the above malfunctions were observed. The first gauge sealed source, 1566CG, installed on October 15, 2001, item 73 on the licensee's source inventory, is mounted on vessel MM-9303 in the MDI-3 unit. The second gauge source, 1567CG, installed on October 15, 2001, item 74 on the licensee's source inventory, is also mounted on vessel MM-9303. The third gauge source, 72930, installed on January 19, 1998, item 38 on the licensee's source inventory, is mounted on the P1 PI scrubber in the MDI-1 unit. [The] Zone Maintenance Coordinator, notified [the RSO] concerning the shearing of screws even with the top of each rotor on the two gauges in the MDI-III unit. [The Zone Maintenance Coordinator] also reported to the RSO that the source holder in the MDI-1 unit experienced a problem with the rotor mechanism not aligning with the shutter handle, which prevented the gauge shutter from closing fully. [The Zone Maintenance Coordinator] learned of the malfunctions during annual inventory work and reported the problem to the RSO on December 16, 2021 at approximately 2:30 pm. The situation with each gauge is under the licensee's control, and there were no exposures to members of the public approaching regulatory limits. Currently, the shutters on gauges, 73, 74, and 38 remain in the open position, as the gauge sources are needed to operate process control equipment. The gauges cannot be locked out in their current state. As a result, no vessel entries will be conducted on either vessel MM-9303 or the P1 PI scrubber vessel until the gauges are repaired by BBP Sales (BBP). Work orders have been written to correct the malfunction of all three devices. The licensee will continue to monitor the gauges and their status of repair. The licensee stated they would keep the LDEQ updated on progress of the repairs."
Louisiana Event Report ID No.: LA 210012
EN Revision Text: AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION
The following was received from the Louisiana Department of Environmental Quality (LDEQ) via e-mail:
"On December 20, 2021, at approximately 1:55 pm, Central Standard Time, [the] Radiation Safety Officer for Rubicon, LLC, notified LDEQ of equipment malfunctions. Three Ohmart Model SH-F1 level/density gauges experienced shutter malfunctions, two installed on a vessel within the MDI-III process unit and one Model SH-F1 gauge installed on a vessel in the MDI-I processing unit. The gauges in the MDI-III unit possess two nominally 20 mCi sealed sources of Cs-137 and the gauge in MDI-I possesses a nominally 70 mCi sealed source of Cs-137. The above gauges were undergoing routine annual shutter tests when the above malfunctions were observed. The first gauge sealed source, 1566CG, installed on October 15, 2001, item 73 on the licensee's source inventory, is mounted on vessel MM-9303 in the MDI-3 unit. The second gauge source, 1567CG, installed on October 15, 2001, item 74 on the licensee's source inventory, is also mounted on vessel MM-9303. The third gauge source, 72930, installed on January 19, 1998, item 38 on the licensee's source inventory, is mounted on the P1 PI scrubber in the MDI-1 unit. [The] Zone Maintenance Coordinator, notified [the RSO] concerning the shearing of screws even with the top of each rotor on the two gauges in the MDI-III unit. [The Zone Maintenance Coordinator] also reported to the RSO that the source holder in the MDI-1 unit experienced a problem with the rotor mechanism not aligning with the shutter handle, which prevented the gauge shutter from closing fully. [The Zone Maintenance Coordinator] learned of the malfunctions during annual inventory work and reported the problem to the RSO on December 16, 2021 at approximately 2:30 pm. The situation with each gauge is under the licensee's control, and there were no exposures to members of the public approaching regulatory limits. Currently, the shutters on gauges, 73, 74, and 38 remain in the open position, as the gauge sources are needed to operate process control equipment. The gauges cannot be locked out in their current state. As a result, no vessel entries will be conducted on either vessel MM-9303 or the P1 PI scrubber vessel until the gauges are repaired by BBP Sales (BBP). Work orders have been written to correct the malfunction of all three devices. The licensee will continue to monitor the gauges and their status of repair. The licensee stated they would keep the LDEQ updated on progress of the repairs."
Louisiana Event Report ID No.: LA 210012