NMED: Report Page 1 of2

Single Event Report

NMED Item Number: 140417

Narrative: Last Updated: 08/12/2014 Montana State University (MSU) reported the loss of a 518 MBq (14 mCi) Ni-63 source from a gas chromatograph/electron capture detector (GC/ECD Varian model 3400, serial #13762) that was in storage. MSU was in the process of disposing all unwanted or unused radioactive sources. The RSO determined that the GC was no longer in Chemistry/Biochemistry Room 28. The GC had been in that room three months earlier during the semi-annual sealed source leak test inspection. None of the individuals occupying that area had any idea what happened to the device. A note and picture of the GC was sent to all personnel in the Land Resources/Environmental Science and Chemistry/Biochemistry departments. In addition, a search of all chemistry laboratories was conducted by the RSO. The GC has not been found. The RSO will search the rest of the campus. Two other GCs were picked up by the RSO and taken to his secure laboratory for removal of their Ni-63 sources, to prevent the incident from happening again. The remaining three GCs were placed on active protocols. During the search for the missing GC, another GC was found in a laboratory that had not been registered with the RSO. The RSO has requested that all principle investigators (Pis) report all radiation producing equipment to him. The RSO is meeting with all Pis to verify there is no unreported radiation producing devices on campus. The RSO has also placed notices on all GCs specifying that the RSO must be contacted prior to relocating devices. All personnel in laboratories containing radiation producing equipment will receive additional training concerning relocation of devices. The RSO has been placed on disciplinary action.

Event Date: 07/03/2014 Date Reported to Agreement State:

Discovery Date: 07/03/2014 Date Reported to NRC: 08/04/2014

Licensee/Reporting Party Information: Regulated By: NRC Reciprocity: NONE

License Number: 25-00326-06 Name: MONTANA STATE UNIVERSITY

NRC Docket Number: 03000871 City: BOZEMAN

NRC Program Code: 01100 State: MT

NRC Region: 4

Site of Event: Site Name: BOZEMAN State: MT

Additional Involved Party: License Number: NA Name:

NRC Docket Number: NA City: NRC Program Code: NA State:

NRC Region: NA

Other Information: NRC Reportable Event:

Agreement State Reportable Event:

Atomic Energy Act Material: Consultant Hired:

Event Type:

NA

NA NA

y

N y

N

LAS - LOST/ABANDONED/STOLEN

Event Cause:

LAS

Abnormal Occurrence: N

Investigation: N

Record Complete: Y Event Closed by Region/State: N T ---

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https://nmed.inl.gov/EventReportFull.aspx?ReportType=Single?ItemNumber= 14041 7 0311212015

NMED: Report

Cause: MANAGEMENT DEFICIENCY

Event IAEA Aggregate Category: LAS

IAEA Aggregate Category: NA

Corrective Actions Information: Event Type: Number: Action: LAS 1 PERSONNEL REPRIMANDED LAS LAS LAS

2 3 4

PERSONNEL RECEIVED ADDITIONAL TRAINING PROCEDURE MODIFIED IMPROVE RADIOACTIVE MATERIAL LABELING AND HANDLING

Source/Radioactive Material Information: LAS Source Number: 1 Source/Material: SEALED SOURCE ECO Radionuclide: Nl-63 Manufacturer: NR Activity (Ci): 0.014 Model Number: NR IAEA Category: NA Serial Number: NR

Device/Associated Equipment Information: LAS Device Number: 1 Device/Equipmemt: GAS CHROMATOGRAPH Model Number: 3400 Manufacturer: VARIAN Serial Number: 13762 LAS Device Number: 2 Device/Equipmemt: ELECTRON CAPTURE DETECTOR Model Number: NR Manufacturer: NR Serial Number: NR

Reporting Requirement Information: Event Type: Requirement:

Page 2 of2

LAS 20.2201 (a)(1 )(ii) - Lost, stolen, or missing licensed material in a quantity greater than 10 times the Appendix C quantities.

Keywords: Event Type: Keyword: LAS MATERIAL LOST AND NOT FOUND LAS TRILATERAL TO CANADA

Reference Documents: Reference Document Number: Entry Date: Retraction Date: Type of Report: EN50339 08/12/2014 EVENT NOTIFICATION

https:/ /nmed.inl.gov/EventReportFull.aspx?ReportType=Single?ItemNumber= 14041 7 03/12/2015

LICENSEE EVENT REPORT EVALUATION FORM Page 1 of3

EVENT CLASS: LAS - LOST. ABANDONED. STOLEN MATERIAL

LICENSEE I REPORTING PARTY INFORMATION:

Licensee/Reporting party name: Montana State University

License number : 25-00326-06

Docket number : 030-00871

Licensee's City of record : Bozeman

Licensees State of record : Montana

NRC regulated? yes I 1t so, what Region? I 1v

Working under reciprocity? no

EVENT INFORMATION:

In what City and State did the event occur? Bozeman, Montana

Event date: July 3, 2014

Discovery date : July 3, 2014

Report date : August 2, 2014

Agreement State reportable? N/A

NRC reportable? yes

Reporting regulation : 20.2201 (a)(2) and/or 20.2201 (a)(1 )(ii)

NMED Item Number : 14047

ADDITIONAL PARTIES INVOLVED:

Name: N/A

License number :

City :

State:

LICENSEE EVENT REPORT EVALUATION FORM Page 2 of3

EVENT CLASS: LAS- LOST. ABANDONED. STOLEN MATERIAL

CONSUL TANT INFORMATION (if any):

Consultant name : Stan Wilson, MMSc, MPH, CHP

Company: Behavioral-Based Improvement Solutions

Who hired consultant? Montana State Unversity

DEVICE INFORMATION:

Manufacturer : Varian (now known as Agilent)

Model number: 3400; 6890

Serial number : 13762; 10212088

RADIATION SOURCE INFORMATION:

Isotope: Ni-63 (missing source; Ni-63 (missing source reported 8/4/14) reported 9/16/2014)

Activity: 13.95 millicuries (as of 13.73 millicuries (as of 1/2015) 1/2015)

Manufacturer : Eckert & Zeilger, IPL Eckert & Zeilger, I PL (formerly New England (formerly New England Nuclear) Nuclear)

Model number : NER-004 NER-004

Serial number : A14442 U4156

LICENSEE EVENT REPORT EVALUATION FORM Page 3of3

EVENT CLASS: LAS - LOST, ABANDONED. STOLEN MATERIAL

NARRATIVE EVENT DESCRIPTION:

Montana State University (MSU) reported the loss of a 518 MBq (14 mCi) Ni-63 source from a gas chromatograph/electron capture detector (GC/ECD Varian model 3400, serial #13762) that was in storage. MSU is in the process of disposing all unwanted or unused radioactive sources. The RSO determined that the GC was no longer in Chemistry/Biochemistry Room 28. The GC had been in that room three months earlier during the semi-annual sealed source leak test inspection. None of the individuals occupying that area had any idea what happened to the device. A note and picture of the GC was sent to all personnel in the Land Resources/Environmental Science and Chemistry/Biochemistry departments. In addition, a search of all chemistry laboratories was conducted by the previous RSO. The previous RSO and staff searched various locations of use on the campus. Two other GCs were picked up by the previous RSO and taken to his secure laboratory for removal of their Ni-63 sources, to prevent the incident from happening again. The remaining three GCs are being placed on active protocols. During the search for the missing GC, another GC was found in a laboratory that had not been registered with the previous RSO. The previous RSO has requested that all principle investigators (Pis) report all radiation producing equipment to him. The previous RSO met with all Pis to verify there is no unreported radiation producing devices on campus. The previous RSO has also placed notices on all GCs specifying that the RSO must be contacted prior to relocating devices. All personnel in laboratories containing radiation producing equipment will receive additional training concerning relocation of devices. The previous RSO has been terminated. An updated report dated September 16, 2014(ML14260A554) was submitted to the NRC, stated that during a recent inventory (by Consultant: Stan Wilson, Behavioral-Based Improvement Solutions), another GC/ECD was missing from its last known location (GC/ECD Agilent model 6890, serial# U4156) at McCall Bldg. Room 25) this device contained a Ni-63 source 517MBq (-13.95 mCi). Additionally, this report included a notification that another Ni-63 source was leak tested and revealed the presence of contamination in excess of 0.005 microcuries (Ni-63 (leaking source) 1.74 millicuries Eckert & Zeilger, IPL (formerly New England Nuclear) NER-9048 SIN 37515-01 ).

A reactive inspection was conducted the October 7 - 9, 2014. At that time, Montana State University provided transfer documentation to the inspector for the source reported in August 2014 (GC/ECD Varian model 3400 seriel #13762/A14442).The documentation stated it was transferred to a community college in Washington State (Drs. Grimsrud/Sears). However, the documentation provided for source reported September 2014, GC/ECD (SN10212088) had been transferred to another department, then ultimately sent to Property Management to be surplussed. Acquisition documentation states that the disposal date was August 1, 2011 and the disposal method was "Salvaged/Cannibalized".

In letter dated January 15, 2015(ML15076A311), the newly appointed RSO stated that they were suspending the search for the one source that remains "missing", which by all accounts was most likely, thrown away in regular trash, while parts of the GC/ECD were surplussed by the Property Management Department.

The inspector confirmed that the leaking source is properly packaged and stored until disposal.

Please note: The manufacturer and model numbers on the initial and updated reports were for the devices (GC/ECD) not the sources. The inspector included the source model numbers in accordance with the SS&D registry (#CA-8253-D-801-B(device) and #CA0406S214S(sources)). MSU is authorized for Ni-63 sealed sources registered pursuant to 10 CFR 32.210.

CORRECTIVE ACTIONS:

Montana State University will provide training to ALL radiation workers and ancillary staff. MSU has also hired a consultant who issued a report with Observations & Recommendations (ML 14295A636) following the missing sources incident. The consultant will assess the Radiation Safety Program, including radioactive material accountability. The consultant will continue to provide comprehensive support to the new RSO and facilitate waste disposal and corrective actions based on the recommendations.

RECOMMENDED FOLLOWUP:

Was a reactive inspection conducted? Yes If so, inspection report pending 01 report number: 2014-001

Is LER recommended for closure? Yes

Is this NMED Item Number • 'Jes recommended to reflect "complete"?

Branch Chief or Designee Review:

Name:-------- Date:. ___ _