United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 16, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/15/2012 - 11/16/2012

** EVENT NUMBERS **


48261 48486 48488 48489 48490

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Agreement State Event Number: 48261
Rep Org: NV DIV OF RAD HEALTH
Licensee: UNIVERSITY OF NEVADA
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-13-0305-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/31/2012
Notification Time: 15:48 [ET]
Event Date: 10/01/2011
Event Time: [PDT]
Last Update Date: 11/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUDENT RECEIVED POTENTIAL INHALATION OVEREXPOSURE

The following information was received from the State of Nevada via email:

"A graduate student inhaled a mixture of U-233 and U-238 while working in the lab grinding a compound of Uranium Octoxide. [The graduate student] used a glove box instead of the hood with the HEPA filter, contrary to UNLV [University of Nevada Las Vegas] approved procedure.

"This happened twice and could have been between October 1, 2011 and April 1, 2012.

"The first bioassay, based on an inhalation date of October 1, 2011, showed 17.72 rem total. When the inhalation date was assumed to be April 1, 2012, the result was 5.52 rem.

"[U-233]*1.6 = [U-238] contribution.

"The student will be getting a third bioassay on September 5, 2012 at the Lawrence Livermore National Lab (LLNL). This will involve a low-energy chest count to detect Th-234 and an organ count, looking at the kidneys for Uranium.

"The student has been restricted from all lab work since April.

"The bioassay was done at Test America."

* * * UPDATE AT 1553 EDT ON 10/24/12 FROM SNEHA RAVIKUMAR TO S. SANDIN * * *

The following update was received from the State of Nevada via email:

"NMED Item No.: NV120022

"Preliminary results:

"1. September 5, 2012:

Low-energy lung count, kidney count and hand count were performed at LLNL.
The lung count was less than MDA for U-233, Th-234, U-234 & U-2235.
The detect/non-detect kidney & hand counts were both non-detect.

"2. September 12, 2012:

Third Bioassay results received.
U-238 - 0.66 dpm/sample
U-235 - less than CRDL
U-233/234 - 1.25 dpm/sample"

Notified R4DO (Hagar) and FSME Events Resource via email.

* * * UPDATE AT 1540 EDT ON 11/15/12 FROM RAVIKUMAR TO HUFFMAN * * *

The following update was received from the State of Nevada via email:

"All personnel having access to the UNLV lab where the original uptake occurred had bioassay samples taken. UNLV determined that 46 persons should be in this group, including the RSO and ARSO. From the data submitted thus far, an additional graduate student appears to have received an uptake. This student has been restricted from further RAM work and a dose assessment undertaken. The actual dose will be dependent on the time and source of the uptake. If the timeframe and source are the same as that of the original graduate student, the magnitude will be the same. Thirteen remaining bioassays remain to be analyzed. Three of the thirteen are yet to be collected. The RSO attributed his elevated uptake to previous DOD work. The latest ten bioassays were collected within the last three weeks and with expedited processing results, should be available by mid-December."

Notified the R4DO (Drake) and FSME Events Resource via e-mail.

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Agreement State Event Number: 48486
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LANTHEUS MEDICAL IMAGING
Region: 1
City: BILLERICA State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/07/2012
Notification Time: 11:15 [ET]
Event Date: 09/01/2012
Event Time: [EST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING PACKAGE CONTAINING GA-67

The following was received from the Commonwealth of Massachusetts via fax:

"On September 1, 2012, [a common carrier] notified Lantheus that a package was missing. The Yellow III package, containing 175 mCi of Ga-67, was shipped on 8/30/12 from Lantheus and destined to Bogota, Colombia. The package was received in Miami on 8/31/12, but never scanned out of Miami. [The common carrier] believes the package shipped unmanifested to Bogota. The licensee agreed to write a follow-up report."

Docket Number: 22-0446

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Agreement State Event Number: 48488
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT FAYETTE HOSPITAL
Region: 1
City: FAYETTEVILLE State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: PETE SNYDER
Notification Date: 11/07/2012
Notification Time: 11:38 [ET]
Event Date: 07/06/2010
Event Time: [EDT]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERENT THAN PRESCRIBED

The following was received from the State of Georgia via email:

"The Licensee reported to the Department [state of Georgia] on July 14, 2010 that a patient who received a prostate seed implant procedure on July 6, 2010 resulted in a medical incident. The patient was scheduled to receive a Cs-131 Isoray seed implantation for the prostate with a total planned activity of 194.3 mCi. During the procedure on July 6, 2010 it was noticed that many of the seeds implanted were not visible on ultrasound. Following final implantation of all the seeds, a cystoscopy was performed on the patient where it was revealed that 19 seeds were implanted in the bladder and not the prostate which was the intended implant site. All 19 seeds were removed from the bladder without difficulty. A post plan evaluation was completed the same day of the treatment. The total activity implanted (seeds implanted to the prostate) was determined to be 140 mCi with a difference of -54.3 mCi deviation from the total planned activity. Post plan D90 for the prostate was calculated to be 62.68% with a D90 deviation of 53.28 Gy from the dose prescribed of 85 Gy. An additional procedure was scheduled for the patient on July 12, 2010 where 18 seeds were implanted to bring the combined dose distribution to the prescribed amount.

"The department [Georgia Radioactive Materials] reported the incident to NMED in November 2012."

Georgia Incident Summary: GA-2010-07i

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: 48489
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: EARTH ENGINEERING INC
Region: 1
City: EAST NORRITON State: PA
County:
License #: PA-1040
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/07/2012
Notification Time: 14:05 [ET]
Event Date: 10/26/2012
Event Time: [EST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - RECOVERED LOST PORTABLE GAUGE

The following was received from the Commonwealth of Pennsylvania via fax:

"NOTIFICATIONS: On October 31, 2012, the PA DEP Southwest Regional Office received a call from the licensee regarding an event that took place between October 26 and October 31, 2012.

"EVENT DESCRIPTION: An employee of the licensee used a portable gauge on October 26th in the south Philadelphia area. He then secured it in his car that evening. The car remained parked near his home until the morning of October 31. The licensee received a call from an unrelated construction worker who found the gauge hidden between shrubberies near a hotel in Philadelphia. The portable gauge was retrieved by Earth Engineering and was found intact but water logged.

"The device is identified as:

"Manufacturer: Troxler
"Model #: 3440 Serial #: 21391
"Isotope: Cs-137 Activity: 8 mCi
" ** Source Serial Number: 35-2906
"Isotope: Am-241 Activity: 40 mCi
" **Source Serial Number: 47-16682

"CAUSE OF THE EVENT: Human error. After a reactive investigation and interview by DEP with the licensee on November 1, 2012, it was determined the gauge was not properly secured within the vehicle, and the vehicle my have been unlocked.

"ACTIONS: The gauge is currently secured with the licensee and will be inspected by a vender before use."

Event Report Number: PA120039

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Agreement State Event Number: 48490
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ATC GROUP SERVICES INC
Region: 4
City: CARROLLTON State: TX
County:
License #: 05920
Agreement: Y
Docket:
NRC Notified By: GENTRY HEARN
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/07/2012
Notification Time: 14:57 [ET]
Event Date: 11/07/2012
Event Time: [CST]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT- DAMAGED MOISTURE DENSITY GAUGE

The following was received from the State of Texas via email:

"On November 7, 2012, the Agency [State of Texas] was notified by the licensee that one of its Troxler model 3411B moisture/density gauges had been damaged. The gauge contained one 8 milliCurie cesium-137 source and one 40 milliCurie americium-241/beryllium source. The operator had stepped aside to a nearby wall to get location information. A bulldozer operator assumed that this meant that the test was finished and drove into the area, impacting the gauge. The gauge was not run over, but suffered a bent top and damaged electronics. The licensee performed a survey and determined that the integrity of the sources and shielding were not impacted. The licensee has performed a leak test and will be returning the device to the manufacturer for evaluation. The investigation into this event is ongoing."

Texas Incident Number: I-9009

Page Last Reviewed/Updated Friday, November 16, 2012
Friday, November 16, 2012