| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
05/27/2014 - 05/28/2014 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 49965 | Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: GEORGIA-PACIFIC, LLC, CROSSETT PAPER OPERATIONS, DP33
Region: 4
City: CROSSETT State: AR
County:
License #: ARK-0321-0312
Agreement: Y
Docket:
NRC Notified By: ANGIE D. HILL
HQ OPS Officer: STEVE SANDIN | Notification Date: 03/27/2014
Notification Time: 17:37 [ET]
Event Date: 03/27/2014
Event Time: 14:20 [CDT]
Last Update Date: 05/27/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAVID PROULX (R4DO)
FSME_EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED GAUGE
The following information was received from the State of Arkansas via email:
"The licensee notified the Arkansas Department of Health via postal mail on Thursday, 03/27/2014 at 1420 hours, of the stuck shutter event. The State's event number is ARK-2014-003.
"The Ohmart source holder model number is HM-8 and the source contains 0.523 Curies of Cs-137. The problem was discovered during shutter checks and inventory. The licensee states that the gauge operations remain to be 24/7. The licensee stated that the area has been roped off and has proper posting. The licensee stated that they have notified applicable facility personnel of the radiological hazard and that there have been no known radiation exposures to personnel and/or members of the public.
"The shutter will be fixed by Ohmart (date unknown at this time), whom will also diagnose the root cause of this event. The State of Arkansas is awaiting a 30 day written report post repairs."
* * * UPDATE PROVIDED BY ANGIE HILL TO JEFF ROTTON AT 1412 EDT ON 03/31/2014 * * *
The State of Arkansas reported that the original discovery date of the stuck shutter was September 16, 2013. The manufacturer, Ohmart, will be on site from May 5-9, 2014 to repair the shutter and perform a root cause evaluation.
Notified R4DO (Gepford) and FSME Resources via email
* * * UPDATE FROM ANGIE HILL TO VINCE KLCO ON 5/27/14 AT 1530 EDT * * *
The following information was received from the State of Arkansas by email:
"The approved Vendor Service Engineer arrived at Georgia-Pacific on Friday, April 11, 2014, to inspect the Ohmart Model HM-8 gauge shutter. The licensee stated that the gauge shutter offered increased resistance, but was not stuck.
"The Vendor Service Engineer was able to move the handle by hand, verified that the shutter was not stuck, performed surveys and sealed source leak tests. The Vendor Service Engineer confirmed that there are no exposures of concern from the gauge, confirmed negative leaks and that the gauge is operating properly at this time.
"The licensee confirmed that there are no known personnel radiation exposures or dose to the member of the public from this event.
"The Department [Arkansas Department of Health] considers this event closed."
Notified the R4DO (Vasquez) and FSME Resources via email. |
| Agreement State | Event Number: 50120 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SILICON VALLEY SOIL ENGINEERING
Region: 4
City: SAN JOSE State: CA
County:
License #: 7930-43
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: STEVE SANDIN | Notification Date: 05/19/2014
Notification Time: 14:53 [ET]
Event Date: 05/16/2014
Event Time: 10:40 [PDT]
Last Update Date: 05/19/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (FAX)
|
| This material event contains a "Less than Cat 3 " level of radioactive material. | Event Text AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE STOLEN FROM TRANSPORT VEHICLE
The following information was provided by the State of California via email:
"RHB [Radiological Health Branch] Richmond received Hazardous Material Spill Report - Cal EMA [Emergency Management Agency] Control #:14-2601, from Warning Center on May 17, 2014. The report stated that the Silicon Valley Soil Engineering's moisture density gauge manufactured by CPN, model MC-1 DR-P, Serial MD 70803844, was stolen from the transport vehicle on May 16, 2014, at 10:40 a.m. [PDT]. The gauge contained 50 mCi of Am-241 and 10 mCi of Cs-137.
"RHB will be inspecting this licensee to develop more information.
"5010 Number (Date Notified): 051914"
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 EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Non-Agreement State | Event Number: 50121 | Rep Org: BECKLEY APPALACHIAN REGIONAL HEALTH
Licensee: BECKLEY APPALACHIAN REGIONAL HEALTH
Region: 1
City: BECKLEY State: WV
County:
License #: 47-17725-02
Agreement: N
Docket:
NRC Notified By: JENNIFER BAILEY
HQ OPS Officer: STEVE SANDIN | Notification Date: 05/19/2014
Notification Time: 16:25 [ET]
Event Date: 05/18/2014
Event Time: 10:30 [EDT]
Last Update Date: 05/21/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text WRONG FORM OF RADIOACTIVE ISOTOPE ADMINISTERED FOR CARDIAC STRESS TEST
A patient received a dose of MDP (25 mCi Tc-99m) which is used for bone scans vice cardiolite (31 mCi Tc-99m) for a cardiac stress test. The wrong dose was administered due to technician error. Both the prescribing physician and patient have been informed. No adverse health effects are anticipated. The licensee has corrective actions under review.
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.
* * * RETRACTION FROM JENNIFER BAILEY TO DONG PARK AT 1012 EDT ON 5/21/2014 * * *
"Retraction of Event # 50121 [is requested] for Beckley Appalachian Regional Healthcare, License # 47-17725-02. The event reported did not exceed 5 rem as specified in section 35.3045 (a) (1)."
Notified the R1DO (Gray) and FSME Events Resource via email. |
| Agreement State | Event Number: 50122 | Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: HEVLY TECHNICAL SERVICES COMPANY
Region: 4
City: PHOENIX State: AZ
County:
License #: 15-096
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: STEVE SANDIN | Notification Date: 05/19/2014
Notification Time: 17:55 [ET]
Event Date: 05/15/2014
Event Time: [MST]
Last Update Date: 05/20/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (FAX)
|
| This material event contains a "Less than Cat 3 " level of radioactive material. | Event Text AGREEMENT STATE REPORT - RECOVERY OF TWO MOISTURE DENSITY GAUGES BY AN ARIZONA LICENSEE
The following information was provided by the State of Arizona via email:
"Date: May 19, 2014
"Time: 2:30 PM (MST)
"First Notice: 14-012
"Arizona Licensee: N/A
"License No.: N/A
"On May 15, 2014, the [Arizona Radiation Regulatory] Agency was contacted by a licensee who stated that he was called about the disposal of a nuclear density gauge. The caller stated that they were not licensed and did not want to go to the regulatory agency but needed to get rid of the gauge. The caller also stated that if [the licensee] did not take the gauge, he would take it to a dumpster or leave it out in the desert. [The licensee] contacted the Agency on the afternoon of the 15th to discuss the situation. [The licensee] was contacted on the 16th and subsequently met the unknown caller and picked up the gauge. The gauge was brought to the Agency, where it was leak tested and secured.
"The depth moisture gauge came in two different wood boxes. The first box contained a Troxler depth moisture probe, model number 1255, with a 100 millicurie Americium-241:Be source and an origin date of 05/03/1975. The second box contained a Troxler depth density gauge, model number 1351, with a 7.7 millicurie Cesium-137 source and an origin date of 07/13/1982
"The Agency continues to investigate the event."
The State of Arizona will notify the Governor's Office and the FBI.
* * * UPDATE AT 1553 EDT ON 05/20/14 FROM BRIAN GORETZKI TO S. SANDIN VIA EMAIL * * *
The State of Arizona identified the Arizona licensee who picked up and dropped off the sources at the Agency.
"The Am-241:Be probe/gauge has 3 labels on it with all different model and serial numbers. They are as follows:
Model: 104a Serial #: J-3475
Model: 1255 Serial #: 810
Serial #: Am-239 Date: 5/30/75
"The Cs-137 gauge has the same thing. They are as follows:
Model: 504 Serial #: 212
Model: 1351 Serial #: 212
Model: 40-6475 Date: 7/13/82
"[The Agency] crossed referenced the model/serial numbers in the NMED database and did not get any hits."
Notified R4DO (Gepford) and FSME (via email).
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 |
| Agreement State | Event Number: 50126 | Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: WATSON CLINIC
Region: 1
City: LAKELAND State: FL
County:
License #: 2619-1
Agreement: Y
Docket:
NRC Notified By: RICHARD DAVIS
HQ OPS Officer: STEVE SANDIN | Notification Date: 05/20/2014
Notification Time: 15:00 [ET]
Event Date: 05/19/2014
Event Time: [EDT]
Last Update Date: 05/20/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HAROLD GRAY (R1DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - PATIENT RECEIVED UNINTENDED SHALLOW SKIN DOSE
The following information was received from the State of Florida via email:
"[On] Monday May 19, 2014, on follow-up visit, the patient presented with burns on the thighs and the labia. [The] Radiation Oncologist ordered an immediate investigation: High Dose Remote After Loader (HDR) Prescription event. No further action will be taken on this incident."
The patient received 21Gy in three (3) fractions. Following completion of treatment, a review of the Treatment Planning on Oncentra TPS revealed a reference length of 1223 mm instead of 1323 (expected value +/- 1 mm). The reference length used in the TPS was measured prior to CT with the SPS (Source Position Simulator) by two physicists. Therefore, the radiation was 10 cm short from reaching the target which explains the occurrence of burns on the patient's thighs.
"The three prescribed fractions were delivered on: 3/31/14, 04/07/14 and 04/14/14."
Florida Incident Number: FL14-043
The device used is an HDR containing Ir-192 with a Capri Applicator.
A corrective action plan has been developed by the licensee to prevent recurrence. The licensee informed both the prescribing physician and the patient. No long-term adverse health effects are expected.
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: 50127 | Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: KAPSTONE KRAFT PAPER CORPORATION
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: STEVE SANDIN | Notification Date: 05/20/2014
Notification Time: 19:03 [ET]
Event Date: 04/08/2014
Event Time: [PDT]
Last Update Date: 05/20/2014 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HEATHER GEPFORD (R4DO)
FSME EVENTS RESOURCE (EMAI)
| Event Text AGREEMENT STATE REPORT - OHMART FIXED GAUGE WITH A BROKEN SHUTTER HANDLE
The following information was received from the State of Washington via email:
"This incident is a report of a broken fixed gauge shutter handle which originally was reported to [Washington Division of Radiation Protection] as a GL [General Licensed] device. This incident is a failure of the on/off (shutter) mechanism with the shutter stuck in the closed (safe) position when the handle broke off. [Washington Division of Radiation Protection] learned later that this was not a GL device as reported . . . but a specific license gauge. [Washington Division of Radiation Protection] acted upon the reporting criteria as this meets 10 CFR 31.5 (c)(5) criteria that applies to general license radioactive material and a report within 30 days with a description and remedial action of actual or indicated failure to the on-off mechanism. This report falls into that 30 day time frame but the device is a specifically licensed device.
"Licensee informed Washington Department of Health (WA DOH) on 14 May 2014 that a shutter handle broke off a fixed gauge during shutdown for routine operations on 8 April 2014. Surveys by radiation safety officer and by health physics service provider consultant confirmed dose rates were within acceptable ranges and consistent with gauge SS&D sealed source and device data. The gauge manufacturer is scheduled to be onsite 23 May 2014 to assess and repair. An investigation continues and corrective actions are pending.
"WA DOH incident number WA-14-019.
"One Ohmart fixed gauge, model SH-F1, serial 2860GK. 100 millicuries original activity [Cs-137] in November 1996; now 67 millicuries today 20 May 2014. Source model pending, source serial believed same as device serial. Source and shutter and device conditions unknown, but believed to be undamaged and intact (dose rates similar to SS&D data). Problem with source and device to be determined by gauge manufacturer scheduled to be onsite 23 May 2014 to assess and repair." | |