Event Notification Report for July 17, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/16/2002 - 07/17/2002
General Information or Other
Event Number: 39072
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA HEART HOSPITAL
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-443
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: JOHN MacKINNON
Licensee: ARIZONA HEART HOSPITAL
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-443
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/19/2002
Notification Time: 11:30 [ET]
Event Date: 07/17/2002
Event Time: 14:30 [MST]
Last Update Date: 07/19/2002
Notification Time: 11:30 [ET]
Event Date: 07/17/2002
Event Time: 14:30 [MST]
Last Update Date: 07/19/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA HOWELL (R4)
FRED BROWN (NMSS)
LINDA HOWELL (R4)
FRED BROWN (NMSS)
AGREEMENT STATE REPORT: EQUIPMENT FAILURE
"On July 17, 2002, the Arizona Radiation Regulatory Agency was notified by the Licensee that a Novoste Beta-Cath system utilizing 55mCi (2.04GBq) of Strontium-90 had failed to retract after completing treatment of a patient. Within seconds of determining that a failure had occurred, the Licensee implemented emergency withdrawal procedures and successfully removed the source without causing a misadministration. The patient was surveyed and confirmed that all treatment radioactive material had been removed.
"Initial examination by the Licensee did not determine a probable cause of the failure of the return of the source to the shielded condition. The entire system is being returned to the manufacturer for evaluation. Georgia is aware of this event.
"Agency continues to investigate this event.
"No press coverage is occurring or expected for this event.
"First Notice: 02-9
"The State of Georgia and the U.S. NRC, is being notified of this event."
"On July 17, 2002, the Arizona Radiation Regulatory Agency was notified by the Licensee that a Novoste Beta-Cath system utilizing 55mCi (2.04GBq) of Strontium-90 had failed to retract after completing treatment of a patient. Within seconds of determining that a failure had occurred, the Licensee implemented emergency withdrawal procedures and successfully removed the source without causing a misadministration. The patient was surveyed and confirmed that all treatment radioactive material had been removed.
"Initial examination by the Licensee did not determine a probable cause of the failure of the return of the source to the shielded condition. The entire system is being returned to the manufacturer for evaluation. Georgia is aware of this event.
"Agency continues to investigate this event.
"No press coverage is occurring or expected for this event.
"First Notice: 02-9
"The State of Georgia and the U.S. NRC, is being notified of this event."
General Information or Other
Event Number: 39073
Rep Org: IOWA RADIATION PROTECTION
Licensee: STORK-TWIN CITY TESTING CORPORATION
Region: 3
City: OSCEOLA State: IA
County:
License #: 0282-2-77-IR1
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: RICH LAURA
Licensee: STORK-TWIN CITY TESTING CORPORATION
Region: 3
City: OSCEOLA State: IA
County:
License #: 0282-2-77-IR1
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: RICH LAURA
Notification Date: 07/19/2002
Notification Time: 12:03 [ET]
Event Date: 07/17/2002
Event Time: 09:00 [CDT]
Last Update Date: 07/19/2002
Notification Time: 12:03 [ET]
Event Date: 07/17/2002
Event Time: 09:00 [CDT]
Last Update Date: 07/19/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MONTE PHILLIPS (R3)
FRED BROWN (NMSS)
MONTE PHILLIPS (R3)
FRED BROWN (NMSS)
BROKEN RADIOGRAPHER CAMERA
"As a result of one of our cameras had a source jammed because the camera fell from a ladder it was sitting on during an exposure, we are submitting the following response.
"Project Information:
"Date: July 17, 2002 at approx. 9:00 A.M.
Rural water tower, south of Osceola, Iowa approx. 4 miles
Jobsite- down a dead-end road, in a field
Source S.N. 04016B 40.5 curies
Contractor: Phoenix Fabricators & Erectors, Inc.
"Stork-Twin City Testing Corporation was at a temporary project site performing radiographic testing when the camera fell off a ladder the camera was sitting on (approx. 3 feet to the ground). The source would not crank back into it's shielded position. I asked him, if they had resecured the area and his response was that they had and that they had also informed the contractor at the site of this incident. I told him, I was on my way and arrived at the site approx. one hour later. I loaded my truck with lead shielding and tools that might be needed to free up the source. Arriving at the project site, I surveyed the guide tube from a distance and found that the source was approx. 1 foot from the camera. They had the crank apart, so you could pull on the cable, in which I had them do prior to my arrival, but they said it would not move, I then tried this myself. I pushed on the cable and then pulled it and the source went in the camera to it safe position. We surveyed the camera and the guide tube and confirmed it was secured in the camera. We then unconnected the control cable and checked the source end with a nogo gauge and found it to be OK, we also cranked the cable out and checked it for any bends or other damage and found it to be OK. We removed the bent guide tube and replaced it with a good tube. We then cranked the source out and made sure everything was functioning properly.
"We then had an onsite safety meeting, which concluded that this would be avoided in the future, by tying the camera to a stationary object so the camera cannot fall to the ground and bend the guide tube.
"There was no over exposure to the public (contractor's personnel) or to the radiographers during this incident and the radiographers performed their duties in a satisfactory manner, concerning the safety for all and the following of our accident procedures."
"As a result of one of our cameras had a source jammed because the camera fell from a ladder it was sitting on during an exposure, we are submitting the following response.
"Project Information:
"Date: July 17, 2002 at approx. 9:00 A.M.
Rural water tower, south of Osceola, Iowa approx. 4 miles
Jobsite- down a dead-end road, in a field
Source S.N. 04016B 40.5 curies
Contractor: Phoenix Fabricators & Erectors, Inc.
"Stork-Twin City Testing Corporation was at a temporary project site performing radiographic testing when the camera fell off a ladder the camera was sitting on (approx. 3 feet to the ground). The source would not crank back into it's shielded position. I asked him, if they had resecured the area and his response was that they had and that they had also informed the contractor at the site of this incident. I told him, I was on my way and arrived at the site approx. one hour later. I loaded my truck with lead shielding and tools that might be needed to free up the source. Arriving at the project site, I surveyed the guide tube from a distance and found that the source was approx. 1 foot from the camera. They had the crank apart, so you could pull on the cable, in which I had them do prior to my arrival, but they said it would not move, I then tried this myself. I pushed on the cable and then pulled it and the source went in the camera to it safe position. We surveyed the camera and the guide tube and confirmed it was secured in the camera. We then unconnected the control cable and checked the source end with a nogo gauge and found it to be OK, we also cranked the cable out and checked it for any bends or other damage and found it to be OK. We removed the bent guide tube and replaced it with a good tube. We then cranked the source out and made sure everything was functioning properly.
"We then had an onsite safety meeting, which concluded that this would be avoided in the future, by tying the camera to a stationary object so the camera cannot fall to the ground and bend the guide tube.
"There was no over exposure to the public (contractor's personnel) or to the radiographers during this incident and the radiographers performed their duties in a satisfactory manner, concerning the safety for all and the following of our accident procedures."