Event Notification Report for August 10, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/09/2004 - 08/10/2004
EVENT NUMBERS
4093840939409424094340979
Other Nuclear Material
Event Number: 40938
Rep Org: EARTH ENGINEERING, INC.
Licensee: EARTH ENGINEERING, INC.
Region: 1
City: UPPER CHICHESTER State: PA
County:
License #: 3728492-01
Agreement: N
Docket:
NRC Notified By: WARD MCMASTER
HQ OPS Officer: MIKE RIPLEY
Licensee: EARTH ENGINEERING, INC.
Region: 1
City: UPPER CHICHESTER State: PA
County:
License #: 3728492-01
Agreement: N
Docket:
NRC Notified By: WARD MCMASTER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/10/2004
Notification Time: 17:28 [ET]
Event Date: 08/10/2004
Event Time: 15:30 [EDT]
Last Update Date: 08/10/2004
Notification Time: 17:28 [ET]
Event Date: 08/10/2004
Event Time: 15:30 [EDT]
Last Update Date: 08/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAYMOND LORSON (R1)
DAN GILLEN (NMSS)
BETSY ULRICH (R1)
RAYMOND LORSON (R1)
DAN GILLEN (NMSS)
BETSY ULRICH (R1)
DAMAGED TROXLER DENSITY GAUGE
At approximately 1530 ET on 08/10/04, a Troxler density gauge (Model # 3440, S/N 35192, 8 milliCuries Cs-137 and 40 milliCuries Am-241/Be) was run over by a compactor at a construction site in Upper Chichester, PA. The gauge source rod was bent, preventing retraction of the source point into its shield. The licensee secured the area and performed radiation surveys. No external contamination was found. The licensee has contacted Troxler who will send a shipping container for returning the gauge for repair. In the interim, the licensee plans on transporting the gauge to their facility in East Norton, PA. Established a conference with NMSS (D. Gillen) and Region 1 (E. Ulrich) who provided advice to the licensee on transporting the gauge.
At approximately 1530 ET on 08/10/04, a Troxler density gauge (Model # 3440, S/N 35192, 8 milliCuries Cs-137 and 40 milliCuries Am-241/Be) was run over by a compactor at a construction site in Upper Chichester, PA. The gauge source rod was bent, preventing retraction of the source point into its shield. The licensee secured the area and performed radiation surveys. No external contamination was found. The licensee has contacted Troxler who will send a shipping container for returning the gauge for repair. In the interim, the licensee plans on transporting the gauge to their facility in East Norton, PA. Established a conference with NMSS (D. Gillen) and Region 1 (E. Ulrich) who provided advice to the licensee on transporting the gauge.
General Information or Other
Event Number: 40939
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CHRISTIAN WHEELER ENGINEERING
Region: 4
City: CARLSBAD State: CA
County:
License #: 6560-37
Agreement: Y
Docket:
NRC Notified By: R. GREGER
HQ OPS Officer: MIKE RIPLEY
Licensee: CHRISTIAN WHEELER ENGINEERING
Region: 4
City: CARLSBAD State: CA
County:
License #: 6560-37
Agreement: Y
Docket:
NRC Notified By: R. GREGER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/10/2004
Notification Time: 21:42 [ET]
Event Date: 08/10/2004
Event Time: 18:30 [PDT]
Last Update Date: 08/12/2004
Notification Time: 21:42 [ET]
Event Date: 08/10/2004
Event Time: 18:30 [PDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
DANIEL GILLEN (NMSS)
AARON DANIS (TAS)
MEXICO (CNSNS)
LINDA SMITH (R4)
DANIEL GILLEN (NMSS)
AARON DANIS (TAS)
MEXICO (CNSNS)
AGREEMENT STATE REPORT - LOST/STOLEN MOISTURE DENSITY GAUGE
"A moisture density gauge, model CPN MC-3, containing approximately 8 milliCuries of Cs-137 and 30 milliCuries of Am-241 was lost from the back of a pickup truck while traveling from a jobsite in Carlsbad, CA to the company home office in San Diego. The jobsite was on Cassia Road (Thomas Guide, page 1127, D4-E4). It was reported that the gauge was inadvertently left in the back of the pickup truck without being put into the transportation case, neither the gauge nor the transportation case were secured to the truck, and the truck tailgate was left down. Both the gauge and the transportation case apparently fell out of the truck in the first few miles of travel. The driver noticed the tailgate down shortly after turning onto Palomar Airport Road from El Camino Real (Thomas Guide, page 1127, E2). The driver back tracked and found the case but not the gauge. Local law enforcement authorities were notified, and the RSO went to the scene to assist in attempting to locate the gauge."
* * * UPDATE ON 8/11/04 AT 1900 EDT FROM ROB GREGER TO GERRY WAIG * * *
Mr. Greger reported that the lost gauge was recovered about 1 block from the jobsite today at approximately 1300 PDT. Additional recovery details will be provided tomorrow, 8/12/04.
Notified R4DO (Linda Smith), NMSS (Daniel Gillen), TAS (Aaron Danis), Mexico (CNSNS) by facsimile.
* * * UPDATE ON 8/12/04 AT 1509 EDT FROM ROB GREGER TO GERRY WAIG VIA FACSIMILE* * *
"The gauge was recovered around 1 pm on 8/11/04. It had apparently fallen from the truck a short distance from the construction site. Someone apparently found it and placed it on an adjacent sidewalk. An adjacent business owner (DELETED) noticed the gauge on the sidewalk in front of their business at the end of the day 8/10/04. When the gauge was still there the next morning, they called the phone number of a gauge service company (Mauer Technical Services) listed on a sticker on the gauge, and reported that the gauge was apparently abandoned. Mauer contacted the company that owned the gauge (Christian Wheeler Engineering), who recovered the gauge. When found, the gauge was locked with the source in a shielded position. There was no apparent damage to the gauge.
"California RHB authorities will be pursuing enforcement action with Christian Wheeler Engineering for the loss of the gauge.
"Some details of the loss that were initially reported to California RHB apparently were incorrect. The attached Investigation form has been revised to reflect our current knowledge of this matter." [See Below]
"A moisture density gauge, model CPN MC-3, containing approximately 8 mCi of Cs-137 and 30 mCi of Am-241 was lost from the back of a pickup truck while traveling between jobsites in Carlsbad, CA on 8/10/04. The truck left a jobsite on Cassia Road (Thomas Guide, page 1127, D4-E4) with the gauge. It was reported that the gauge was inadvertently left in the back of the pickup truck without being put into the transportation case, and with the truck tailgate was left down. Within a couple miles of travel, the driver noticed the tailgate down while he was driving on El Camino Real (Thomas Guide, page 1127, E2). The driver back tracked, but could not find the gauge. Local law enforcement authorities were notified, and the RSO went to the scene to assist in attempting to locate the gauge."
Notified R4DO (Linda Smith), NMSS (Daniel Gillen), TAS (Matt Hahn)
"A moisture density gauge, model CPN MC-3, containing approximately 8 milliCuries of Cs-137 and 30 milliCuries of Am-241 was lost from the back of a pickup truck while traveling from a jobsite in Carlsbad, CA to the company home office in San Diego. The jobsite was on Cassia Road (Thomas Guide, page 1127, D4-E4). It was reported that the gauge was inadvertently left in the back of the pickup truck without being put into the transportation case, neither the gauge nor the transportation case were secured to the truck, and the truck tailgate was left down. Both the gauge and the transportation case apparently fell out of the truck in the first few miles of travel. The driver noticed the tailgate down shortly after turning onto Palomar Airport Road from El Camino Real (Thomas Guide, page 1127, E2). The driver back tracked and found the case but not the gauge. Local law enforcement authorities were notified, and the RSO went to the scene to assist in attempting to locate the gauge."
* * * UPDATE ON 8/11/04 AT 1900 EDT FROM ROB GREGER TO GERRY WAIG * * *
Mr. Greger reported that the lost gauge was recovered about 1 block from the jobsite today at approximately 1300 PDT. Additional recovery details will be provided tomorrow, 8/12/04.
Notified R4DO (Linda Smith), NMSS (Daniel Gillen), TAS (Aaron Danis), Mexico (CNSNS) by facsimile.
* * * UPDATE ON 8/12/04 AT 1509 EDT FROM ROB GREGER TO GERRY WAIG VIA FACSIMILE* * *
"The gauge was recovered around 1 pm on 8/11/04. It had apparently fallen from the truck a short distance from the construction site. Someone apparently found it and placed it on an adjacent sidewalk. An adjacent business owner (DELETED) noticed the gauge on the sidewalk in front of their business at the end of the day 8/10/04. When the gauge was still there the next morning, they called the phone number of a gauge service company (Mauer Technical Services) listed on a sticker on the gauge, and reported that the gauge was apparently abandoned. Mauer contacted the company that owned the gauge (Christian Wheeler Engineering), who recovered the gauge. When found, the gauge was locked with the source in a shielded position. There was no apparent damage to the gauge.
"California RHB authorities will be pursuing enforcement action with Christian Wheeler Engineering for the loss of the gauge.
"Some details of the loss that were initially reported to California RHB apparently were incorrect. The attached Investigation form has been revised to reflect our current knowledge of this matter." [See Below]
"A moisture density gauge, model CPN MC-3, containing approximately 8 mCi of Cs-137 and 30 mCi of Am-241 was lost from the back of a pickup truck while traveling between jobsites in Carlsbad, CA on 8/10/04. The truck left a jobsite on Cassia Road (Thomas Guide, page 1127, D4-E4) with the gauge. It was reported that the gauge was inadvertently left in the back of the pickup truck without being put into the transportation case, and with the truck tailgate was left down. Within a couple miles of travel, the driver noticed the tailgate down while he was driving on El Camino Real (Thomas Guide, page 1127, E2). The driver back tracked, but could not find the gauge. Local law enforcement authorities were notified, and the RSO went to the scene to assist in attempting to locate the gauge."
Notified R4DO (Linda Smith), NMSS (Daniel Gillen), TAS (Matt Hahn)
General Information or Other
Event Number: 40942
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES OILFIELD OPERATIONS
Region: 4
City: ODESSA State: TX
County:
License #: L05178-018
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: GERRY WAIG
Licensee: BAKER HUGHES OILFIELD OPERATIONS
Region: 4
City: ODESSA State: TX
County:
License #: L05178-018
Agreement: Y
Docket:
NRC Notified By: JIM OGDEN
HQ OPS Officer: GERRY WAIG
Notification Date: 08/11/2004
Notification Time: 13:26 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/11/2004
Notification Time: 13:26 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
JOHN HICKEY (NMSS)
LINDA SMITH (R4)
JOHN HICKEY (NMSS)
AGREEMENT STATE REPORT - WELL LOGGING SOURCE LOST IN WELL DURING TRAINING
The following is taken from a facsimile sent by the Agreement State (Texas)
"Event description: After well logging operations on the afternoon of August 10, 2004, the well logger was removing the source from the tool on the training well. The tool was not fully engaged with the source. When the source cleared the logging tool, the well logger bumped the source into the deflector, causing the source to drop from the handling tool. The deflector performed properly and deflected the source, an 18 curie Am/Be (neutron) source downhole. This is the Atlas No. 2 well, an un-cased hard-rock well located on the Baker Hughes property for training of Baker Hughes staff. The source is a GammaTron Model DA20, Serial No 36313. The source is known to be at the bottom of the 5750 foot well. The training well is currently full of fluid. The operator is going to replace the fluid with clear fluid and begin 'fishing' operations. The wellbore is 8-7/8 inches and this source with nose plug is 9 inches in length."
TX Incident # I-8152
The following is taken from a facsimile sent by the Agreement State (Texas)
"Event description: After well logging operations on the afternoon of August 10, 2004, the well logger was removing the source from the tool on the training well. The tool was not fully engaged with the source. When the source cleared the logging tool, the well logger bumped the source into the deflector, causing the source to drop from the handling tool. The deflector performed properly and deflected the source, an 18 curie Am/Be (neutron) source downhole. This is the Atlas No. 2 well, an un-cased hard-rock well located on the Baker Hughes property for training of Baker Hughes staff. The source is a GammaTron Model DA20, Serial No 36313. The source is known to be at the bottom of the 5750 foot well. The training well is currently full of fluid. The operator is going to replace the fluid with clear fluid and begin 'fishing' operations. The wellbore is 8-7/8 inches and this source with nose plug is 9 inches in length."
TX Incident # I-8152
General Information or Other
Event Number: 40943
Rep Org: NY STATE DEPARTMENT OF HEALTH
Licensee:
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: JEFF ROTTON
Licensee:
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/12/2004
Notification Time: 17:12 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [EDT]
Last Update Date: 08/12/2004
Notification Time: 17:12 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [EDT]
Last Update Date: 08/12/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAYMOND LORSON (R1)
DANIEL GILLEN (NMSS)
RAYMOND LORSON (R1)
DANIEL GILLEN (NMSS)
AGREEMENT STATE REPORT - CONTAMINATED BRACHYTHERAPY SEEDS
"A New York State Department of Health licensee reported on 8/10/04 that prostate seed implant needles were found to be contaminated during a post implant radiological survey in the operating room. Two post implant urine samples from the patient were saved and were found to be contaminated as well. Radiograph of the prostate post implant indicated all seeds were implanted. Hospital staff believed that the contamination was attributable to the implant procedure as the patient had not received a diagnostic nuclear medicine procedure and there was no evidence of any other source for the contamination. The radiation oncologist contacted the patient and was able to administer KI [Potassium Iodide] later in the day, and he will evaluate the need for ongoing treatment with KI.
"New York State Department of Health staff went to the hospital on 8/11/04 to investigate this incident. Confirmatory measurements were made and the plastic needle packing tray, needles, lead pouch and urine samples were found to be contaminated. A third urine sample was obtained from the patient on 8/11/04, which also is contaminated. The radiation oncologist who performed the procedure stated that there were no problems with the needles or the implant procedure. The needles were examined and no bends, crimps or damage were observed. The hospital, has notified the pharmacy that had provided the preloaded sterile needles. NRC Region 1 staff were contacted by phone and were given the name of the pharmacy.
"The Radiation Safety Officer took the initial urine sample to another New York State Department of Health licensee on 8/11/04 for nuclide identification and rough quantification using a HPGe detector. The isotope in the urine was identified as I-125 and the activity was estimated to be 34 nanocuries per cc (volume of urine sample collected was 200 cc). The patient's urine samples will be sent to DOH Wadsworth Laboratories for analysis. Future samples are expected to be collected and analyzed.
"The brachytherapy seeds were manufactured by Mills Biopharmarmaceuticals, Inc., sold by Mentor MBI (Oklahoma City, OK) and loaded into needles by the pharmacy. Brachytherapy seed specifics are:
Model: 125SL
Lot Number: 042814
Batch Number: IB040142N
Seed activity on 8/10/04: 0.405 millicuries"
"A New York State Department of Health licensee reported on 8/10/04 that prostate seed implant needles were found to be contaminated during a post implant radiological survey in the operating room. Two post implant urine samples from the patient were saved and were found to be contaminated as well. Radiograph of the prostate post implant indicated all seeds were implanted. Hospital staff believed that the contamination was attributable to the implant procedure as the patient had not received a diagnostic nuclear medicine procedure and there was no evidence of any other source for the contamination. The radiation oncologist contacted the patient and was able to administer KI [Potassium Iodide] later in the day, and he will evaluate the need for ongoing treatment with KI.
"New York State Department of Health staff went to the hospital on 8/11/04 to investigate this incident. Confirmatory measurements were made and the plastic needle packing tray, needles, lead pouch and urine samples were found to be contaminated. A third urine sample was obtained from the patient on 8/11/04, which also is contaminated. The radiation oncologist who performed the procedure stated that there were no problems with the needles or the implant procedure. The needles were examined and no bends, crimps or damage were observed. The hospital, has notified the pharmacy that had provided the preloaded sterile needles. NRC Region 1 staff were contacted by phone and were given the name of the pharmacy.
"The Radiation Safety Officer took the initial urine sample to another New York State Department of Health licensee on 8/11/04 for nuclide identification and rough quantification using a HPGe detector. The isotope in the urine was identified as I-125 and the activity was estimated to be 34 nanocuries per cc (volume of urine sample collected was 200 cc). The patient's urine samples will be sent to DOH Wadsworth Laboratories for analysis. Future samples are expected to be collected and analyzed.
"The brachytherapy seeds were manufactured by Mills Biopharmarmaceuticals, Inc., sold by Mentor MBI (Oklahoma City, OK) and loaded into needles by the pharmacy. Brachytherapy seed specifics are:
Model: 125SL
Lot Number: 042814
Batch Number: IB040142N
Seed activity on 8/10/04: 0.405 millicuries"
General Information or Other
Event Number: 40979
Rep Org: ALABAMA RADIATION CONTROL
Licensee: NORTHEAST ALABAMA REGIONAL MEDICAL CENTER
Region: 1
City: Montgomery State: AL
County:
License #: 315
Agreement: Y
Docket:
NRC Notified By: DAVID TUBERVILLE
HQ OPS Officer: HOWIE CROUCH
Licensee: NORTHEAST ALABAMA REGIONAL MEDICAL CENTER
Region: 1
City: Montgomery State: AL
County:
License #: 315
Agreement: Y
Docket:
NRC Notified By: DAVID TUBERVILLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2004
Notification Time: 08:52 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2004
Notification Time: 08:52 [ET]
Event Date: 08/10/2004
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
EUGENE COBEY (R1)
GARY JANOSKO (NMSS)
EUGENE COBEY (R1)
GARY JANOSKO (NMSS)
MEDICAL MISADMINISTRATION
The following information was received from the State of Alabama Department of Public Health via facsimile:
"SUBJECT: Licensee identification of I-131 Misadministration.
"By telefax notification on August 17, 2004, Northeast Alabama Regional Medical Center (Alabama Radioactive Material License No. 315) notified the State of Alabama of a misadministration involving Iodine-131.
"In the telefaxed report, the licensee indicated that the event occurred on August 10, 2004 and was discovered on August 12, 2004. The dose prescribed was 25 microcuries of I-131 and the dose administered was 3.0 millicuries. Based on the information supplied by the licensee, it appears that the imaging technologist misunderstood the referring physician's request and the dose was not approved by the authorized user. The licensee indicated in their report that there was no apparent effects to the patient. Corrective measures included reinstructing personnel and ensuring that all procedures are approved by the authorized user.
"At this time, the Office of Radiation Control is requesting additional information from the licensee. Once made available, the information will be supplied via the NMED database system."
The following information was received from the State of Alabama Department of Public Health via facsimile:
"SUBJECT: Licensee identification of I-131 Misadministration.
"By telefax notification on August 17, 2004, Northeast Alabama Regional Medical Center (Alabama Radioactive Material License No. 315) notified the State of Alabama of a misadministration involving Iodine-131.
"In the telefaxed report, the licensee indicated that the event occurred on August 10, 2004 and was discovered on August 12, 2004. The dose prescribed was 25 microcuries of I-131 and the dose administered was 3.0 millicuries. Based on the information supplied by the licensee, it appears that the imaging technologist misunderstood the referring physician's request and the dose was not approved by the authorized user. The licensee indicated in their report that there was no apparent effects to the patient. Corrective measures included reinstructing personnel and ensuring that all procedures are approved by the authorized user.
"At this time, the Office of Radiation Control is requesting additional information from the licensee. Once made available, the information will be supplied via the NMED database system."