Event Notification Report for January 01, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/31/2004 - 01/01/2005
General Information or Other
Event Number: 41306
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CARDINAL HEALTH
Region: 1
City: SILVER SPRING State: MD
County:
License #: MD-31-263-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: BILL HUFFMAN
Licensee: CARDINAL HEALTH
Region: 1
City: SILVER SPRING State: MD
County:
License #: MD-31-263-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/04/2005
Notification Time: 10:47 [ET]
Event Date: 01/01/2005
Event Time: 05:00 [EST]
Last Update Date: 01/04/2005
Notification Time: 10:47 [ET]
Event Date: 01/01/2005
Event Time: 05:00 [EST]
Last Update Date: 01/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1)
SANDRA WASTLER (NMSS)
JAMES TRAPP (R1)
SANDRA WASTLER (NMSS)
AGREEMENT STATE REPORT OF TRUCK CRASH RESULTING IN MINOR CONTAMINATION AND LOSS OF RADIOPHARMACEUTICAL VIALS
A truck carrying radiopharmaceuticals for Cardinal Health had an accident on Eastbound Route 50 near the Cape St. Claire exit in Annapolis MD. Police, Fire Department and an ambulance responded to the scene. The licensee's Radiation Safety Officer (RSO) also responded. Survey indicated contamination over an area of approximately 100 feet. It was determined that an 8 mCi vial of Tc99 MAA had been damaged and spilled during the accident. The Maryland Department of Environment and Hazmat were summoned. The area was decontaminated with a high-powered water spray. However, further investigation determined that an ammo can containing two vials of TC99m and TC99 MAA was missing at the accident scene. The two vials had a total activity of 566 mCi as of 0400 on 1/01/05. An extensive search of the area was unable to locate the ammo can with the two missing vials. Neither the licensee nor the Maryland Department of Environment believe that the vials pose any health risk since the Tc99m has a 6 hour half life.
A truck carrying radiopharmaceuticals for Cardinal Health had an accident on Eastbound Route 50 near the Cape St. Claire exit in Annapolis MD. Police, Fire Department and an ambulance responded to the scene. The licensee's Radiation Safety Officer (RSO) also responded. Survey indicated contamination over an area of approximately 100 feet. It was determined that an 8 mCi vial of Tc99 MAA had been damaged and spilled during the accident. The Maryland Department of Environment and Hazmat were summoned. The area was decontaminated with a high-powered water spray. However, further investigation determined that an ammo can containing two vials of TC99m and TC99 MAA was missing at the accident scene. The two vials had a total activity of 566 mCi as of 0400 on 1/01/05. An extensive search of the area was unable to locate the ammo can with the two missing vials. Neither the licensee nor the Maryland Department of Environment believe that the vials pose any health risk since the Tc99m has a 6 hour half life.
Agreement State
Event Number: 48090
Rep Org: NV DIV OF RAD HEALTH
Licensee: JAMES HARDIE BUILDING PRODUCTS
Region: 4
City: SPARKS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: JOHN KNOKE
Licensee: JAMES HARDIE BUILDING PRODUCTS
Region: 4
City: SPARKS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/11/2012
Notification Time: 11:36 [ET]
Event Date: 01/01/2005
Event Time: 00:00 [PDT]
Last Update Date: 07/11/2012
Notification Time: 11:36 [ET]
Event Date: 01/01/2005
Event Time: 00:00 [PDT]
Last Update Date: 07/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
DENNIS ALLSTON (ILTA)
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)
DENNIS ALLSTON (ILTA)
AGREEMENT STATE REPORT - LOST CS-137 SOURCE USED IN DENSITY METER
The following information was provided by the State of Nevada via email:
"The licensee issued a report of a lost radioactive source previously in service at James Hardie's McCarran, NV manufacturing facility. The missing source material in question was a component of a Thermo Measuretech density meter, Model 5201. The radiation source housing has the serial # B4106. The source's serial # is GV-9532. The isotope is Cesium-137, and the activity is 50 mCi.
"This unit was received on site in July, 2004 and put into commission in December of 2004. This particular unit was installed on the agitator feed line (a process line that transfers feed material in a mixing vessel to a production machine). At some time in 2005, the density meter in question was removed from service and replaced with an inline flow meter.
"Thermo Scientific was contacted to determine if the source material in question had ever been sent back to them for recycling or disposal. They have no record of receiving the material in question. In early 2012, the McCarran facility executed a major site clean-up effort. This included taking inventory of all spare parts in the warehouse and cleaning up the 'bone yard'.
"Western Metals Recycling was contacted prior to this clean-up initiative and asked if they had ever found radioactive material in a scrap metal load from James Hardie. They said that they had not. They also stated that all inbound loads are screened for the presence of radioactive material, and that they would have located the lost device had it come into their yard. No scrap metal shipments generated from the 'bone yard' clean-up initiative were found to contain radioactive material.
"At this time James Hardie believes that it has done all that can be done to locate the lost source material. The facility is now easily inspected due to recent clean-up efforts, and effort will continue to be made to locate the lost radiological material. In the event that the lost material is located, the licensee will notify the State of Nevada immediately and initiate action to return the source material to Thermo Scientific for recycling or disposal.
"There is currently one Thermo Measuretech density meter in service at this facility. The device is operated under a General License. In accordance with license requirements, annual training is provided to all site personnel."
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
The following information was provided by the State of Nevada via email:
"The licensee issued a report of a lost radioactive source previously in service at James Hardie's McCarran, NV manufacturing facility. The missing source material in question was a component of a Thermo Measuretech density meter, Model 5201. The radiation source housing has the serial # B4106. The source's serial # is GV-9532. The isotope is Cesium-137, and the activity is 50 mCi.
"This unit was received on site in July, 2004 and put into commission in December of 2004. This particular unit was installed on the agitator feed line (a process line that transfers feed material in a mixing vessel to a production machine). At some time in 2005, the density meter in question was removed from service and replaced with an inline flow meter.
"Thermo Scientific was contacted to determine if the source material in question had ever been sent back to them for recycling or disposal. They have no record of receiving the material in question. In early 2012, the McCarran facility executed a major site clean-up effort. This included taking inventory of all spare parts in the warehouse and cleaning up the 'bone yard'.
"Western Metals Recycling was contacted prior to this clean-up initiative and asked if they had ever found radioactive material in a scrap metal load from James Hardie. They said that they had not. They also stated that all inbound loads are screened for the presence of radioactive material, and that they would have located the lost device had it come into their yard. No scrap metal shipments generated from the 'bone yard' clean-up initiative were found to contain radioactive material.
"At this time James Hardie believes that it has done all that can be done to locate the lost source material. The facility is now easily inspected due to recent clean-up efforts, and effort will continue to be made to locate the lost radiological material. In the event that the lost material is located, the licensee will notify the State of Nevada immediately and initiate action to return the source material to Thermo Scientific for recycling or disposal.
"There is currently one Thermo Measuretech density meter in service at this facility. The device is operated under a General License. In accordance with license requirements, annual training is provided to all site personnel."
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: 46895
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: HOWIE CROUCH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/26/2011
Notification Time: 14:29 [ET]
Event Date: 01/01/2005
Event Time: 00:00 [EDT]
Last Update Date: 05/26/2011
Notification Time: 14:29 [ET]
Event Date: 01/01/2005
Event Time: 00:00 [EDT]
Last Update Date: 05/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - DOSE ADMINISTERED >20% DIFFERENT FROM PRESCRIBED DOSE
The following information was provided by the State of New York via email:
"A patient was prescribed 11 mCi of Iodine-131 for hyperthyroidism but received 7 mCi. Discovered during routine NYS DOH [New York State Department of Health] inspection on 10/18/2007. DOH staff reviewed a memo from the physicist to the RSO discussing the event, but their concern was only that the expiration date on the capsule was 12/28/04 (consultation with the pharmacy after the fact indicated that it was still acceptable to us this dose). A 'left-over' capsule from the previous week (15 mCi on 12/27/2004) with activity of 7 mCi on 01/01/2005 was administered to a patient who was prescribed 11 mCi with the permission of the RSO. Additional dose was ordered and an additional 4 mCi was administered the following day so they RSO did not think it was a misadministration. Follow-up letter from RSO concluded that there was no adverse effect on the patient. Corrective actions included changing procedures and staff training on proper course of action to take in the future and incident reporting requirements. Incident is closed."
New York Report Id No.: NY-11-09
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.
The following information was provided by the State of New York via email:
"A patient was prescribed 11 mCi of Iodine-131 for hyperthyroidism but received 7 mCi. Discovered during routine NYS DOH [New York State Department of Health] inspection on 10/18/2007. DOH staff reviewed a memo from the physicist to the RSO discussing the event, but their concern was only that the expiration date on the capsule was 12/28/04 (consultation with the pharmacy after the fact indicated that it was still acceptable to us this dose). A 'left-over' capsule from the previous week (15 mCi on 12/27/2004) with activity of 7 mCi on 01/01/2005 was administered to a patient who was prescribed 11 mCi with the permission of the RSO. Additional dose was ordered and an additional 4 mCi was administered the following day so they RSO did not think it was a misadministration. Follow-up letter from RSO concluded that there was no adverse effect on the patient. Corrective actions included changing procedures and staff training on proper course of action to take in the future and incident reporting requirements. Incident is closed."
New York Report Id No.: NY-11-09
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.