Event Notification Report for November 29, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/28/2006 - 11/29/2006
General Information or Other
Event Number: 43015
Rep Org: NV DIV OF RAD HEALTH
Licensee: LAS VEGAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0196-01
Agreement: Y
Docket:
NRC Notified By: WAYNE YATES
HQ OPS Officer: STEVE SANDIN
Licensee: LAS VEGAS VALLEY WATER DISTRICT
Region: 4
City: LAS VEGAS State: NV
County:
License #: 00-11-0196-01
Agreement: Y
Docket:
NRC Notified By: WAYNE YATES
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/29/2006
Notification Time: 17:48 [ET]
Event Date: 11/29/2006
Event Time: 10:40 [PST]
Last Update Date: 12/01/2006
Notification Time: 17:48 [ET]
Event Date: 11/29/2006
Event Time: 10:40 [PST]
Last Update Date: 12/01/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RUSSELL BYWATER (R4)
JOSEPH HOLONICH (NMSS)
ILTAB via email
RUSSELL BYWATER (R4)
JOSEPH HOLONICH (NMSS)
ILTAB via email
AGREEMENT STATE REPORT INVOLVING A LOST TROXLER GAUGE
The following information was provided via fax:
On November 29, 2006, the NV Health Division Radiological Heath Section was notified by the Las Vegas Water District that a portable moisture density gauge, a Troxler Model 3440, S/N 33786, was lost from the bed of a pickup truck at 10:40AM in Las Vegas, NV. When the loss occurred the gauge was sitting on the open tailgate of the service truck, out of the shipping container and not secured. However, the handle was locked. The Troxler Model 3440 gauge contains two (2) radioactive sources; 8 millicuries Cs-137 and 40 millicuries Am-241/Be. Licensee corrective actions include additional training for gauge operators.
NV Event Report ID: NV-06-007
* * * UPDATE PROVIDED BY NEVADA (VERELLEN) VIA FAX TO KOZAL ON 12/01/06 AT 1409 * * *
The missing gauge was recovered and returned to the licensee intact on 12/01/06.
Notified R4DO (Bywater), NMSS EO (Wastler), and ILTAB via e-mail.
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.
The following information was provided via fax:
On November 29, 2006, the NV Health Division Radiological Heath Section was notified by the Las Vegas Water District that a portable moisture density gauge, a Troxler Model 3440, S/N 33786, was lost from the bed of a pickup truck at 10:40AM in Las Vegas, NV. When the loss occurred the gauge was sitting on the open tailgate of the service truck, out of the shipping container and not secured. However, the handle was locked. The Troxler Model 3440 gauge contains two (2) radioactive sources; 8 millicuries Cs-137 and 40 millicuries Am-241/Be. Licensee corrective actions include additional training for gauge operators.
NV Event Report ID: NV-06-007
* * * UPDATE PROVIDED BY NEVADA (VERELLEN) VIA FAX TO KOZAL ON 12/01/06 AT 1409 * * *
The missing gauge was recovered and returned to the licensee intact on 12/01/06.
Notified R4DO (Bywater), NMSS EO (Wastler), and ILTAB via e-mail.
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.
General Information or Other
Event Number: 43035
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: JASON KOZAL
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C SCROGGS
HQ OPS Officer: JASON KOZAL
Notification Date: 12/06/2006
Notification Time: 16:16 [ET]
Event Date: 11/29/2006
Event Time: 00:00 [PST]
Last Update Date: 01/24/2007
Notification Time: 16:16 [ET]
Event Date: 11/29/2006
Event Time: 00:00 [PST]
Last Update Date: 01/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LINDA SMITH (R4)
GARY JANOSKO (NMSS)
LINDA SMITH (R4)
GARY JANOSKO (NMSS)
AGREEMENT STATE REPORT - LOST CANCER THERAPY SEEDS
The State provided the following information via email:
"Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006)
"Location of Event: Seattle, Washington (main campus operating room)
"ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention.
"Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries).
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected.
"Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known.
"Disposition/recovery: To be determined.
"Leak test? Original, by Manufacturer, within past six months.
"Release of activity? The seeds were apparently released to the waste water drain. No contamination was found.
"Consequences: None so far, none expected."
WA-06-068
* * * UPDATE FROM A. SCROGGS TO W. GOTT AT 1455 ON 01/24/07 * * *
The State provided the following information via email:
"The actual cause was determined to be inadequate training of the CS employee. The licensee has revised the procedure for handling seed implants. Now only a properly trained scrub nurse or tech will handle the applicator and accessories. At this time no consequences are expected and there has been no media attention." The six missing sources were never recovered.
Notified R4DO (M. Hay) and NMSSEO (G. Morell)
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.
The State provided the following information via email:
"Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006)
"Location of Event: Seattle, Washington (main campus operating room)
"ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention.
"Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries).
"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected.
"Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known.
"Disposition/recovery: To be determined.
"Leak test? Original, by Manufacturer, within past six months.
"Release of activity? The seeds were apparently released to the waste water drain. No contamination was found.
"Consequences: None so far, none expected."
WA-06-068
* * * UPDATE FROM A. SCROGGS TO W. GOTT AT 1455 ON 01/24/07 * * *
The State provided the following information via email:
"The actual cause was determined to be inadequate training of the CS employee. The licensee has revised the procedure for handling seed implants. Now only a properly trained scrub nurse or tech will handle the applicator and accessories. At this time no consequences are expected and there has been no media attention." The six missing sources were never recovered.
Notified R4DO (M. Hay) and NMSSEO (G. Morell)
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.