Event Notification Report for December 13, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/12/2007 - 12/13/2007
Other Nuclear Material
Event Number: 43844
Rep Org: JANX INTEGRITY GROUP
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/14/2007
Notification Time: 16:22 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Notification Time: 16:22 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
JOSEPH HOLONICH (FSME)
JOHN MADERA (R3)
JOSEPH HOLONICH (FSME)
JOHN MADERA (R3)
POTENTIAL OVEREXPOSURE
The licensee reported that two personnel, a radiography technician and assistant, were performing radiography shots at a fabrication shop in Detroit, MI. After completion of a shot, the technician cranked the SPEC-150 camera source into the shielded position. The assistant then surveyed the camera and got a background reading, indicating the source was, indeed, shielded. The survey was verified by the technician. The assistant then removed the camera from a hook that it was hanging on and set it on the ground. He then started preps for the next shot and set the survey meter down on the ground. After completing the preps, the assistant noticed that the survey meter was pegged high on the X10 scale. He immediately moved away from in front of the camera and notified the technician. The source was again verified in the shielded position after the technician locked the camera. No rate alarm occurred on the assistant's rate device but his pocket dosimeter indicated off-scale. The Radiation Safety Officer was immediately notified.
The assistance estimated he was in front of camera for approximately two to five minutes. The estimated dose received by the assistant was calculated to be between one and five REM. This will be confirmed when the assistant's TLD is read. The RSO has overnighted the TLD to a lab for processing.
The camera was removed from service and will be evaluated by the vendor for suspected failure of an internal safety mechanism.
The licensee reported that two personnel, a radiography technician and assistant, were performing radiography shots at a fabrication shop in Detroit, MI. After completion of a shot, the technician cranked the SPEC-150 camera source into the shielded position. The assistant then surveyed the camera and got a background reading, indicating the source was, indeed, shielded. The survey was verified by the technician. The assistant then removed the camera from a hook that it was hanging on and set it on the ground. He then started preps for the next shot and set the survey meter down on the ground. After completing the preps, the assistant noticed that the survey meter was pegged high on the X10 scale. He immediately moved away from in front of the camera and notified the technician. The source was again verified in the shielded position after the technician locked the camera. No rate alarm occurred on the assistant's rate device but his pocket dosimeter indicated off-scale. The Radiation Safety Officer was immediately notified.
The assistance estimated he was in front of camera for approximately two to five minutes. The estimated dose received by the assistant was calculated to be between one and five REM. This will be confirmed when the assistant's TLD is read. The RSO has overnighted the TLD to a lab for processing.
The camera was removed from service and will be evaluated by the vendor for suspected failure of an internal safety mechanism.
Other Nuclear Material
Event Number: 43845
Rep Org: JANX INTEGRITY GROUP
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/14/2007
Notification Time: 16:33 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Notification Time: 16:33 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN MADERA (R3)
JOSEPH HOLONICH (FSME)
JOHN MADERA (R3)
JOSEPH HOLONICH (FSME)
SAFETY EQUIPMENT FAILURE
In a remote area in Missouri, radiography personnel were x-raying welds on a pipe that was placed in a trench. Away from the radiographers, the pipeline contractors moved another pipe in the trench which caused the trench to collapse, allowing water into the trench. The radiography saw it happening and immediately cranked the source into the shielded position. The water submerged the SPEC-150 radiography camera and equipment.
Using the same camera, the radiographer set up for a shot in a different location. When exposing the source, it became stuck in the unshielded position. The radiographer immediately notified the RSO and marked off the area with boundary tape while he awaited assistance from the vendor.
When the vendor could not immediately respond due to weather related travel issues, the radiography personnel procured a heater to thaw the camera as they suspected the camera was frozen from the earlier water intrusion. Surrounding temperatures were in the twenties. After warming the camera, they were able to successfully retrieve the source to the shielded position.
In a remote area in Missouri, radiography personnel were x-raying welds on a pipe that was placed in a trench. Away from the radiographers, the pipeline contractors moved another pipe in the trench which caused the trench to collapse, allowing water into the trench. The radiography saw it happening and immediately cranked the source into the shielded position. The water submerged the SPEC-150 radiography camera and equipment.
Using the same camera, the radiographer set up for a shot in a different location. When exposing the source, it became stuck in the unshielded position. The radiographer immediately notified the RSO and marked off the area with boundary tape while he awaited assistance from the vendor.
When the vendor could not immediately respond due to weather related travel issues, the radiography personnel procured a heater to thaw the camera as they suspected the camera was frozen from the earlier water intrusion. Surrounding temperatures were in the twenties. After warming the camera, they were able to successfully retrieve the source to the shielded position.
Hospital
Event Number: 43882
Rep Org: HACKLEY HOSPITAL
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANNA
HQ OPS Officer: JEFF ROTTON
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANNA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/04/2008
Notification Time: 15:20 [ET]
Event Date: 12/13/2007
Event Time: 00:00 [EST]
Last Update Date: 01/04/2008
Notification Time: 15:20 [ET]
Event Date: 12/13/2007
Event Time: 00:00 [EST]
Last Update Date: 01/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATRICK LOUDEN (R3)
GREG MORELL (FSME)
PATRICK LOUDEN (R3)
GREG MORELL (FSME)
PATIENT RECEIVED LESS THAT PRESCRIBED DOSE
"On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131.
"The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131.
"Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours."
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.
"On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131.
"The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131.
"Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours."
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.