Event Notification Report for May 18, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/17/2012 - 05/18/2012
Agreement State
Event Number: 48160
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: GRENADA LAKE MEDICAL CENTER
Region: 4
City: GRENADA State: MS
County:
License #: MS-410-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: PETE SNYDER
Licensee: GRENADA LAKE MEDICAL CENTER
Region: 4
City: GRENADA State: MS
County:
License #: MS-410-01
Agreement: Y
Docket:
NRC Notified By: JASON MOAK
HQ OPS Officer: PETE SNYDER
Notification Date: 08/06/2012
Notification Time: 12:59 [ET]
Event Date: 05/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2012
Notification Time: 12:59 [ET]
Event Date: 05/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)
MICHAEL VASQUEZ (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)
AGREEMENT STATE REPORT - UNACCOUNTED FOR BARIUM-133 SOURCES
The following information was received from the Mississippi Department of Radiation Health via e-mail:
"Two (2) Ba-133 [3.86 mCi each] attenuation sources were discovered missing from a quarterly health physics audit at Grenada Lake Medical Center by their consultant. It was discovered by the health physics consultant in early July that documentation regarding the receipt of the sources was not available.
"On 5-18-2012, Bayshore Medical, a third party company was contracted by Philips Healthcare to disassemble and remove a Marconi Axis gamma camera from Grenada Lake Medical Center. The sources were encased inside tungsten holders that were installed inside beacon devices attached to each head of the camera. The nuclear medicine technologist at Grenada Lake Medical Center showed the service engineer for de-installation of the camera the location of the camera and explained to him that Grenada Lake Medical Center would need a receipt record for the two (2) sources removed. The technologist left work for a week during the time the gamma camera was being disassembled and removed from the facility. Upon returning back to the facility the technologist forgot to verify receipt of the sources from the service company.
"Bayshore Medical claimed there was no radioactive sources installed on the Marconi camera removed from Grenada Lake Medical Center. Neither Bayshore Medical or the company that de-installed / bought the camera has a radioactive materials license. Grenada Lake Medical Center has been in contact with Bayshore Medical to track the location of the beacon devices and return them to their facility. The licensee has contacted Philips Healthcare for copies of service records to show the sources were previously installed in the camera. DRH [Mississippi Department of Radiation Health] was contacted by Grenada Lake Medical Center's health physics consultant on 8-3-2012 with a scheduled return date of 8-6-2012, for the beacon devices and sources in question.
"DRH [Mississippi Department of Radiation Health] received a written report of the incident on 8-3-2012. Grenada Lake Medical Center's Radiation Safety Committee has discussed the issue and has developed a policy for future source transfers to prevent a reoccurrence of this incident. Grenada Lake Medical Center will have a person physically verify the removal of any radioactive source along with completing a transfer record prior to any source transfer. Also, Grenada Lake Medical Center will verify that a service company has a radioactive material license to possess and transfer radioactive material."
MS Event: 120002
* * * UPDATE ON 8/14/12 AT 1237 EDT FROM JAYSON MOAK TO DONG PARK * * *
The following information was received from the Mississippi Department of Radiation Health via e-mail:
"Between 5-18-2012 and 5-28-2012, a service engineer from IRS disassembled and removed a Marconi Axis gamma camera from Grenada Lake Medical Center. The camera was previously sold to Philips Healthcare by the licensee. Philips Healthcare then sold the camera to Bayshore Medical who then sold the camera to IRS. The camera remained at the licensee's location throughout the multiple transactions.
"On 8-10-2012, IRS, the company who bought the camera from Bayshore Medical and de-installed the camera from the licensee's location on 5-18-2012, was contacted by DRH [Mississippi Department of Radiation Health]. IRS claimed there were no sources present prior to de-installation of the camera from the licensee's facility."
Notified R4DO (Hagar) and FSME Resources Events via email.
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
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.
The following information was received from the Mississippi Department of Radiation Health via e-mail:
"Two (2) Ba-133 [3.86 mCi each] attenuation sources were discovered missing from a quarterly health physics audit at Grenada Lake Medical Center by their consultant. It was discovered by the health physics consultant in early July that documentation regarding the receipt of the sources was not available.
"On 5-18-2012, Bayshore Medical, a third party company was contracted by Philips Healthcare to disassemble and remove a Marconi Axis gamma camera from Grenada Lake Medical Center. The sources were encased inside tungsten holders that were installed inside beacon devices attached to each head of the camera. The nuclear medicine technologist at Grenada Lake Medical Center showed the service engineer for de-installation of the camera the location of the camera and explained to him that Grenada Lake Medical Center would need a receipt record for the two (2) sources removed. The technologist left work for a week during the time the gamma camera was being disassembled and removed from the facility. Upon returning back to the facility the technologist forgot to verify receipt of the sources from the service company.
"Bayshore Medical claimed there was no radioactive sources installed on the Marconi camera removed from Grenada Lake Medical Center. Neither Bayshore Medical or the company that de-installed / bought the camera has a radioactive materials license. Grenada Lake Medical Center has been in contact with Bayshore Medical to track the location of the beacon devices and return them to their facility. The licensee has contacted Philips Healthcare for copies of service records to show the sources were previously installed in the camera. DRH [Mississippi Department of Radiation Health] was contacted by Grenada Lake Medical Center's health physics consultant on 8-3-2012 with a scheduled return date of 8-6-2012, for the beacon devices and sources in question.
"DRH [Mississippi Department of Radiation Health] received a written report of the incident on 8-3-2012. Grenada Lake Medical Center's Radiation Safety Committee has discussed the issue and has developed a policy for future source transfers to prevent a reoccurrence of this incident. Grenada Lake Medical Center will have a person physically verify the removal of any radioactive source along with completing a transfer record prior to any source transfer. Also, Grenada Lake Medical Center will verify that a service company has a radioactive material license to possess and transfer radioactive material."
MS Event: 120002
* * * UPDATE ON 8/14/12 AT 1237 EDT FROM JAYSON MOAK TO DONG PARK * * *
The following information was received from the Mississippi Department of Radiation Health via e-mail:
"Between 5-18-2012 and 5-28-2012, a service engineer from IRS disassembled and removed a Marconi Axis gamma camera from Grenada Lake Medical Center. The camera was previously sold to Philips Healthcare by the licensee. Philips Healthcare then sold the camera to Bayshore Medical who then sold the camera to IRS. The camera remained at the licensee's location throughout the multiple transactions.
"On 8-10-2012, IRS, the company who bought the camera from Bayshore Medical and de-installed the camera from the licensee's location on 5-18-2012, was contacted by DRH [Mississippi Department of Radiation Health]. IRS claimed there were no sources present prior to de-installation of the camera from the licensee's facility."
Notified R4DO (Hagar) and FSME Resources Events via email.
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
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.
Agreement State
Event Number: 47964
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ALCOA
Region: 1
City: ALCOA CENTER State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Licensee: ALCOA
Region: 1
City: ALCOA CENTER State: PA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/25/2012
Notification Time: 13:29 [ET]
Event Date: 05/18/2012
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2012
Notification Time: 13:29 [ET]
Event Date: 05/18/2012
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1DO)
FSME VIA EMAIL
JAMES TRAPP (R1DO)
FSME VIA EMAIL
AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS
The following information was obtained from the Commonwealth of Pennsylvania via fax:
"Alcoa was doing some renovations and had a previous inventory of nine (9) general license [GL] tritium exit signs. During the renovation it was discovered that only seven (7) were accounted for.
"Details of the two missing exit signs: Evenlite, Inc. Model #201, serial numbers 1388F and 389F, each containing 10.5 Ci of tritium.
"CAUSE OF THE EVENT: Though these GL tritium exit signs comply with NRC regulations for labeling to alert the user that they contain radioactive material, the size of the label is woefully inadequate to prevent unintentional loss of the GL device. This event is another example.
"ACTIONS: No reactive inspection is planned at this time. It is expected these two tritium exit signs have or will end up in an unlicensed Commonwealth of Pennsylvania landfill."
PA Report ID No.: PA120015
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
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
The following information was obtained from the Commonwealth of Pennsylvania via fax:
"Alcoa was doing some renovations and had a previous inventory of nine (9) general license [GL] tritium exit signs. During the renovation it was discovered that only seven (7) were accounted for.
"Details of the two missing exit signs: Evenlite, Inc. Model #201, serial numbers 1388F and 389F, each containing 10.5 Ci of tritium.
"CAUSE OF THE EVENT: Though these GL tritium exit signs comply with NRC regulations for labeling to alert the user that they contain radioactive material, the size of the label is woefully inadequate to prevent unintentional loss of the GL device. This event is another example.
"ACTIONS: No reactive inspection is planned at this time. It is expected these two tritium exit signs have or will end up in an unlicensed Commonwealth of Pennsylvania landfill."
PA Report ID No.: PA120015
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
This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source