Event Notification Report for September 20, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/19/2014 - 09/20/2014
Agreement State
Event Number: 50479
Rep Org: COLORADO DEPT OF HEALTH
Licensee: AVISTA ADVENTIST HOSPITAL
Region: 4
City: LOUISVILLE State: CO
County:
License #: CO 793-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Licensee: AVISTA ADVENTIST HOSPITAL
Region: 4
City: LOUISVILLE State: CO
County:
License #: CO 793-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2014
Notification Time: 13:06 [ET]
Event Date: 09/20/2014
Event Time: 12:30 [MDT]
Last Update Date: 09/22/2014
Notification Time: 13:06 [ET]
Event Date: 09/20/2014
Event Time: 12:30 [MDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PATRICIA MILLIGAN (EMAI)
ANGELA MCINTOSH (EMAI)
JAMES DRAKE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PATRICIA MILLIGAN (EMAI)
ANGELA MCINTOSH (EMAI)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following report was received from the State of Colorado via email:
"The State of Colorado received a report this morning from a medical licensee of a misadministration. The licensee reported that at 1230 [MDT] on Saturday 9/20/14, the technologist injected a patient with a bulk dose of Tc-99m instead of a [smaller] patient dose. The initial estimate for the amount injected is 140 mCi. The initial potential whole body dose is 6-7 rem with 30 rad as the highest potential organ dose (upper intestine). The investigation is ongoing."
Additional information regarding the intended patient dose will be provided when available. The attending physician and patient will be informed by the licensee.
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 report was received from the State of Colorado via email:
"The State of Colorado received a report this morning from a medical licensee of a misadministration. The licensee reported that at 1230 [MDT] on Saturday 9/20/14, the technologist injected a patient with a bulk dose of Tc-99m instead of a [smaller] patient dose. The initial estimate for the amount injected is 140 mCi. The initial potential whole body dose is 6-7 rem with 30 rad as the highest potential organ dose (upper intestine). The investigation is ongoing."
Additional information regarding the intended patient dose will be provided when available. The attending physician and patient will be informed by the licensee.
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.
Agreement State
Event Number: 50477
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAKER HUGHES OILFIELD OPERATIONS INC
Region: 4
City: HOUSTON State: TX
County: DIMMIT
License #: 06453
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: BAKER HUGHES OILFIELD OPERATIONS INC
Region: 4
City: HOUSTON State: TX
County: DIMMIT
License #: 06453
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/21/2014
Notification Time: 09:09 [ET]
Event Date: 09/20/2014
Event Time: 00:00 [CDT]
Last Update Date: 09/22/2014
Notification Time: 09:09 [ET]
Event Date: 09/20/2014
Event Time: 00:00 [CDT]
Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TOM ANDREWS (R4DO)
FSME EVENTS RESOURCE (E-MA)
PAM HENDERSON (FSME)
TOM ANDREWS (R4DO)
FSME EVENTS RESOURCE (E-MA)
PAM HENDERSON (FSME)
AGREEMENT STATE REPORT - VEHICLE FIRE INVOLVING TWO DENSITY GAUGES
The following report was received via e-mail:
"On September 20, 2014, the licensee notified the Agency [Texas Department of State Health Services] that two nuclear gauges, Thermo Fisher Scientific Model 5190 density gauges containing a 200 milliCurie cesium (Cs) - 137 source, were inside a large fire that occurred in the early morning hours. The fire at an oil field temporary job site in Dimmit County, Texas burned over twenty vehicles and the two gauges stored in Type A containers were in the fire. Status of the gauges is unknown. An additional two similar gauges were at the site but not in the area of the fire. An investigation is ongoing and additional information in accordance with SA-300 will be reported. There was no public or worker exposures due to the incident as no one was on site at the time of the fire.
"Gauge Serial Numbers are B6610 and B7600."
Texas Incident #I-9236
* * * UPDATE FROM KAREN BLANCHARD TO JOHN SHOEMAKER AT 1247 EDT ON 9/22/14 * * *
The following event report update was received from the State of Texas via email:
"[The State was informed by the licensee at 1345 CDT on 9/22/14, that] the licensee surveyed and inspected the two Thermo Fisher Scientific Model 5190 gauges that were in a fire on September 20, 2014. Radiation measurement of 7 R/hr on contact with the outer surface of one of the gauges was detected, indicating that the lead shielding had been compromised (gauge SN: B7500). There were no elevated radiation levels detected on the second gauge. The licensee has secured all four gauges that were at the site and set up appropriate barrier while it awaits permission to remove them from the site. The cause of the fire is still under investigation. The manufacturer is sending a transport container. The licensee reported it will add external lead around the compromised gauge for transport. Upon receipt, the manufacturer will inspect/evaluate all four gauges."
Notified R4DO (Drake), FSME Events Resource via email.
The following report was received via e-mail:
"On September 20, 2014, the licensee notified the Agency [Texas Department of State Health Services] that two nuclear gauges, Thermo Fisher Scientific Model 5190 density gauges containing a 200 milliCurie cesium (Cs) - 137 source, were inside a large fire that occurred in the early morning hours. The fire at an oil field temporary job site in Dimmit County, Texas burned over twenty vehicles and the two gauges stored in Type A containers were in the fire. Status of the gauges is unknown. An additional two similar gauges were at the site but not in the area of the fire. An investigation is ongoing and additional information in accordance with SA-300 will be reported. There was no public or worker exposures due to the incident as no one was on site at the time of the fire.
"Gauge Serial Numbers are B6610 and B7600."
Texas Incident #I-9236
* * * UPDATE FROM KAREN BLANCHARD TO JOHN SHOEMAKER AT 1247 EDT ON 9/22/14 * * *
The following event report update was received from the State of Texas via email:
"[The State was informed by the licensee at 1345 CDT on 9/22/14, that] the licensee surveyed and inspected the two Thermo Fisher Scientific Model 5190 gauges that were in a fire on September 20, 2014. Radiation measurement of 7 R/hr on contact with the outer surface of one of the gauges was detected, indicating that the lead shielding had been compromised (gauge SN: B7500). There were no elevated radiation levels detected on the second gauge. The licensee has secured all four gauges that were at the site and set up appropriate barrier while it awaits permission to remove them from the site. The cause of the fire is still under investigation. The manufacturer is sending a transport container. The licensee reported it will add external lead around the compromised gauge for transport. Upon receipt, the manufacturer will inspect/evaluate all four gauges."
Notified R4DO (Drake), FSME Events Resource via email.