Event Notification Report for December 16, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/15/2014 - 12/16/2014
EVENT NUMBERS
50684506855068050692
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 50684
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: IBA MOLECULAR
Region: 1
City: TOTOWA State: NJ
County:
License #: 452369
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: JOHN SHOEMAKER
Licensee: IBA MOLECULAR
Region: 1
City: TOTOWA State: NJ
County:
License #: 452369
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/16/2014
Notification Time: 16:16 [ET]
Event Date: 12/16/2014
Event Time: 13:40 [EST]
Last Update Date: 04/27/2015
Notification Time: 16:16 [ET]
Event Date: 12/16/2014
Event Time: 13:40 [EST]
Last Update Date: 04/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN ROGGE (R1DO)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (EMAI)
PATRICIA MILLIGAN (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
JOHN ROGGE (R1DO)
LAURA DUDES (NMSS)
ANGELA MCINTOSH (EMAI)
PATRICIA MILLIGAN (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - INDIVIDUAL EXCEEDS OCCUPATIONAL DOSE LIMIT OF 50 REM TO THE SKIN
The following report was received from the State of New Jersey via fax:
"Event Description: [The licensee,] IBA is a PET [Positron Emission Tomography] manufacturer and radiopharmacy. When the dosimetry reports for November 2014, were reviewed, it was noted that one individual exceeded the 20.1201(a)(2)(ii) occupational dose limit of 50 rem to the skin of an extremity. This was caused by a November dose of greater than 46 rem to the left extremity, bringing the year to-date dose to greater than 62 rem. The licensee is investigating this unusual November dose and will be preparing a written report. The individual has been removed from work with radioactive materials and the dosimeter for December has been sent in early for processing."
* * * RETRACTION AT 1512 ON 4/27/2015 FROM CATHY BIEL TO MARK ABRAMOVITZ * * *
After discussions with the licensee, the dose to the left hand was reduced from 46 Rem to 20.592 Rem which gives an annual dose to the extremity of 37 Rem. This dose is below the reporting requirements and the event is retracted.
Notified the R1DO (Gray) and NMSS Events Notification Group (via e-mail).
The following report was received from the State of New Jersey via fax:
"Event Description: [The licensee,] IBA is a PET [Positron Emission Tomography] manufacturer and radiopharmacy. When the dosimetry reports for November 2014, were reviewed, it was noted that one individual exceeded the 20.1201(a)(2)(ii) occupational dose limit of 50 rem to the skin of an extremity. This was caused by a November dose of greater than 46 rem to the left extremity, bringing the year to-date dose to greater than 62 rem. The licensee is investigating this unusual November dose and will be preparing a written report. The individual has been removed from work with radioactive materials and the dosimeter for December has been sent in early for processing."
* * * RETRACTION AT 1512 ON 4/27/2015 FROM CATHY BIEL TO MARK ABRAMOVITZ * * *
After discussions with the licensee, the dose to the left hand was reduced from 46 Rem to 20.592 Rem which gives an annual dose to the extremity of 37 Rem. This dose is below the reporting requirements and the event is retracted.
Notified the R1DO (Gray) and NMSS Events Notification Group (via e-mail).
Power Reactor
Event Number: 50685
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETER MOODIE
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETER MOODIE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/16/2014
Notification Time: 17:07 [ET]
Event Date: 12/16/2014
Event Time: 13:00 [CST]
Last Update Date: 12/16/2014
Notification Time: 17:07 [ET]
Event Date: 12/16/2014
Event Time: 13:00 [CST]
Last Update Date: 12/16/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
AARON MCCRAW (R3DO)
AARON MCCRAW (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT - DISCOVERY OF A PROHIBITED ITEM IN THE PROTECTED AREA
The licensee discovered evidence of prohibited material inside the protected area. The material has been removed. The licensee has notified the NRC Resident Inspector.
The licensee discovered evidence of prohibited material inside the protected area. The material has been removed. The licensee has notified the NRC Resident Inspector.
Non-Agreement State
Event Number: 50680
Rep Org: MIDWEST TESTING
Licensee: MIDWEST TESTING
Region: 3
City: OVERLAND State: MO
County:
License #: 24-24619-02
Agreement: N
Docket:
NRC Notified By: JOE HONICH
HQ OPS Officer: JEFF HERRERA
Licensee: MIDWEST TESTING
Region: 3
City: OVERLAND State: MO
County:
License #: 24-24619-02
Agreement: N
Docket:
NRC Notified By: JOE HONICH
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/16/2014
Notification Time: 09:21 [ET]
Event Date: 12/16/2014
Event Time: 07:42 [CST]
Last Update Date: 01/05/2015
Notification Time: 09:21 [ET]
Event Date: 12/16/2014
Event Time: 07:42 [CST]
Last Update Date: 01/05/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
NEIL OKEEFE (R4DO)
AARON MCCRAW (R3DO)
NMSS EVENTS (EMAI)
ILTAB (EMAI)
NEIL OKEEFE (R4DO)
AARON MCCRAW (R3DO)
NMSS EVENTS (EMAI)
ILTAB (EMAI)
LOST HUMBOLDT 5001EZ DENSITY GAUGE
A trailer containing a Humboldt 5001EZ Density gauge was found missing/stolen by a technician staying at the Holiday Inn Express in Oklahoma City, OK. The gauge was chained and locked to the trailer. The licensee reported that there have been no press or media inquiries and no rewards are currently being considered for the return of the density gauge. The licensee was performing work in OK under reciprocity.
The gauge is a Humboldt 5001EZ model, Serial Number: 3309 containing 10 mCi of Cs-137 and 40 mCi of Am-241/Be.
The local police department and the State of Oklahoma were notified.
* * * UPDATE FROM JOE HONICH TO CHARLES TEAL AT 0920 EST ON 1/5/15 * * *
The Oklahoma Police Department located the gauge. It was dumped on the side of the road in a cardboard box. The gauge was fully intact and did not appear to be tampered with. The gauge is currently in the possession of an Oklahoma licensee until arrangements can be made for a transfer back to Midwest Testing.
Notified R3DO (Cameron), R4DO (Pick) and NMSS 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
A trailer containing a Humboldt 5001EZ Density gauge was found missing/stolen by a technician staying at the Holiday Inn Express in Oklahoma City, OK. The gauge was chained and locked to the trailer. The licensee reported that there have been no press or media inquiries and no rewards are currently being considered for the return of the density gauge. The licensee was performing work in OK under reciprocity.
The gauge is a Humboldt 5001EZ model, Serial Number: 3309 containing 10 mCi of Cs-137 and 40 mCi of Am-241/Be.
The local police department and the State of Oklahoma were notified.
* * * UPDATE FROM JOE HONICH TO CHARLES TEAL AT 0920 EST ON 1/5/15 * * *
The Oklahoma Police Department located the gauge. It was dumped on the side of the road in a cardboard box. The gauge was fully intact and did not appear to be tampered with. The gauge is currently in the possession of an Oklahoma licensee until arrangements can be made for a transfer back to Midwest Testing.
Notified R3DO (Cameron), R4DO (Pick) and NMSS 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
Non-Agreement State
Event Number: 50692
Rep Org: AIR FORCE MEDICAL SUPPORT AGENCY
Licensee: AIR FORCE MEDICAL SUPPORT AGENCY
Region: 4
City: TRAVIS AFB State: CA
County:
License #: 42-23539-01/A
Agreement: Y
Docket:
NRC Notified By: DANIEL SHAW
HQ OPS Officer: DONG HWA PARK
Licensee: AIR FORCE MEDICAL SUPPORT AGENCY
Region: 4
City: TRAVIS AFB State: CA
County:
License #: 42-23539-01/A
Agreement: Y
Docket:
NRC Notified By: DANIEL SHAW
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2014
Notification Time: 12:57 [ET]
Event Date: 12/16/2014
Event Time: 18:00 [PST]
Last Update Date: 12/18/2014
Notification Time: 12:57 [ET]
Event Date: 12/16/2014
Event Time: 18:00 [PST]
Last Update Date: 12/18/2014
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):
NEIL OKEEFE (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
NEIL OKEEFE (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
PRESCRIBED DOSE CHANGED BY UNAUTHORIZED USER
"On 16 December 2014, at 1800 [PST], a patient was prescribed to receive 8-12 mCi of I-123 MIBG [metaiodobenzylguanidine]. The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC [Officer-in-Charge] changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. [The Nuclear Medicine OIC] is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that [the Nuclear Medicine OIC] meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee).
"Location: Travis AFB, David Grant USAF Medical Center"
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 16 December 2014, at 1800 [PST], a patient was prescribed to receive 8-12 mCi of I-123 MIBG [metaiodobenzylguanidine]. The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC [Officer-in-Charge] changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. [The Nuclear Medicine OIC] is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that [the Nuclear Medicine OIC] meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee).
"Location: Travis AFB, David Grant USAF Medical Center"
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.