Event Notification Report for August 19, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/18/2015 - 08/19/2015
Non-Agreement State
Event Number: 51332
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: HOWIE CROUCH
Licensee: U.S. ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2015
Notification Time: 15:05 [ET]
Event Date: 08/19/2015
Event Time: 15:52 [EDT]
Last Update Date: 08/20/2015
Notification Time: 15:05 [ET]
Event Date: 08/19/2015
Event Time: 15:52 [EDT]
Last Update Date: 08/20/2015
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):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)
LOST/STOLEN U.S. ARMY RADIOACTIVE CHEMICAL ALARMS FOR SALE OR SOLD ON EBAY
The U.S. Army TACOM Radiation Safety Program Manager in Warren, MI was notified via email of what appeared to be U.S. Army material containing radioactive sources were for sale on eBay. The program manager was not able to find the listing but the information received indicated that the material was already sold or the listing expired. When the program manager contacted eBay about the material and the seller, eBay was uncooperative, citing privacy of the individuals selling/buying the material.
The program manager contacted the U.S. Army Criminal Investigative Command in Troy, MI and provided them with all the information pertaining to the material. Since the material was not recovered, the U.S. Army considers the material lost/stolen.
The materials are two M8A1 Chemical Agent Alarms each containing nominally 300 microcuries of Am-241.
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
The U.S. Army TACOM Radiation Safety Program Manager in Warren, MI was notified via email of what appeared to be U.S. Army material containing radioactive sources were for sale on eBay. The program manager was not able to find the listing but the information received indicated that the material was already sold or the listing expired. When the program manager contacted eBay about the material and the seller, eBay was uncooperative, citing privacy of the individuals selling/buying the material.
The program manager contacted the U.S. Army Criminal Investigative Command in Troy, MI and provided them with all the information pertaining to the material. Since the material was not recovered, the U.S. Army considers the material lost/stolen.
The materials are two M8A1 Chemical Agent Alarms each containing nominally 300 microcuries of Am-241.
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 EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 51342
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: WOOD COUNTY HOSPITAL
Region: 3
City: BOWLING GREEN State: OH
County:
License #: 02120880005
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Licensee: WOOD COUNTY HOSPITAL
Region: 3
City: BOWLING GREEN State: OH
County:
License #: 02120880005
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/25/2015
Notification Time: 10:52 [ET]
Event Date: 08/19/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/27/2015
Notification Time: 10:52 [ET]
Event Date: 08/19/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/27/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
OHIO AGREEMENT STATE REPORT - PROSTATE TREATMENT UNDERDOSE
The following information was provided by the State of Ohio via email:
On 8/20/2015, the Ohio Department of Health (ODH) was notified by voice mail regarding a prostate seed implant to a patient performed on 07/16/2015. This implant consisted of [60] seeds (each seed - 23.6 milliCi of I-125). On 8/18/2015, a post seed implant CT scan was done to verify dose distribution. It was discovered that the D90 "dose" delivered [an under dose] that varied by 34 percent of the prescribed D90 dose for a prostate seed implant. The Referring physician and patient have been notified.
Ohio Item Number: OH150008
* * * RETRACTION PROVIDED FROM STEPHEN JAMES TO JEFF ROTTON VIA EMAIL AT 1454 ON 08/27/2015 * * *
The following information was provided by the State of Ohio via email:
"After additional reporting by the licensee and investigation by ODH, it was determined that the patient did NOT receive the under dose as initially reported and DOES NOT qualify as a medical event. This report is RETRACTED, as of 8/27/15."
Notified R3DO (Skokowski) and NMSS Events Notification via email.
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 information was provided by the State of Ohio via email:
On 8/20/2015, the Ohio Department of Health (ODH) was notified by voice mail regarding a prostate seed implant to a patient performed on 07/16/2015. This implant consisted of [60] seeds (each seed - 23.6 milliCi of I-125). On 8/18/2015, a post seed implant CT scan was done to verify dose distribution. It was discovered that the D90 "dose" delivered [an under dose] that varied by 34 percent of the prescribed D90 dose for a prostate seed implant. The Referring physician and patient have been notified.
Ohio Item Number: OH150008
* * * RETRACTION PROVIDED FROM STEPHEN JAMES TO JEFF ROTTON VIA EMAIL AT 1454 ON 08/27/2015 * * *
The following information was provided by the State of Ohio via email:
"After additional reporting by the licensee and investigation by ODH, it was determined that the patient did NOT receive the under dose as initially reported and DOES NOT qualify as a medical event. This report is RETRACTED, as of 8/27/15."
Notified R3DO (Skokowski) and NMSS Events Notification via email.
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: 51358
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: JARDEN ZINC PRODUCTS
Region: 1
City: GREENVILLE State: TN
County:
License #: R-30012-L23
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: JARDEN ZINC PRODUCTS
Region: 1
City: GREENVILLE State: TN
County:
License #: R-30012-L23
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/31/2015
Notification Time: 13:20 [ET]
Event Date: 08/19/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/31/2015
Notification Time: 13:20 [ET]
Event Date: 08/19/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/31/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHNATHAN LILLIENDAH (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JOHNATHAN LILLIENDAH (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE SHUTTER STUCK CLOSED
The following was received via e-mail:
"The Tennessee Division of Radiological Health was notified on August 19, 2015 of an inoperable fixed nuclear gauge at the Jarden Zinc facility in Greeneville, TN. The gauge shutter was stuck in the closed position due to a defective solenoid in the gauge. The gauge was a LFE Model SS3A containing a 1 curie Americium 241 source."
Tennessee Event: TN-15-126
The following was received via e-mail:
"The Tennessee Division of Radiological Health was notified on August 19, 2015 of an inoperable fixed nuclear gauge at the Jarden Zinc facility in Greeneville, TN. The gauge shutter was stuck in the closed position due to a defective solenoid in the gauge. The gauge was a LFE Model SS3A containing a 1 curie Americium 241 source."
Tennessee Event: TN-15-126