| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
02/24/2004 - 02/25/2004 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 40532 | Rep Org: COLORADO DEPT OF HEALTH
Licensee: SOIL TESTING AND ENGINEERING, INC
Region: 4
City: COLORADO SPRINGS State: CO
County:
License #: 61201
Agreement: Y
Docket:
NRC Notified By: TOM PENTECOST
HQ OPS Officer: JEFF ROTTON | Notification Date: 02/20/2004
Notification Time: 10:41 [ET]
Event Date: 02/19/2004
Event Time: 15:50 [MST]
Last Update Date: 02/20/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JACK WHITTEN (R4)
JOHN HICKEY (NMSS)
TOM ANDREWS (R4)
| Event Text AGREEMENT STATE REPORT CONCERNING STOLEN GAUGE
"At 3:50 PM [MST] on 19 Feb 04 - The Department received telephone notification of a stolen gauge by Larry W. Chisman, the RSO for Soil Testing and Engineering Inc.
"The theft occurred between 11:30 AM and 2:00 PM [MST] on 19 Feb 04 in a parking lot at 314 W. Bijou, Colorado Springs, Colorado. The gauge was locked within its orange transport case which was locked within a Suburban. The windows were reported to be intact and it is unknown how entry to the vehicle was gained.
"The stolen gauge is a CPN Model MC-2, serial number M21084026. The gauge contains 10 milliCi of Cs-137 and 50 milliCi of Am-241:Be. The incident was reported to local police on the day of the theft." |
| Hospital | Event Number: 40540 | Rep Org: UNIVERSITY OF VIRGINIA HOSPITAL
Licensee: UNIVERSITY OF VIRGINIA HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: RALPH ALLEN
HQ OPS Officer: RICH LAURA | Notification Date: 02/23/2004
Notification Time: 14:20 [ET]
Event Date: 02/21/2004
Event Time: 09:00 [EST]
Last Update Date: 02/24/2004 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
MOHAMED SHANBAKY (R1)
ROBERTO TORRES (NMSS)
| Event Text MISSING MEDICAL SOURCE FOR 2 HOURS AT UVA HOSPITAL
The licensee at University of Virginia Hospital reported an event where a radioactive medical source was missing for approximately 2 hours. The patient was being treated for uterine cancer. At the end of the treatment, the licensee removed 8 catheters from the patient. Unknown at the time, one ribbon with 8 seeds of Ir-192, with an approximate activity of 5 millicuries, fell onto the floor. The licensee performed a search and radiological surveys, and the missing ribbon was located 2 hours later in a trash compactor. The licensee is performing an assessment of any unplanned exposures that resulted from this event.
* * * UPDATE AT 1530 EST ON 2/24/04 FROM R. ALLEN TO E. THOMAS * * *
The licensee has conclude their assessment of any unplanned exposures from this incident, along with determining its root cause.
In the unlikely case that the patient was laying directly on top of the source (on contact) for the entire 30 minutes from the time the physicians removed the sources until the missing ribbon was discovered, her skin exposure would have been 662 rad. This exposure is less than her skin exposure from other treatments of the tumor thus far, and would result in minimal adverse effects. If the 30 minute exposure occurred at a distance of 1.5 millimeters from the patient, her exposure would have been 41 rad to the skin.
It is highly unlikely that the patient received anywhere near these exposure levels, as the missing ribbon was most likely picked up with other trash shortly after the room was de-posted, and prior to the physicians discovering the loss. In the brief time (1-2 minutes) it took to transport the ribbon with other trash to the dumpster, and during the time the ribbon was in the dumpster, any exposures to additional personnel would have been negligible.
The root cause of the lost ribbon is that the meter used to survey the room following the procedure was defective. Another meter was used to locate the ribbon in the trash compactor.
Notified R1DO (Shanbaky) and NMSS (Essig) | |