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Event Notification Report for July 22, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/21/2005 - 07/22/2005

** EVENT NUMBERS **


41849 41854 41860

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General Information or Other Event Number: 41849
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PETRA GEOTECHNICAL
Region: 4
City: YAKAIPA State: CA
County:
License #: 2933-30
Agreement: Y
Docket:
NRC Notified By: R. GREGOR
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/18/2005
Notification Time: 12:52 [ET]
Event Date: 07/18/2005
Event Time: 08:30 [PDT]
Last Update Date: 07/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
MICHELE BURGESS (NMSS)
TAS (EMAIL) ()
MEXICO (CNSNS) ()

Event Text

CALIFORNIA AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGES

The State provided the following information via email:

"At 0830 on July 18, 2005, [NAME DELETED], RSO for the licensee called to report that two model MC-3 gauges (each containing nominally 10 mCi of Cs-137 and 50 mCi of Am-241) were stolen from the secured temporary job storage site in Yucaipa, CA . There were three gauges at this site, but the model MC-1 gauge (an older gauge) was not taken. The licensee last saw these gauges when the job-site was shut down for the weekend, approximately 1700 on July 15, 2005. This morning [07/18/05], in preparation for returning to work, it was noted that two gauges were missing at approximately 0630-0700 hours [PDT]. The RSO is in transit to the job-site, to meet the local police, and will provide more details as he gets them. The licensee intends to post a reward in the Press-Enterprise newspaper in the Riverside area."

State 5010 Report No.: 071805

* * * UPDATE FROM STATE (GREGOR) TO M. RIPLEY 1839 EDT 07/18/05 * * *

The State provided the following information via email:

" The window in which the gauges were stolen was 7/16-18/05 instead of 7/15-18/05 as indicated on our form. Also, we have been informed that there was other construction equipment stolen in addition to the two gauges. We have been informed in the past by law enforcement in the area that there is a ring who apparently raids construction sites stealing construction materials for resale in Mexico. Don't know if this is the situation in this case."

Notified R4 DO (L. Smith), NMSS EO (Dan Gillen), TAS and Mexico CNSNS (email)

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General Information or Other Event Number: 41854
Rep Org: ALABAMA RADIATION CONTROL
Licensee: INLAND DREDGONG
Region: 1
City: JACKSON State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/19/2005
Notification Time: 10:04 [ET]
Event Date: 07/18/2005
Event Time: [CDT]
Last Update Date: 07/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1)
MICHELE BURGESS (NMSS)

Event Text

ALABAMA AGREEMENT STATE REPORT - IMPROPER USE AND SHIPMENT OF NUCLEAR GAUGE

The State provided the following information via facsimile:

"Description of Event: A dredging company using GL devices in Alabama illegally, removed and shipped a device containing a 200 milliCuries cesium 137 source to Ronan Engineering Company in Kentucky for repair. The shutter was not locked in the closed position. The owner had painted over the marking and labeling on the source holder so that they were illegible. The dredging company has hired a consultant to reconstruct the incident and try to determine any possible exposures received.

"Additional information will be submitted after the investigation is completed."

The following, additional information was obtained from the State via telephone:

Dredging Company: Inland Dredging, Co. based in Dyersberg, TN, doing work in the vicinity of Jackson, AL
The gauge is currently at Ronan Engineering Co., Florence, KY
Event date is unknown, but the State was notified on the evening of 7/18/05.

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Hospital Event Number: 41860
Rep Org: MONTGOMERY REGIONAL HOSPITAL
Licensee: MONTGOMERY REGIONAL HOSPITAL
Region: 1
City: BLACKSBURG State: VA
County:
License #: 45-19057-01
Agreement: N
Docket:
NRC Notified By: JAMES NUNN
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/21/2005
Notification Time: 14:30 [ET]
Event Date: 07/20/2005
Event Time: 11:00 [EDT]
Last Update Date: 07/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD CONTE (R1)
TOM ESSIG (NMSS)

Event Text

MEDICAL EVENT - DELIVERED DOSAGE EXCEEDED PRESCRIBED DOSAGE

"On Wednesday July 20, 2005 it was discovered, during a routine audit of the Nuclear Medicine records, that two patients were administered I-131 in amounts exceeding 30 microcuries without a written directive. Furthermore, the doses fell more than 20% outside the prescribed dose range as set by the Authorized User (AU) physician. Below I will discuss the particulars of each administration.

"1. Patient #1: 25 year old female was administered 31 Ci of I-131 Sodium Iodide (Nal) on 18 July 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. The prescribed does range, as set by the AU, was 8 to18 microcuries. This dose was 72% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour thyroid uptake fraction was 27.5%).

"2. Patient #2: 61 year old female was administered 42 Ci of I-131 Nal on 14 July, 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. This dose was 133% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour uptake fraction was 14%).

"Dose Estimates From These Procedures

"1. Patient #1: Using data found in NUREG CR-6435 "Radiation Dose Estimated from Radiopharmaceuticals" we estimate the following doses for the (a) Whole Body: 1.209 rem, and (b) Thyroid (target organ) 40.3 rad

"2. Patient #2: Using data from NUREG CR-6345 and from other sources we estimate the following dose for the (a) Whole Body: 1.638 rem, and (b) Thyroid: 17.6 rad."

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012