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Event Notification Report for September 29, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/28/2005 - 09/29/2005

** EVENT NUMBERS **


42014 42015 42016 42022 42023

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General Information or Other Event Number: 42014
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: DOCTORS OHIOHEALTH CORP.
Region: 3
City: COLUMBUS State: OH
County:
License #: 02120250020
Agreement: Y
Docket:
NRC Notified By: MIKE SNEE
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/26/2005
Notification Time: 11:30 [ET]
Event Date: 09/24/2005
Event Time: [EDT]
Last Update Date: 09/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
TOM ESSIG (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING MISSING I-131 SHIPMENT

"The Ohio Department of Health was notified by Doctors OhioHealth Corporation on September 26 of a missing 25 millicurie I-131 capsule. The I-131 capsule was to be delivered to the Doctors OhioHealth Corporation Columbus, Ohio location for a thyroid therapy September 26, 2005, at 9 a.m.

"The capsule was delivered on Saturday by AirNet but not to the Doctors OhioHealth Corporation location. The person who signed for the I-131 on Saturday, September 24 is not employed by Doctors OhioHealth Corporation. Security at Doctors OhioHealth Corporation and AirNet are trying to locate the I-131 capsule as of 9:30 a.m. Monday September 26th, 2005. The I-131 was sent to Doctors OhioHealth Corporation from Anazao Health in Tampa, Florida via AirNet. The Ohio Department of Health is currently attempting to track the missing I-131 capsule."

OH Reference Number: 05-114.

Less than the quantity of an IAEA Category 3 source.

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.

For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.

*** UPDATE ON 09/26/05 AT 1147 EDT BY MIKE SNEE TO MACKINNON ****

"The I-131 capsule was located by AirNet in the Hazmat trailer at Rickenbacher Airport in Columbus, Ohio. The material was never delivered to the hospital as originally reported. AirNet will deliver the material to the hospital today, September 26."

R3DO (David Hills) and NMSS (Tom Essig) notified of the update.

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Other Nuclear Material Event Number: 42015
Rep Org: US GEOLOGICAL SURVEY
Licensee: US GEOLOGICAL SURVEY
Region: 4
City: DENVER State: CO
County:
License #: 05-01399-08
Agreement: Y
Docket:
NRC Notified By: DARRELL LILES
HQ OPS Officer: BILL GOTT
Notification Date: 09/26/2005
Notification Time: 15:31 [ET]
Event Date: 09/26/2005
Event Time: [MDT]
Last Update Date: 09/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
BLAIR SPITZBERG (R4)
CHRISTOPHER CAHILL (R1)
SCOTT MOORE (NMSS)
LANCE ENGLISH email (TAS)

Event Text

SOURCE LOST IN SHIPMENT

"This memo is to report a missing/lost Cs-137 (s/n A5-509 100 milliCuries) source and describe the events of its loss under the US Geological Survey License 05-01399-08 as required in 10CFR20.2201. Two well logging sources (Cs-137 and Americium-Beryllium) were shipped by FedEx Overnight on September 21, 2005 from Denver, Colorado to arrive in Salisbury, Maryland on September 22, 2005.

"The Cs-137 never arrived at its destination. The status of the sources during transportation was being monitored by the licensee. FedEx was called on September 21, and 22, 2005, about both sources. FedEx assured the license that the sources were in transport and they had only been delayed by normal transportation delays. On Monday, September 23, 2005, when the Cs-137 source still was not at its final destination, the licensee had FedEx put a trace on the Cs-137 source. Later on September 23, 2005, the licensee was informed by FedEx that the Cs-137 source could not be found, that FedEx would continue looking for it and the source had made it to Baltimore-Washington Airport but did not make it to the next scheduled scan point.

"The Americium/Beryllium (AmBe) source arrived in Salisbury on September 24, 2005 after being delayed in Memphis, TN. A well logging supervisor picked up the AmBe source at the FedEx location in Salisbury, MD and noticed that both Declaration of Dangerous Goods Forms (Cs-137 and AmBe) had been erroneously placed on the AmBe package. This apparently happened in route since FedEx checked both declarations when the shipments were picked up in Denver and placed them back on their respective package."

* * * UPDATE FROM D. LILES TO W GOTT AT 1717 ON 09/28/05 * * *

The package containing the Cs-137 source was located at approximately 1530 CT 09/28/05, in Memphis, TN. The package will be delivered to the Salisbury, MD facility on 09/29/05.

Notified NMSS (Reamer), R1DO (Cahill), and R4DO (Spitzburg).

Less than the quantity of an IAEA Category 3 source.

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.

For some of these sources, such as moisture density gauges or thickness gauges that are IAEA 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.

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General Information or Other Event Number: 42016
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BAPTIST MEDICAL CENTER
Region: 1
City: BIRMINGHAM State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/26/2005
Notification Time: 16:00 [ET]
Event Date: 09/26/2005
Event Time: 13:45 [CDT]
Last Update Date: 09/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
LYDIA CHANG (NMSS)

Event Text

ALABAMA AGREEMENT STATE REPORT - IODINE-125 CONTAMINATION

"[The State of Alabama Department of Public Health] Received a call from Baptist Medical Center -Princeton, Birmingham, Alabama, that they had found I-125 contamination during the post-operative clean-up of an I-125 prostate seed implant therapy. Licensee indicated that they were not sure that there was a leaking seed inserted into the patient. None of the seeds remaining after the procedure were leaking. The licensee performed a thyroid scan on the patient on 9/22/05, which showed that there was an uptake. Potassium iodide was administered at that time. The Seeds are Model ProstaSeed I125-SL, distributed by Mantor Brachytherapy. The applicator is MICK Model 200TP. The licensee is performing dose assessment to include in their written report."

Event ID Number: AL-05-48

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Other Nuclear Material Event Number: 42022
Rep Org: SAINT-GOBAIN PERFORMANCE PLASTICS
Licensee: SAINT-GOBAIN PERFORMANCE PLASTICS
Region: 1
City: NEW HAVEN State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: JOHN MITLAND
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/28/2005
Notification Time: 15:02 [ET]
Event Date: 09/26/2005
Event Time: [EDT]
Last Update Date: 09/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CHRISTOPHER CAHILL (R1)
LYDIA CHANG (NMSS)
JIM WHITNEY (TAS)

Event Text

MISSING TWO KRYPTON-85 THICKNESS GAUGES

Saint-Gobain Performance Plastic located in Hoosick, NY, said that they are missing two 500 millicurie Kr-85 thickness gauges (500 millicuries in 1967, half life 10.4 years) from their Saint-Gobain Performance Plastic company in New Haven, CT, which was closed in late 2003 or early 2004. The Kr-85 thickness gauges license number is 20-01382-02 (license expired in 1994 and were licensed through LFE Industrial System Corp.). Caller stated that the krypton thickness gauges were not licensed through the State of New York but to CT which is an NRC non-agreement state. On 09/26/05 the two krypton thickness gauges were discovered missing while putting together an ionizing radiation report for the State of CT for the radioactive materials that were located in their New Haven facility. The two krypton thickness gauges were made by LFE Tracer Units (now known as EGS Gauging located in MA) and each contained 500 millicures of Kr-85 as of 1967. Based on a total of activity 1000 millicuries for the two Kr-85 thickness gauges at the end of 1968 as of 2005 the total activity of the two thickness gauges would be around 85 millicuries (37years, half life 10.4 years). Model number of the two gauges are S-6A and their serial numbers are 24A & T9A.

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Hospital Event Number: 42023
Rep Org: ST. VINCENT HOSPITAL
Licensee: ST.VINCENT HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: ED WROBLEWSKI
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/28/2005
Notification Time: 17:16 [ET]
Event Date: 03/11/2004
Event Time: [CST]
Last Update Date: 09/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVID HILLS (R3)
C. W. REAMER (NMSS)

Event Text

MEDICAL EVENT INVOLVING TREATMENT TO WRONG LOCATION

"As a result of a retrospective review of HDR brachytherapy cases, a medical event was discovered. This event occurred on March 11, 2004, which involved a single esophageal HDR brachytherapy treatment. In this case, a 62 year old female patient, was treated with a Nucletron High Dose Rate (HDR) brachytherapy remote afterloader for esophageal cancer . The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a N/G tube (naso-gastric tube) for an active length of 8.0 cm using a 8.49 Curie Iridium-192 source. The treatment plan called for 17 indexer step positions at 5.0mm spacing to begin at dwell position 23 and terminating at dwell position 39. The medical physicist entered 17 indexer step positions with 5.0 mm spacing at dwell positions 1 through 17 and treatment was delivered.

"As the intended delivery site was to be delivered an intended dosage of 500 cGy for one fraction for a total of 500 cGy, the dose delivered to the unintended site was 500 cGy while the intended treatment site was not treated.

"This patient is now deceased. It is not believed this medical event was a significant contributing factor in the cause of death when consideration of the prognosis of the disease is given.

"Although this medical event occurred March 11, 2004, it was discovered 17:45 ET on September 27, 2005, as a result of a retrospective review."

The licensee has notified Region 3 (Madera and Mulay) about this event.

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