United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2006 > January 24

Event Notification Report for January 24, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/23/2006 - 01/24/2006

** EVENT NUMBERS **


42265 42268 42270 42271 42273 42275 42283

To top of page
General Information or Other Event Number: 42265
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GWINNETT MEDICAL CENTER
Region: 1
City: LAWRENCEVILLE State: GA
County: GWINNETT
License #: GA677-1
Agreement: Y
Docket:
NRC Notified By: LIZ R. SEALE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/18/2006
Notification Time: 07:34 [ET]
Event Date: 01/10/2006
Event Time: [EST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT

The State provided the following information via fax:

"On January 10, 2006, a patient was to receive an Iodine-131 therapy dose of 150 mCi (2 capsules). Upon review of the dose it was determined that the dose received was only 75 mCi (1 capsule)."

This incident was reported to the GA Radiation Control Program on 1/17/06. GA Incident Summary: GA-2006-03I.

To top of page
General Information or Other Event Number: 42268
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH SCIENCE CONSULTANTS
Region: 4
City: SALINAS State: CA
County:
License #: 6775-27
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/18/2006
Notification Time: 15:30 [ET]
Event Date: 01/21/2005
Event Time: [PST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)
BENJAMIN SANDLER (TAS)
MEXICO via fax ()

Event Text

AGREEMENT STATE REPORT OF MISSING MOISTURE DENSITY GAUGE

The State provided the following information via email:

"RSO for Earth Consultants, claims his company has broken up and his Alternate RSO has taken their single moisture density gauge. The gauge is a CPN model 503, source model 131 serial number H300305517. This information was first provided in a letter dated 1/21/05 and he has not been able to locate his former ARSO. RHB Richmond has determined that the former ARSO is probably located in Greenfield, CA. RHB will continue its efforts to locate the former RSO and the gauge. RHB Richmond has spoken to the RSO and suggested that he report the gauge as stolen by his former ARSO to the local authorities and request license termination."

These gauges typically contain 10 milliCi of Cs-137 and 40 milliCi 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.

To top of page
General Information or Other Event Number: 42270
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY
Region: 1
City: CHARLOTTE State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: J. MARION EADDY III
HQ OPS Officer: BILL GOTT
Notification Date: 01/18/2006
Notification Time: 17:38 [ET]
Event Date: 01/14/2006
Event Time: [EST]
Last Update Date: 01/18/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via fax:

"N.C. Radiation Protection Section was notified on 18 Jan 2006 by the RSO for the Charlotte Mecklenburg Hospital Authority of a misadministration during a manual brachytherapy treatment. The authorized user's written directive called for a temporary implant 'tandem and ovoid' using Cs-137 sources to deliver a total dose of 4883 RAD (approximately 49Gy) over 68 hours, with following source loading in the applicator:

"Right Ovoid: 1 at 14.6 mgRaEq [milligram Radium Equivalent] (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 14.6 mgRaEq

"A medical dosimetrist loaded the tandem and ovoid incorrectly. The actual loading of the applicator was:

"Right Ovoid: 1 at 14.6 mgRaEq (approximately 51.1 mCi or 1891 MBq)
Left Ovoid: 1 at 14.6 mgRaEq
Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 24.8 mgRaEq (approximately 86.8 mCi or 3212 MBq)

"This errant loading of applicator resulted in the patient receiving 6474 RAD (approximately 65 Gy) to the treatment area. The delivered dose was 33 percent more than prescribed.

"The Cs-137 sources utilized in the procedure were:

"3M Model 6503 (14.6 mgRaEq)
3M Model 6502 (11.2 mgRaEq)
AEA Technology/QSA Model CDC.T1 (24.8 mgRaEq)

"The licensee is conducting follow-up investigations and will make a report the Radiation Protection Section within 15 days of the discovery of the event. The report will contain root cause analysis and procedures to prevent recurrence.

"N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued."

Event Report ID No.: NC-06-04

To top of page
General Information or Other Event Number: 42271
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: COLUMBIA WEST ENGINEERING
Region: 4
City: VANCOUVER State: WA
County:
License #: WN-I0517-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/18/2006
Notification Time: 18:05 [ET]
Event Date: 01/12/2006
Event Time: [PST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT REGARDING A DAMAGED TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via email:

"ABSTRACT: The licensee states the gauge was in use near several construction vehicles [at a work site in Clackamas, Oregon]. The gauge was located behind a nearby pickup truck attached flatbed trailer. The gauge user thought the vehicles were not occupied. A driver in the truck started the vehicle and promptly backed it into the gauge before it could be moved by the operator, resulting in damage to the index rod. No other damage was noted. The licensee says the gauge operator was in proper control of the gauge at the time the truck struck the gauge. Regardless, the licensee will provide training to the operators reminding them of the requirements to maintain proper surveillance and control of gauges while away from the licensed storage locations. An explanation of what occurred in this event was also provided to the operators as lessons learned.

"Notification Reporting Criteria: WAC 246-221-250 Notification of Incidents.

"Isotope and Activity involved: 8 mCi of Cesium 137, and 40 mCi of Americium 241/Beryllium.

"Damaged Troxler 3430, serial number 31153.

"Disposition/recovery: The licensee was able to get the source rod back into the shielded position. They had a count rate survey meter and used it to determine that readings were normal. They called the manufacturer's local representative and the RSO for Troxler in North Carolina. The licensee was instructed on how to package the gauge properly. The gauge was taken back to the licensed and secured storage area where additional gauge packaging was used to secure the damaged index rod. They took a wipe test of the gauge. The results came back normal to allow for a normal means of shipping back to Troxler in North Carolina. Shipping is scheduled for January 19, 2004.

"Leak test? Leak test analysis - less than 0.005 microcuries.

"Release of activity? None found.

"Consultant used? Local Troxler representative and Troxler RSO.

Event Report # WA-05-006.

* * * UPDATE ON 01/20/06 * * *

The correct Washington Event report number is WA-06-006.

To top of page
General Information or Other Event Number: 42273
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CARDINAL HEALTH
Region: 4
City: HOUSTON State: TX
County:
License #: L01911
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/19/2006
Notification Time: 09:35 [ET]
Event Date: 01/18/2006
Event Time: [CST]
Last Update Date: 01/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT OF AN EXTREMITY EXPOSURE GREATER THAN LIMIT

The State provided the following information via email:

"A Nuclear Pharmacy Technician was preparing Tc-99m doses in a very busy pharmacy when his weekly extremity monitor reached an annual limit with a reading of 53,440 mrem for the calendar year of 2005. The licensee's corrective action includes additional training, possible modification of technique, and having corporate health physics staff investigate the incident. The dose was being monitored and management did not anticipate that the employee would exceed the maximum but he had a 'hard week' (12/26-01/06) where his right hand received 3,120 mrem. Corrective action will include hiring new techs since two other dose drawing techs have been 'benched' earlier in the year before their extremity doses would have exceeded the regulatory maximum. Reportedly the RSO and manager [redacted] did not receive the report until today. This is the 3rd busiest nuclear pharmacy in the world supplying ~1,000 doses/day to the greater Houston area. "

TX Event Report ID: TX-06-42273
TX Incident # I-8289

To top of page
General Information or Other Event Number: 42275
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SARASOTA MEMORIAL HOSPITAL
Region: 1
City: SARASOTA State: FL
County:
License #: 2219-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL GOTT
Notification Date: 01/19/2006
Notification Time: 17:02 [ET]
Event Date: 01/19/2006
Event Time: 13:00 [EST]
Last Update Date: 01/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRIS HOTT (R1)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST IODINE SEED

"Thirteen I-125 seeds were implanted in a patient on 1/11/2006 and removed on 1/18/2006. After removal, seeds were transferred to Hot Lab at which time it was discovered that one of the seeds [1.43 millicuries I-125] was missing. All seeds were moved from patient. A search was conducted of the O.R., the patient and the traverse route. The seed has not been found at this time. The licensee stated that a doctor rinsed the item containing the sources in the sink in the O.R., and that it is possible that the missing source was rinsed down the drain. Florida is investigating."

Incident Number: FL06-012

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.

To top of page
Power Reactor Event Number: 42283
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: COY BLAIR
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/23/2006
Notification Time: 17:00 [ET]
Event Date: 01/23/2006
Event Time: 12:40 [CST]
Last Update Date: 01/23/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
BLAIR SPITZBERG (R4)
LAWRENCE KOKAJKO (NMSS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOST AMERICIUM SOURCES

The station commenced an inventory of sources in December 2005. Two sources were missing and are still unaccounted for. The licensee suspects that the sources were thrown away in radioactive trash. The two americium-241 sources were 0.025 microCuries and 0.026 microCuries. The sources were purchased in 1981 and had since been retired from use and placed in storage.

The licensee will notify the NRC Resident Inspector.

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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