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Event Notification Report for August 17, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/16/2006 - 08/17/2006

** EVENT NUMBERS **


42765 42768

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General Information or Other Event Number: 42765
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEO TEK, INC
Region: 4
City: VISTA State: CA
County: SAN DIEGO
License #:
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JASON KOZAL
Notification Date: 08/11/2006
Notification Time: 14:36 [ET]
Event Date: 08/11/2006
Event Time: [PDT]
Last Update Date: 08/11/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSSELL BYWATER (R4)
CINDY FLANNERY (NMSS)
ILTAB E-MAIL ()
MEXICO VIA FAX ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The State provided the following information via email:

"The RSO called RHB this morning to report a missing gauge that he believes was stolen. He personally had placed the gauge in the locked storage location in Vista, CA on Wednesday, August 2, 2006. The gauge user that normally uses this gauge states he used a different one on August 3 - 4, 2006, but did not sign the in and out log on those two days. That user was on vacation Monday and Tuesday. On Wednesday and Thursday August 9 - 10, he did sign out a different gauge. On August 9, that user asked the RSO what had happened to the gauge he normally used. The RSO said it was either in the storage locker, or someone else had checked it out. The RSO decided to perform a full inventory of the gauges on Friday morning, the 11th. It was at this point that the RSO discovered that gauge was missing. The storage location is locked, and the gauges are stored in a locked area within that location. Nothing else was apparently taken, although there are several other gauges stored there. The RSO reported this to the San Diego County Sheriff's Office, who will be investigating. The RSO also stated he would post a reward in a local paper. The RSO has contacted all the gauge users, and they state they have no information about the whereabouts of this gauge. The gauge is a Troxler, Model 3440, with a nominal 9 mCi Cs-137 and 44 mCi Am-241. RHB will follow up with the licensee."

The licensee will post reward in either San Diego Union Tribune or North County Times.

* * *UPDATE PROVIDED BY HAMERICK TO KOZAL VIA E-MAIL ON 8/11/06 AT 1808* * *

"Earlier today the California Radiologic Health Branch (RHB) provided a report regarding a stolen moisture-density gauge from Geo Tek, Inc. The RSO from Geo Tek just called, and the gauge had been taken out three days ago by an authorized technician who failed to record it being checked out on the daily log. As of now, all gauges owned by Geo Tek are accounted for and in their locked storage area. RHB will follow up with the licensee regarding the potential procedural violations."

Notified R4DO (Gody), NMSS (Holahan), ILTAB (e-mail), Mexico (via fax)

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.

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General Information or Other Event Number: 42768
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NORTH OAKS RADIATION CENTER
Region: 4
City: THOUSAND OAKS State: CA
County:
License #: 3693-56
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/14/2006
Notification Time: 19:19 [ET]
Event Date: 08/09/2006
Event Time: [PDT]
Last Update Date: 08/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE - MEDICAL EVENT

The State provided the following information via email:

"On August 11, 2006, RHB received notification from North Oaks Radiation Center of a potential medical event. On August 9, 2006, a patient was undergoing the third of three fractional doses from a Nucletron Model MicroSelectron-HDR Classic Afterloader, using Ir-192. The first two fractions had been delivered properly. When this fraction was delivered, the medical physicist inadvertently selected the wrong delivery tube. There are two delivery tubes available depending upon the treatment plan. In this case, the longer tube was incorrectly selected for this fraction, and the source remained outside the patient for the entire fraction. The preliminary estimate of the highest dose in this configuration was approximately 100 - 125 rads to the perineum, which was not the intended treatment site, and which would have received less than 50 rads with the intended configuration. The patient has been notified. The California Radiologic Health Branch will investigate this incident."

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