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Event Notification Report for March 21, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/20/2007 - 03/21/2007

** EVENT NUMBERS **


42819 43241 43251 43252

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Other Nuclear Material Event Number: 42819
Rep Org: ALASKA INDUSTRIAL X-RAY, INC
Licensee: ALASKA INDUSTRIAL X-RAY, INC
Region: 4
City: ANCHORAGE State: AK
County:
License #:
Agreement: N
Docket:
NRC Notified By: PETE MILLAR
HQ OPS Officer: JASON KOZAL
Notification Date: 08/31/2006
Notification Time: 14:36 [ET]
Event Date: 08/31/2006
Event Time: 10:30 [YDT]
Last Update Date: 03/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MICHELLE BURGESS (NMSS)
CHUCK CAIN (R4)

This material event contains a "Category 3" level of radioactive material.

Event Text

LOST RADIOGRAPHY CAMERA ON WAKE ISLAND

The licensee reported a loss of a 10 Ci [based on source decay starting December of 2005] IR-192 radiography camera on Wake Island. In preparation for evacuation of the island on 8/29/2006 the camera was loaded in a type B(U) storage container. On 8/30/2006 Super Typhoon Yoke made land fall on Wake Island producing 150 mph winds and 30 - 40 ft storm surge. The status of the camera is unknown due to the uncertain condition of Wake Island. There currently is no information of the habitability of Wake Island and thus it is uncertain when a search can be conducted.

The licensee will update the status of the material as more information becomes available.

* * * UPDATE ON 09/25/06 AT 1300 ET BY PETE MILLAR TO MACKINNON * * *

Per Pete Millar the US NAVY landed on Wake Island and the CONEX shipping container, in which the Industrial Nuclear Radiography Camera is stored, is still on the island and it has not been opened. In about 2 weeks a barge will leave Wake Island to ship the CONEX shipping container back to Alaska Industrial X-Ray. Mr. Millar said that they should have Industrial radiography camera back in their possession in about 3 weeks.

R4DO (Zach Dunham) & NMSS EO (Greg Morell) notified.

* * * UPDATE ON 03/20/07 AT 1346 EDT FROM PETE MILLAR TO MACKINNON * * *

Alaska Industrial X-Ray, regained possession of their radiography camera on 12/15/06.

R4DO (Greg Pick) & FSME (Greg Morell) notified.


THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example, level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event.

Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3"

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General Information or Other Event Number: 43241
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: GEOTECHNICAL ENVIRONMENTAL CONSULTANTS
Region: 4
City: PHOENIX State: AZ
County:
License #: 07-402
Agreement: Y
Docket:
NRC Notified By: WILLIAM WRIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/15/2007
Notification Time: 13:45 [ET]
Event Date: 03/14/2007
Event Time: 17:30 [MST]
Last Update Date: 03/16/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT ON DAMAGED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"At approximately 8:30 AM, March 15, 2007, the Agency was informed that a Density Moisture Gauge had been run over by a large steel compacting roller which crushed the gauge. This had occurred at approximately 5:30 PM on March 14, 2007. It appeared that when it occurred, the operating rod was in the safe position and the source was shielded. During the attempt to retrieve the gauge, the source fell out of the shielded position and the internal sources fell out of the capsule. These were retrieved from the site and placed along with the crushed gauge into the transport container and returned to the office of the licensee. Wipe tests were taken and no spreadable contamination was noted.

"The Agency is currently inspecting the licensee and will continue follow-up evaluations as necessary. "

State Report # 07-05

* * * UPDATE FROM THE STATE OF ARIZONA (VIA FAX) TO HUFFMAN AT 14:04 EDT ON 3/16/07 * * *

"The Agency performed an inspection of the broken gauge and source at the licensee's office on the morning of March 15, 2007. The broken gauge and source were removed from the Troxler transport case and the broken Cs-137 source and AmBe/241 source were examined and wipe tested. The sources and broken gauge were returned to the transport case, stored in the gauge storage room with additional shielding material placed around it and locked up awaiting shipping and transport containers from Troxler. A field survey of the site where the gauge was run over was conducted again and no radioactive material was detected. Initial wipe test data from the two sources indicates no spreadable radioactive contamination. Discussion with the licensee indicates that exposure to the gauge technician during source retrieval was minimized."

R4DO (Shannon) and FSME EO (Giitter) notified.

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Other Nuclear Material Event Number: 43251
Rep Org: UNDERWOOD ENGINEERING
Licensee: UNDERWOOD ENGINEERING
Region: 1
City: BELMAR State: NJ
County:
License #: 29-23425-01
Agreement: N
Docket:
NRC Notified By: PATRICIA BEMESDERFER
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/20/2007
Notification Time: 07:41 [ET]
Event Date: 03/19/2007
Event Time: 17:00 [EDT]
Last Update Date: 03/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MEL GRAY (R1)
GREG MORELL (FSME)
ILTAB (email) ()

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

Event Text

STOLEN TROXLER MOISTURE DENSITY GAUGE

Licensee's truck was parked at worksite from 0930 until 1700 EDT on 03/19/07 with the gauge triple locked in the bed of the truck the entire day. When the licensee's employee was leaving the worksite at the end of the workday, it was noticed that the gauge was missing. The worksite is located Audenreid High School, 3301 Tasker Street, Philadelphia, PA. The Philadelphia Police Department was notified (Report # 07-17-011252). The gauge is a Troxler, Model 3430, Serial Number 030500 with a Cs-137 8 millicurie source, and an Am-241:Be 40 millicurie source.

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: 43252
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: DOCTORS HOSPITAL, INC
Region: 1
City: CORAL GABLES State: FL
County:
License #: 3823-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/20/2007
Notification Time: 10:57 [ET]
Event Date: 03/05/2007
Event Time: [EDT]
Last Update Date: 03/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE - MEDICAL EVENT RELATED TO DOSE LESS THAN 20% PRESCRIBED

"Upon quality review a misadministration was discovered by hospital staff on March 3, 2007; the actual medical procedure was performed on January 23, 2007. It is estimated that patient was administered a dose less than 20% of the intended dose. State was notified on 19 March 2007. This incident is referred to [the State's] radioactive materials [office] for investigation."

The misadministration involved a Gamma Knife. A quality review by the licensee confirmed that a treatment dose was prescribed as
- 40% of maximum dose equivalent equals 11Gy; but was calculated as - 50% of maximum dose equals 11Gy.

This discrepancy resulted in the administration of a dose that was 20% less than intended.

State Report FL07-046

* * * Update on 03/20/07 at 1408 EDT via e-mail from FSME (C. Flannery) to MacKinnon * * *

This event has been reviewed and determined to be a medical event. Immediate release to the public is authorized.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012