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Event Notification Report for July 26, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/25/2007 - 07/26/2007

** EVENT NUMBERS **


43506 43509 43512 43513

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General Information or Other Event Number: 43506
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SOUTH TEXAS CARDIOVASCULAR CONSULTANTS, PLLC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L03833-003
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/19/2007
Notification Time: 14:16 [ET]
Event Date: 07/18/2007
Event Time: 15:50 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF TEXAS

"On 07/18/07 at 3:50 pm, the agency received a telephone call from (deleted), the Chief Tech for the licensee, reporting the misadministration of patient involving Thallous Chloride. The nuclear medicine tech reported that a patient was injected twice with a total of 4mCi of Thallous Chloride.

"The licensee reported that the patient was informed the same day of the misadministration.

"Licensee was informed that the 30-day report is due 08/17/07."

Agency Action Taken: The licensee will submit the required written report within 30-days as per 25 Texas Administrative Code (TAC) 289.202(xx).

Texas Incident number: I-8427


* * * UPDATE PROVIDED BY CINDY FLANNERY TO JEFF ROTTON AT 0741 ON 07/24/07 * * *

This event (EN43506) has been reviewed and determined to NOT be a reportable medical event.

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General Information or Other Event Number: 43509
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON-DICKINSON INFUSION THERAPY SYSTEM, INC
Region: 4
City: BROKEN BOW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: DEFRAIN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/20/2007
Notification Time: 17:28 [ET]
Event Date: 07/19/2007
Event Time: 12:00 [CDT]
Last Update Date: 07/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY GODY (R4)
E. WILLIAM BRACH (FSME)

Event Text

AGREEMENT STATE REPORT FROM THE STATE OF NEBRASKA


On 07/20/07 at 1445 CDT the Radiation Safety Officer for Becton-Dickinson Infusion Therapy System, Inc Pool Irradiator located in Broken Bow reported a component failure at the Pool Irradiator.

The irradiator was operating on 07/19/07 when one of the totes carrying medical supplies to be sterilized became jammed in the irradiator. The alarm sounded as expected. The source of the Pool Irradiator went back to its shielded position, lowered back into the pool. The Control Panel for the pool irradiator did not indicate, light did not come on, that the source had gone back into the pool. The licensee went to the penthouse, above the irradiator pool, and found that there was no extra cable in the penthouse which indicated the source had gone to its safe position, entered the pool. Radiation readings taken in the penthouse also indicated that the source was in the pool.

The licensee tried to unlock the door to enter the maze to unjam the tote but they were unable to unlock the door because the control panel indicated that the source had not gone to its safe position.

The licensee then called MDS Nordion, manufacturer of the irradiator and owner of the irradiator fuel, and informed them of the problem. MDS Nordion informed them how to over ride the access system. After three tries they successfully over rode the access system, required 3 people at 3 different locations at the same time to over ride the system. After opening the access door 2 people with 2 separate radiation survey meters entered the maze. Normal background radiation levels were detected. It was found that the control switch indicating that the source was in its safe position was not in its correct position, down. The switch was replaced.

As of 07/20/07 the Pool Irradiator is operating.

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General Information or Other Event Number: 43512
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GREENHORN AND OMARA, INC
Region: 1
City: LAUREL State: MD
County:
License #: MD-33-047-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/23/2007
Notification Time: 10:58 [ET]
Event Date: 07/23/2007
Event Time: 07:00 [EDT]
Last Update Date: 07/23/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAT FINNEY (R1)
MICHELE BURGESS (FSME)
ILTAB (via email) ()

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

Event Text

MARYLAND AGREEMENT STATE REPORT - STOLEN TROXLER

At 1000 EDT on 07/23/07, the licensee notified the State of Maryland of a Troxler moisture density gauge that was stolen from a trailer at a temporary job site located at 11540 Berry Road, Waldorf, MD. The gauge is a Model 3430, serial # 22355, with an 8 millicurie Cs-137 source and a 40 millicurie Am-241:Be source. While the gauge was in storage, the source rod was locked, the gauge case was locked, and the gauge was stored in a locked trailer on the temporary job site. The local police have been notified and are investigating. The State of Maryland will issue a press release on 07/24/07 if the gauge is not recovered.

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: 43513
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MCNDT LEASING INC
Region: 3
City: DARIEN State: IL
County:
License #: IL-01875-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JASON KOZAL
Notification Date: 07/23/2007
Notification Time: 15:36 [ET]
Event Date: 07/20/2007
Event Time: 08:00 [CDT]
Last Update Date: 07/23/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - STUCK RADIOGRAPHY CAMERA SOURCE

"On the morning of July 20, [DELETED], RSO for McNDT, called. He was taking some radiographs while inside a water tower in Darien, IL and the magnetic cable stand used to hold the film cartridge fell over onto the cable and crushed the guide tube. He reported that he could not retract the source to the shielded position in the camera. The source is a 34 Ci Ir-192 source; the camera is a QSA 660B. The scene was secured and under constant oversight by the RSO. [DELETED] reported that there have been no overexposures or any injuries. [DELETED] estimated that some 6 inches of guide tube used to position the radiography source had been crushed/deformed by equipment that had been used to position the radiography source 8 feet high up against the wall of the tank. The guide tube was then stretched straight along the floor of the water tower which is approximately 50 feet in diameter. The damaged section of the tube was approximately 30 inches from the end of the 14 foot length of guide tube. A 'hot zone' barrier required by regulations was established around the water tower before the radiography job was begun. Dose rates around that zone were less than 60 milliR/hr. The water tower is near the intersection of Plainfield and Cass Avenues in Darien behind a retail shopping area. As the area is a construction area, there is fencing surrounding the work site so control of the scene has been relatively easy to maintain.

"Upon arrival at the scene, the investigators added bags of lead shot to the area where the source was determined to be. The drive cables and crank were then physically secured with the camera and a strong force was applied to the cranking mechanism. This resulted in the successful return of the cable with the Ir-192 source back into the radiography camera. Afterwards, the guide tube was surveyed and found to be free of contamination. The camera ports were likewise monitored with negative removable contamination present. The device (AEA QSA, Inc. model 660B w/ S/N B2020) has been secured and tagged as out of service until it can be returned to the manufacturer for source exchange and recertification. Surface dose rates on the radiography camera were at the expected 5 to 10 milliR/hr. Total exposures to personnel as measured by pocket dosimeters were very low (70 milliR to the RSO, 60 milliR to [DELETED] and 55 milliR to [DELETED]). [DELETED] was advised of our expectations for return of the potentially damaged source cable and the need to send in his own dosimetry in for immediate analysis to confirm the measured exposure prior to our staffs' arrival."

Illinois Item Number: IL070040

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Thursday, March 29, 2012