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Event Notification Report for August 3, 2007

U.S. Nuclear Regulatory Commission
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Event Reports For
08/03/2007 - 08/03/2007

** EVENT NUMBERS **


43539 43540

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General Information or Other Event Number: 43539
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSEN LUTHERAN MEDICAL CENTER
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/31/2007
Notification Time: 15:40 [ET]
Event Date: 07/16/2007
Event Time: 12:00 [CDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3)
DENNIS RATHBUN (FSME)

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

Event Text

AGREEMENT STATE REPORT FROM WISCONSIN - LOSS OF TWO PALLADIUM-103 SEEDS

RSO telephoned DHFS July 31, 2007.

"The RSO notified DHFS by telephone of the possible loss of two Pd-103 implant seeds. The two seeds were unaccounted for following a July 16, 2007 prostate seed implant procedure.

"During the procedure, the Physicist was making the strands using the BARD QuickLink system. About half way through the case he made a relatively long link. When the authorized User tried to load this link it was easily traveling through the implant needle so he retracted it and emptied the entire strand on the OR table backwards through the needle. A new link was made and properly implanted into the patient. Because they needed to use nearly all the ordered seeds for the procedure, the Physicist attempted to take apart the problem link using a pair of tweezers. This required some force to separate the links and seeds. While doing this at least two of the links separated and 'flew' off the table. The past experience with seeds falling in the operating room was that they were relatively easy to find immediately post procedure with the survey meter, so they completed the implant. The on-going inventory indicated there would be 5 leftover seeds. Multiple surveys of the operating room resulted in the recovery of 3 seeds. Surveys of all bed linens were conducted, no additional seeds were located."

The patient be returning to the facility for routine post implant CT imaging. The implant seed count will be repeated at that time.

Event Report ID No.: WI070015


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: 43540
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: DBA WELDSONIX INC
Region: 3
City: ROME State: WI
County:
License #: TX L05718
Agreement: Y
Docket:
NRC Notified By: KURT PEDERSEN
HQ OPS Officer: JOE O'HARA
Notification Date: 07/31/2007
Notification Time: 16:07 [ET]
Event Date: 07/31/2007
Event Time: [CDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3)
SANDLER ILTAB ()
DENNIS RATHBUN (FSME)

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

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOACTIVE MATERIAL

"On July 31, 2007, the licensee notified DHFS of the theft of a control device for a Masterminder 2 x-ray crawler. It has been stored in a locked storage trailer at a temporary jobsite located a few miles north of Rome, WI. The lock had been cut, and other equipment had been stolen. The device contains a Cs-137 source with an approximately activity of 126.5 mCi. Local law enforcement and the Federal Bureau of Investigation have been notified, and are investigating. State and local emergency management have been notified, and a DHFS emergency responder has been dispatched to the site.

"The company was doing radiography on a natural gas pipeline. WeldSonix has provided a picture of the device.

"DHFS is planning on issuing a press release."

The state indicated that the device was 25 years old, and the activity level should be reduced by one half-life.

"Event Report ID No.: WI 07-0014"

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

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