Event Notification Report for September 10, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/09/2007 - 09/10/2007
General Information or Other
Event Number: 43628
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: AMERICAN ENGINEERING AND TESTING
Region: 3
City: DEXTER State: MN
County:
License #: MN07005
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: JASON KOZAL
Licensee: AMERICAN ENGINEERING AND TESTING
Region: 3
City: DEXTER State: MN
County:
License #: MN07005
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: JASON KOZAL
Notification Date: 09/10/2007
Notification Time: 15:53 [ET]
Event Date: 09/10/2007
Event Time: 03:00 [CDT]
Last Update Date: 09/10/2007
Notification Time: 15:53 [ET]
Event Date: 09/10/2007
Event Time: 03:00 [CDT]
Last Update Date: 09/10/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SONIA BURGESS (R3)
MICHELLE BURGESS (FSME)
SONIA BURGESS (R3)
MICHELLE BURGESS (FSME)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The State provided the following information via email:
"On Monday, September 10, 2007, the Minnesota Department of Health (MDH) was notified by American Engineering and Testing that a fire had destroyed a Troxler Model 3430 moisture density gauge. The fire occurred at a private residence, which was a farm, and spread to a pick-up truck that was parked beside the garage to that residence. The fire melted the plastic components of the gauge but did not effect the Cesium-137 source in the source rod or the Americium-241:Beryllium source that was in the lead shielding. Members of the Fire Department who responded to the fire were instructed to maintain a safe distance from the truck to avoid minimize radiation exposures.
"MDH completed radiation and contamination surveys of both sources. No contamination was detected and the radiation levels were as would be expected with the shielding intact. The sources were placed in containers filled with sand to provide shielding and removed to a secure permanent storage location. The RSO and the Corporate RSO will complete leak tests and arrange for the appropriate containers for shipment to the manufacturer.
"The gauge was a Troxler Model 3430, Serial Number 23279, which contained approximately 9 millicuries of Cesium-137 (Serial Number 75-5294) and 44 millicuries of Americium-241:Be (Serial Number 47-19161)."
Minnesota Report number: MN07005
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.
The State provided the following information via email:
"On Monday, September 10, 2007, the Minnesota Department of Health (MDH) was notified by American Engineering and Testing that a fire had destroyed a Troxler Model 3430 moisture density gauge. The fire occurred at a private residence, which was a farm, and spread to a pick-up truck that was parked beside the garage to that residence. The fire melted the plastic components of the gauge but did not effect the Cesium-137 source in the source rod or the Americium-241:Beryllium source that was in the lead shielding. Members of the Fire Department who responded to the fire were instructed to maintain a safe distance from the truck to avoid minimize radiation exposures.
"MDH completed radiation and contamination surveys of both sources. No contamination was detected and the radiation levels were as would be expected with the shielding intact. The sources were placed in containers filled with sand to provide shielding and removed to a secure permanent storage location. The RSO and the Corporate RSO will complete leak tests and arrange for the appropriate containers for shipment to the manufacturer.
"The gauge was a Troxler Model 3430, Serial Number 23279, which contained approximately 9 millicuries of Cesium-137 (Serial Number 75-5294) and 44 millicuries of Americium-241:Be (Serial Number 47-19161)."
Minnesota Report number: MN07005
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.
General Information or Other
Event Number: 43629
Rep Org: INDIANA STATE DEPT OF TRANSPORATION
Licensee: INDIANA STATE DEPT OF TRANSPORATION
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-26341-01
Agreement: N
Docket:
NRC Notified By: FRANK THOMAS JOHN
HQ OPS Officer: JOHN KNOKE
Licensee: INDIANA STATE DEPT OF TRANSPORATION
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-26341-01
Agreement: N
Docket:
NRC Notified By: FRANK THOMAS JOHN
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/11/2007
Notification Time: 10:53 [ET]
Event Date: 09/10/2007
Event Time: 08:30 [EDT]
Last Update Date: 09/11/2007
Notification Time: 10:53 [ET]
Event Date: 09/10/2007
Event Time: 08:30 [EDT]
Last Update Date: 09/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
SONIA BURGESS (R3)
CINDY FLANNERY (FSME)
ILTAB email
SONIA BURGESS (R3)
CINDY FLANNERY (FSME)
ILTAB email
STOLEN TROXLER GAUGE
On the morning of 09/10/07 the licensee [DELETED] was getting ready to calibrate a Troxler Moisture Density Gauge (Model 3440). The gauge (s/n 22678) was in the back of the company truck on the calibration block. The employee left the truck for 3-5 minutes to use the restroom and when he returned the gauge was gone. The sources in the Troxler gauge are Am-241/Be (40 mCi), and Cs-137 (8 mCi). The employee contacted his supervisor, who in turn contacted the State police (Report # 52-44047). Within 90 minutes the gauge was found in a vacant lot about a mile from the job site. The gauge was checked and found undamaged with the sources in the safe position. No one saw who might have taken the gauge from the truck.
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.
On the morning of 09/10/07 the licensee [DELETED] was getting ready to calibrate a Troxler Moisture Density Gauge (Model 3440). The gauge (s/n 22678) was in the back of the company truck on the calibration block. The employee left the truck for 3-5 minutes to use the restroom and when he returned the gauge was gone. The sources in the Troxler gauge are Am-241/Be (40 mCi), and Cs-137 (8 mCi). The employee contacted his supervisor, who in turn contacted the State police (Report # 52-44047). Within 90 minutes the gauge was found in a vacant lot about a mile from the job site. The gauge was checked and found undamaged with the sources in the safe position. No one saw who might have taken the gauge from the truck.
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.
Hospital
Event Number: 43630
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MAC RICHARD
HQ OPS Officer: JOE O'HARA
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MAC RICHARD
HQ OPS Officer: JOE O'HARA
Notification Date: 09/11/2007
Notification Time: 16:03 [ET]
Event Date: 09/10/2007
Event Time: 11:20 [EDT]
Last Update Date: 09/13/2007
Notification Time: 16:03 [ET]
Event Date: 09/10/2007
Event Time: 11:20 [EDT]
Last Update Date: 09/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
SONIA BURGESS (R3)
JACK DAVIS (FSME)
SONIA BURGESS (R3)
JACK DAVIS (FSME)
MEDICAL EVENT - PATIENT RECEIVED AN UNDERDOSE OF YTTRIUM-90
On Monday 9/10/07, the licensee was administering a 66 millicurie dose of Yttrium-90 microspheres to a patient for the treatment of liver cancer through a catheter. The patient only received a dose of 47 millicuries, a 27% underdose. The licensee is investigating the cause of the misadministration, but they believe the catheter used for the administration of the isotope failed or is leaking. The licensee believes there is no permanent functional damage to the patient. The physicians have been informed by the RSO that they need to notify the patient of the underdose and report that notification to the RSO. The treatment device is from MDS Nordion and a MDS Nordion company representative was on site during the administration of the isotope. The licensee intends to use the MDS Nordion representative for technical assistance in troubleshooting this problem once background radiation levels permit a closer inspection of the catheter.
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.
* * * UPDATE PROVIDED BY CINDY FLANNERY (FSME) TO JASON KOZAL ON 9/13/07 AT 1352 * * *
This event (EN43630) has been reviewed and determined to be a reportable medical event.
On Monday 9/10/07, the licensee was administering a 66 millicurie dose of Yttrium-90 microspheres to a patient for the treatment of liver cancer through a catheter. The patient only received a dose of 47 millicuries, a 27% underdose. The licensee is investigating the cause of the misadministration, but they believe the catheter used for the administration of the isotope failed or is leaking. The licensee believes there is no permanent functional damage to the patient. The physicians have been informed by the RSO that they need to notify the patient of the underdose and report that notification to the RSO. The treatment device is from MDS Nordion and a MDS Nordion company representative was on site during the administration of the isotope. The licensee intends to use the MDS Nordion representative for technical assistance in troubleshooting this problem once background radiation levels permit a closer inspection of the catheter.
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.
* * * UPDATE PROVIDED BY CINDY FLANNERY (FSME) TO JASON KOZAL ON 9/13/07 AT 1352 * * *
This event (EN43630) has been reviewed and determined to be a reportable medical event.