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Event Notification Report for October 26, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/25/2007 - 10/26/2007

** EVENT NUMBERS **


43731 43734 43739 43744 43748

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General Information or Other Event Number: 43731
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-3385-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2007
Notification Time: 09:55 [ET]
Event Date: 09/24/2007
Event Time: [CDT]
Last Update Date: 10/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING AN IMPROPER INJECTION

The following information was received from the Louisiana Department of Environmental Quality via fax:

"On September 24, 2007, a customer called the pharmacy to inform them that a Tc-99m mertiatide prescription for renal imaging showed no renal distribution and instead showed only liver distribution. After an investigation by the licensee, it was determined that the error occurred in the pharmacy and all customers who could have been affected by the event were notified. Only one of the patients was injected. The radiation dose to the patient involved was minimal. Procedures not followed is the root cause of this incident. The corrective actions for this incident include retraining on policy and procedures regarding compounding doses.

"Event Report ID No.: LA070028"

* * * UPDATE PROVIDED BY CINDY FLANNERY (FSME) TO JEFF ROTTON AT 1243 ON 10/19/07 * * *

This event (EN43731) has been reviewed and determined to not meet the definition of a medical event.

Notified R4DO (Proulx) and FSME EO (Flannery).

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General Information or Other Event Number: 43734
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA HOSPITAL
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: JOE O'HARA
Notification Date: 10/19/2007
Notification Time: 18:43 [ET]
Event Date: 10/19/2007
Event Time: 04:00 [CDT]
Last Update Date: 10/19/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3)
MICHAEL TSCHILTZ (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE GREATER THAN 50 REM

A patient intervened during a vaginal iridium seed implant treatment by removing one of the needles from her body. The needle was found by a nurse approximately 30 minutes after it had been removed by the patient. The needle was located at the foot of the bed near the patients right foot and ankle. The doctor directed the nurse to place the source back into the pig. There were six sources in the needle. Total activity is 7 milliCuries of Ir-192. The estimated dose to the nurses hand was 13 milliRem, and she was wearing a whole body dosimeter, which is being examined. The estimated dose to the patients right ankle is 4.6 to 165 Rem. The patient will be monitored for acute radiation signs. The patient is in the process of receiving the planned dose.

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.

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General Information or Other Event Number: 43739
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOMAT TESTING LABS., INC.
Region: 4
City: RIVERSIDE State: CA
County:
License #: 5735-33
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/22/2007
Notification Time: 14:21 [ET]
Event Date: 10/15/2007
Event Time: 17:30 [PDT]
Last Update Date: 10/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
MICHELE BURGESS (FSME)
ILTAB (EMAIL) ()
MEXICO (EMAILED) ()

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

Event Text

CALIFORNIA AGREEMENT STATE REPORT

Received the following information via e-mail:

"On October 22, 2007, a letter, dated 10/17/07, was received from Haytham (deleted), RSO, reporting a stolen nuclear gauge (Troxler 3400 Series, S/N 14411). The incident happened on 10/15/07 at San Bernardino County. According to the incident report, the nuclear gauge was taken to Southwest Calibration in San Bernardino for repair. After the repair, at about 5:30 pm, the field technician stopped at an automobile garage in San Bernardino to have the company truck tail light repaired. The nuclear gauge metal box was bolted close to the tail light access location and was asked by the shop technician to remove the box so they can repair the tail light. The metal box was placed on the side near the waiting room. Then, the technician went inside the waiting room. After the tail light was repaired, the technician went outside and did not find the nuclear gauge.

"The technician called the RSO and left a message. The incident was reported to San Bernardino County Sheriff's Office (Police Report # 030705898) and an ad was placed in the 'SUN', San Bernardino newspaper for seven days.

"RHB - South RAM office will investigate this incident."



5010 Number (Date Notified): 102207

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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Other Nuclear Material Event Number: 43744
Rep Org: MEAD JOHNSON & COMPANY
Licensee: MEAD JOHNSON & COMPANY
Region: 3
City: EVANSVILLE State: IN
County:
License #: 13-00772-02
Agreement: N
Docket:
NRC Notified By: CHAD BURNETT
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/25/2007
Notification Time: 10:25 [ET]
Event Date: 10/11/2007
Event Time: [EDT]
Last Update Date: 10/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
DAVID HILLS (R3)
GREG MORELL (FSME)
ILTAB EMAIL ()

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

Event Text

MISSING N-63 FOIL SOURCE DETECTORS

Back in 1992 licensee had four detectors stored at their facility in Evansville, IN. These 4 detectors had Ni-63 foil sources with activity of 15 milliCuries each. The model/serial number of these detector are 18803-60520/C2141; 18803-60520/C0844; 18713A/83047; and 19312/S11091. About September 2007 the licensee went to retrieve these electron capture detectors, however, they could not find them. The licensee contacted Hewlett Packard (HP) and asked if they had the missing detectors. HP said they did not. After several weeks of searching , the Licensee believed that the missing detectors are a result of inventory accountability, rather than an actual theft.

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: 43748
Rep Org: ENERTECH
Licensee: ENERTECH
Region: 4
City: BREA State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEVIN McKOWN
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/25/2007
Notification Time: 19:10 [ET]
Event Date: 10/25/2007
Event Time: [PDT]
Last Update Date: 10/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CHUCK CAIN (R4)
ROBERT HAAG (R2)
VERN HODGE (email) (NRR)

Event Text

POTENTIAL 10CFR PART 21 REPORTABLE CONDITION FOR ENERTECH CARTRIDGE SOLENOID VALVE

The following notification was received via fax:

"This submittal provides initial notification to your office that we have opened an evaluation for a potential reportable condition under 10CFR Part 21. Based on technical data provided by the San Onofre Power Plant, two (2) Enertech normally energized, normally open, cartridge solenoid valves, part number C9113S, installed on PME dump valves have not operated within the closure time design parameters. Upon investigation SCE determined higher than expected levels of contamination, internal oxidation and pitting collectively effected the valves response time. This valve was introduced to the industry in Dec 2004. Enertech is working closely with plant personnel to determine the cause of this condition, determine a resolution, and prepare a formal Evaluation Report within the next 50 days. If at any time during the evaluation process, a defect is discovered, we will provide an amended notification to this communication.

"No other Power Plants have reported similar problems to Enertech. The solenoid valve under evaluation has multiple safety related applications. The following plants will be contacted if a reportable condition exists: SCE, STP, KHNP, Entergy (Waterford), and Dominion (Surry)."

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