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Event Notification Report for December 7, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/06/2007 - 12/07/2007

** EVENT NUMBERS **


43818 43819 43822 43826

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General Information or Other Event Number: 43818
Rep Org: NV DIV OF RAD HEALTH
Licensee: CITY OF HENDERSON, NV
Region: 4
City: HENDERSON State: NV
County:
License #: 03-14-0116-01
Agreement: Y
Docket:
NRC Notified By: ERIC MATUS
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/03/2007
Notification Time: 12:56 [ET]
Event Date: 11/27/2007
Event Time: 13:30 [PST]
Last Update Date: 12/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
MICHELE BURGESS (FSME)
ILTAB (VIA EMAIL) ()

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

Event Text

NEVADA AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

"At approximately 1330 [PST] on Tuesday November 27, 2007, a technician and asst. RSO for the City of Henderson NV, drove away from a jobsite where he had been taking a backscatter density measurement with a Troxler 3440 Nuclear Density Gauge. He left the gauge sitting on the side of the road with the probe unlocked and not in a safe mode. At 1333, he returned to the site to find that the gauge had been removed. The RSO filed a report with Henderson PD [on 11/27/07] and phoned in a report to Nevada Radiological Health Section the following day [11/28/07] at 1010. The gauge [Serial #26655] contains [2] sealed sources: 8 milliCuries Cs-137, and 40 milliCuries Am-241/Be ."

The licensee issued a press release (print, radio, and TV) to notify the public of the incident, warn them of the potential danger and ask for the return of the gauge.

Nevada Item Number: NV070009

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: 43819
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LONGMONT UNITED HOSPITAL
Region: 4
City: DENVER State: CO
County:
License #: 73-01
Agreement: Y
Docket:
NRC Notified By: JENNIFER OPILA
HQ OPS Officer: JOE O'HARA
Notification Date: 12/03/2007
Notification Time: 15:21 [ET]
Event Date: 08/08/2007
Event Time: 08:00 [MST]
Last Update Date: 12/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE NOTIFICATION - MEDICAL EVENT INVOLVING IODINE 125 SEEDS

The State provided the following information via facsimile:

"On August 8, 2007 a patient presented to Longmont United Hospital, Colorado Radioactive Materials license #73-01, for implantation of I-125 seeds into the prostate for treatment of adenocarcinoma of the prostate. The Authorized User was Radiation Oncologist [DELETED], MD; the surgeon was [DELETED], MD; the Authorized Medical Physicist was [DELETED], MS.

"In the course of the operative procedure, some seeds were placed inferior to the prostate rather than into the gland itself. Due to the misplacement of the seeds, the total dose to the prostate differed from the prescribed dose by more than 20%.

"The prescribed dose to the prostate was 160 Gy. A total of 63 0.476U Bard Model STM 1251 [seeds] were implanted. [Total activity 0.3 milliCurie per seed]. Post-implant dosimetry was performed, based on a CT scan of pelvic region. The mean dose to the prostate was 14.4 Gy, the mean dose to the rectum was 44.7 Gy, and the mean dose to the urethra was 73.4 Gy. No other critical structures were substantially irradiated.

"At the root of this event was displacement of the prostate gland that was not detected by image guidance caused by substantial peri-prostatic bleeding and hematoma formation. The tissues adjacent to the prostate provided an image with features mimicking the appearance of the prostate, though with non-distinct borders. Due to the bleeding, even these non-distinct borders were expected. In short, enough plausible indicators of correct positioning were present that the surgical team proceeded with the implant until the misplacement of the seeds was discovered.

"Due to the unusual circumstances of this specific procedure, no underlying deficiency in the prostate brachytherapy program of this licensee is indicated. The program has since implemented the use of stabilization needles at initiation of the implantation procedure. The primary element deserving of attention lies in the inherent dependence upon the ultrasound image. In such rare cases as this of limited visualization, it may behoove all users to use alternative methods to verify position, such as the digital exam performed on this patient or fluoroscopic visualization of the anatomy. It might be recommended to perform the verification in such circumstances prior to the implantation of any seeds.

"The spouse of the patient was informed immediately after the surgical procedure, and the patient was informed when he regained his faculties after anesthesia. The CT scan was performed later that day for dosimetric purposes.

"It is understood that the notification provided in this report to your Agency [State of Colorado] should have occurred within 15 days of the event. However, there was miscommunication between the Licensee and the QMP, each thinking that the other had made the report. [Licensee] apologizes for this delay. In the future if such an event should occur, a single person will be appointed to submit a report so that this confusion will not occur again."

A total of 23 milliCuries from 63 seeds were implemented during this procedure.

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: 43822
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: SAGINAW State: TX
County: TARRANT
License #: L04590-008
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/03/2007
Notification Time: 23:13 [ET]
Event Date: 12/03/2007
Event Time: 21:00 [CST]
Last Update Date: 12/04/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
DENNIS RATHBUN (FSME)
JEFFREY CRUZ (IRD)
BENJAMIN SANDLER (ILTA)
MIKE INZER (DHS)
MIKE SMITH (DOE)
MIKE LAFORTY (FEMA)
THREET (EPA)
JIMENEZ (USDA)
KELLEHER (HHS)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST RADIOGRAPHY CAMERA

The licensee's radiography team left the temporary jobsite with their SPEC 150 radiography camera on the tailgate. The camera contained a 24 Curie Ir-192 source. The licensee drove approximately 15 miles down the road prior to remembering the gauge was on the tailgate. It was then noticed that the camera was no longer in the truck. The licensee team is retracing their route in search of the camera and will be contacting the Tarrant County Sheriff's Department to aid in the search. The licensee is not sure if the camera had been secured properly prior to driving down the highway. The route taken was from Tinsley Lane to North Business 287 in Saginaw, TX towards Justin, TX in Tarrant County.

Notified NORTHCOM and Mexico via email.

Texas Report TX-07-43822

*** UPDATE FROM TEXAS DEPARTMENT OF HEALTH (JISHA) TO HOWIE CROUCH AT 0743 ON 12/04/07 ***

The SPEC 150 radiography camera was recovered at 0633 CST. A member of the public found the camera and placed it in the back of his private vehicle. Upon hearing about the lost source on the local news this morning, the citizen turned the camera over to the Fort Worth Fire Department. The camera appears intact and undamaged. Texas Department of Health is responding to the fire department to conduct a survey and inspection of the camera. No overexposures are expected.

Notified DHS (Haselton), DOE (Parsons), FEMA (Burckart), USDA (Watts), HHS (Garcia), EPA (Johnson), Mexico (via email), NORTHCOM (via email), R4DO (Hay), FSME EO (Burgess) and ILTAB (Sandler).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

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General Information or Other Event Number: 43826
Rep Org: ROSEMOUNT NUCLEAR
Licensee: ROSEMOUNT NUCLEAR
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID T. ROBERTS
HQ OPS Officer: JASON KOZAL
Notification Date: 12/06/2007
Notification Time: 14:03 [ET]
Event Date: 11/15/2007
Event Time: [CST]
Last Update Date: 12/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RICHARD BARKLEY (R1)
RANDY MUSSER (R2)
CHUCK CAIN (R4)
PART 21 GROUP -EMAIL ()
JULIO LARA (R3)

Event Text

PART 21 - POTENTIAL INSUFFICIENT THREAD ENGAGEMENT FOR CERTAIN PRESSURE TRANSMITTERS

Rosemount Nuclear Instruments, Inc. (RNII) reported that certain Model 1152, 1153 Series B and D, and 1154, and 1154 Series H Pressure Transmitters may have inadequate thread engagement between the electronics housing and sensor module. Transmitters affected by this notification may not confirm to RNII specifications under accident conditions. Supplier testing has determined that no immediate risk exists, however it is RNII's opinion that two threads of engagement may not be sufficient to assure that the product will perform its intended safety function over the qualified life of the transmitter.

The following are the potentially affected licensees: Oyster Creek, Calvert Cliffs, Kewaunee, North Anna, Millstone, Surry, Turkey Point, Vogtle, Diablo Canyon, Shearon Harris, South Texas Project, Browns Ferry, and Wolf Creek.

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