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Event Notification Report for December 17, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/14/2007 - 12/17/2007

** EVENT NUMBERS **


43831 43833 43838 43839 43844 43845

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General Information or Other Event Number: 43831
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY SERVICES
Region: 4
City: SCOTTSDALE State: AZ
County:
License #: 07-016
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GODWIN
HQ OPS Officer: JASON KOZAL
Notification Date: 12/10/2007
Notification Time: 16:36 [ET]
Event Date: 12/03/2007
Event Time: 14:30 [MST]
Last Update Date: 12/10/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSSELL BYWATER (R4)
JOSEPH GIITTER (FSME)

Event Text

AGREEMENT STATE - LEAKING CESIUM-131 SOURCE

The State provided the following information via email:

"At approximately 2:30 PM on December 3, 2007 the Agency was notified that a Cesium 131 seed was found to be leaking. The source was an IsoRay Medical, Inc., Model CS-1, 3.12 milliCuries. The seed became jammed in the Mick applicator cartridge. The patient bed, the OR [Operating Room], and trash all surveyed clean. Upon opening the cartridge, contamination was discovered. One person received some contamination of their hands which was removed within 15 minutes. The licensee estimates the exposure to the hands of that individual as less than 50 rems.

"The source has been secured for decay and ultimate disposal. The Agency [Arizona Radiation Regulatory Agency] continues to investigate this event. The U.S. NRC is being notified of this event."

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General Information or Other Event Number: 43833
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF NORTH DAKOTA
Region: 4
City: GRAND FORKS State: ND
County:
License #: 33-12827-01
Agreement: Y
Docket:
NRC Notified By: CHRIS SCHMALTZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/11/2007
Notification Time: 09:17 [ET]
Event Date: 12/10/2007
Event Time: 15:45 [MST]
Last Update Date: 12/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RUSSELL BYWATER (R4)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT FROM NORTH DAKOTA OF A POSSIBLE OVEREXPOSURE

A physician researcher at the University of North Dakota received a report from Landauer of a radiation exposure reading on his badge of 74 Rem deep dose and 69 Rem shallow dose. The monitoring period for the badge (monthly or quarterly) was not known to the State. Investigation has determined that the researcher is believed to have worked only with P-32 and has done nothing out of the ordinary. The lab area where the researcher worked has been surveyed and there is no indication of contamination. The researcher is currently having blood work done to determine if there is any indication of radiation damage. The licensee is also working with Landauer focusing on the discrepancy between the deep dose and shallow dose readings on the badge. For an overexposure of this magnitude, it would be expected that the shallow dose would be much greater than the deep dose.

The University Radiation Committee is leading the investigation for the licensee. The State plans to evaluate the results of the licensee's investigation findings before considering what actions it will take .

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General Information or Other Event Number: 43838
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BAPTIST HOSPITAL
Region: 1
City: PENSACOLA State: FL
County:
License #: 0158-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/12/2007
Notification Time: 10:53 [ET]
Event Date: 12/11/2007
Event Time: 15:20 [EST]
Last Update Date: 12/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JIM KRAFTY (R1)
GREG MORELL (FSME)

Event Text

FLORIDA AGREEMENT STATE REPORT

"A misadministration occurred on 11-Dec-2007 this office notified at 1520 hours. The prostate was to receive 140 Gy, but received only 100 Gy. This incident referred to Radioactive Materials for Investigation. This office will take no further action on this incident."

Isotope: I-125

Activity: 92 seeds at 0.295 millicuries per seed

Material Form: Interstitial Brachytherapy Seeds

Incident Number: FL07-193


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 BY FSME (FLANNERY) TO MACKINNON AT 1105 ON 12/13/07* * *

"This event (EN43838) has been reviewed and determined to be a reportable medical event."

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General Information or Other Event Number: 43839
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: TIERRA INC.
Region: 1
City: WEST PALM BEACH State: FL
County:
License #: 2307-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/12/2007
Notification Time: 10:54 [ET]
Event Date: 12/12/2007
Event Time: 09:00 [EST]
Last Update Date: 12/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JIM KRAFTY (R1)
GREG MORELL (FSME)
ILTAB (e-mailed) ()

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

Event Text

FLORIDA AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE


"Troxler gauge stolen from storage facility. Incident discovered at 0900 12-Dec-07; this office notified at 1015 same day. Police on scene. Owner will offer reward. No further action will be taken by this office."


Isotopes: Cs-137 & Am-241

Activities: 8 mCi's & 40 mCi's

Material Form: By-product; Special Form

Probable Disposition of Material: Material stolen and not recovered

Model Number: Troxler 3430, Serial Number 32900


Organizations Notified: HSER, HSERE, St. Augustine Police Dept. Case #021610


Incident Location: 150 St. Johns Business Place Suite 303, St. Augustine, FL 32095

Location Classification: Controlled Area

FL Incident Number: FL07-194

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: 43844
Rep Org: JANX INTEGRITY GROUP
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/14/2007
Notification Time: 16:22 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
JOSEPH HOLONICH (FSME)
JOHN MADERA (R3)

Event Text

POTENTIAL OVEREXPOSURE

The licensee reported that two personnel, a radiography technician and assistant, were performing radiography shots at a fabrication shop in Detroit, MI. After completion of a shot, the technician cranked the SPEC-150 camera source into the shielded position. The assistant then surveyed the camera and got a background reading, indicating the source was, indeed, shielded. The survey was verified by the technician. The assistant then removed the camera from a hook that it was hanging on and set it on the ground. He then started preps for the next shot and set the survey meter down on the ground. After completing the preps, the assistant noticed that the survey meter was pegged high on the X10 scale. He immediately moved away from in front of the camera and notified the technician. The source was again verified in the shielded position after the technician locked the camera. No rate alarm occurred on the assistant's rate device but his pocket dosimeter indicated off-scale. The Radiation Safety Officer was immediately notified.

The assistance estimated he was in front of camera for approximately two to five minutes. The estimated dose received by the assistant was calculated to be between one and five REM. This will be confirmed when the assistant's TLD is read. The RSO has overnighted the TLD to a lab for processing.

The camera was removed from service and will be evaluated by the vendor for suspected failure of an internal safety mechanism.

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Other Nuclear Material Event Number: 43845
Rep Org: JANX INTEGRITY GROUP
Licensee: JANX INTEGRITY GROUP
Region: 3
City: PARMA State: MI
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: JOHN NEWLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/14/2007
Notification Time: 16:33 [ET]
Event Date: 12/13/2007
Event Time: 20:00 [EST]
Last Update Date: 12/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN MADERA (R3)
JOSEPH HOLONICH (FSME)

Event Text

SAFETY EQUIPMENT FAILURE

In a remote area in Missouri, radiography personnel were x-raying welds on a pipe that was placed in a trench. Away from the radiographers, the pipeline contractors moved another pipe in the trench which caused the trench to collapse, allowing water into the trench. The radiography saw it happening and immediately cranked the source into the shielded position. The water submerged the SPEC-150 radiography camera and equipment.

Using the same camera, the radiographer set up for a shot in a different location. When exposing the source, it became stuck in the unshielded position. The radiographer immediately notified the RSO and marked off the area with boundary tape while he awaited assistance from the vendor.

When the vendor could not immediately respond due to weather related travel issues, the radiography personnel procured a heater to thaw the camera as they suspected the camera was frozen from the earlier water intrusion. Surrounding temperatures were in the twenties. After warming the camera, they were able to successfully retrieve the source to the shielded position.

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Thursday, March 29, 2012