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Event Notification Report for May 9, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/08/2008 - 05/09/2008

** EVENT NUMBERS **


44189 44194

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General Information or Other Event Number: 44189
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ACCURATE NDE AND INSPECTION LLC
Region: 4
City:  State: LA
County:
License #: LA-10207-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JASON KOZAL
Notification Date: 05/06/2008
Notification Time: 11:42 [ET]
Event Date: 12/31/2007
Event Time: [CDT]
Last Update Date: 05/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
MICHELE BURGESS (FSME)

Event Text

LOUISIANA AGREEMENT STATE REPORT - PERSONNEL OVEREXPOSURE

The State provided the following information via facsimile:

"An overexposure was discovered during a routine compliance inspection of Accurate NDE & Inspection on March 25, 2008. This overexposure was not reported to the Louisiana Department of Environmental Quality. An industrial radiographer received a dose of 7819 mrem for the calendar year 2007. The licensee has been cited for the overexposure and for not reporting the overexposure. This overexposure is being investigated by the LA Department of Environmental Quality."

LA Report ID No.: LA08009

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Other Nuclear Material Event Number: 44194
Rep Org: WASHINGTON UNIVERSITY IN ST LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/08/2008
Notification Time: 17:30 [ET]
Event Date: 05/07/2008
Event Time: 16:35 [CDT]
Last Update Date: 05/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RICHARD SKOKOWSKI (R3)
TERRANCE REIS (FSME)
ILTAB (via email) ()

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

Event Text

LOST I-125 SEEDS

RSO reported that two I-125 seeds have been lost following a prostate implant procedure. Seeds have an apparent activity of 0.37 milliCuries each, and actual contained activity of 0.518 milliCuries each. Facility received 15 seeds from the seed manufacturer for a scheduled prostate implant procedure at 0900 CDT on 05/07/08. 13 seeds were implanted successfully by the authorized user. After the procedure was completed, the technologist completed surveys around the patient and in the area of the procedure. At this time, it is believed that the technologist disassembled the MIC applicator improperly and left a part in the MIC that contained the seeds. The technologist did not verify, visually or by survey, that the seeds were contained in the part of the MIC applicator that was going to storage. It is believed that the seeds went with the part of the MIC unit that went into a soap basin for cleaning and that during cycling of the plunger the seeds came out and went into the soap basin and down the drain into the buildings sanitary sewer system. The loss was not identified until 1630 on 05/07/08, when the medical physicist was going to use the two remaining seeds for other testing. Several medical physicists from Radiation/Oncology went to survey the operating room area used for the procedure and were unsuccessful in locating either seed. At 1830, Radiation Safety organization was notified and the facility continued looking for the missing seeds. A survey was performed on the drain trap area of the soap basin and no increased background was identified. The facility does not believe that the seeds will be recovered. The investigation is still ongoing.

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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