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Event Notification Report for December 24, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/23/2008 - 12/24/2008

** EVENT NUMBERS **


44730 44731 44733 44734

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General Information or Other Event Number: 44730
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RENDA MARINE
Region: 4
City: ROANOKE State: TX
County:
License #: G02084
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/18/2008
Notification Time: 15:46 [ET]
Event Date: 01/01/2003
Event Time: [CST]
Last Update Date: 12/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHRIS EINBERG (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING NUCLEAR GAUGE

"The gauge was discovered missing after Agency [Texas Department of Health] attempts to collect fees. Gauge registrant had provided self evaluation reports indicating they possessed the gauge and, after being contacted, admitted it was missing. The company had 2 gauges. The second was returned to Thermo Scientific. The missing gauge is reported to contain 1 curie of Cs-137. However, the manufacturer's information indicates it held 2 curies. A site investigation will be performed 12/09/08. A site investigation will be performed 12/09/08.

"The licensee continues to dispute inappropriate disposition of the gauge/source but cannot produce documentation to support the statement. The gauge is most likely fixed on a dredge in Florida but until definitive documentation is produced to support or show the whereabouts of the source, the Agency must formerly declare the source missing. A draft Notice of Violation is being developed to call the company in for enforcement.

"The source information follows:

"Manufacturer: Thermo
"MeasureTech (Now Thermo Fisher Scientific), Model: 5203,
"Serial Number: B996, Isotope: Cs-137, Activity: 2 Ci,
"Source serial number: GK3804"

Texas Incident Report # I-8587


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: 44731
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DELEK REFINING LTD
Region: 4
City: TYLER State: TX
County:
License #: 02289
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/18/2008
Notification Time: 14:41 [ET]
Event Date: 12/18/2008
Event Time: 13:25 [CST]
Last Update Date: 12/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
CHRIS EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - NON-NUCLEAR WORKERS RECEIVE RADIATION OVEREXPOSURE

The following report was received via e-mail:

"On December 18, 2008, the licensee confirmed that four of their workers, who are not considered to be radiation workers, exceeded the annual exposure limit for members of the general public of 100 millirem due to the detachment of the source from the operating rod. The dose to these individuals are: employee 1 - 280 mrem, employee 2 - 2962 mrem, employee 3 - 960 mrem, employee 4 - 78 mrem, employee 5 - 166 mrem.

"The licensee will send supporting information to the Agency [Texas Department of Health] within the next few days."

Texas Incident # I-8576

Texas Event Report 44609

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Hospital Event Number: 44733
Rep Org: TRINITAS HOSPITAL
Licensee: TRINITAS HOSPITAL
Region: 1
City: ELIZABETH State: NJ
County:
License #: 29-04333-01
Agreement: N
Docket:
NRC Notified By: LINDA VELDKAMP
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/18/2008
Notification Time: 17:41 [ET]
Event Date: 12/17/2008
Event Time: 14:00 [EST]
Last Update Date: 12/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD BARKLEY (R1)
JIM LUEHMAN (FSME)

Event Text

MEDICAL DOSE LESS THAN 50 PERCENT OF PRESCRIBED DOSE

"Suspected movement of catheter during endobronchial high dose rate remote afterloading treatment procedure may have resulted in a single fraction of a multifraction treatment to differ from the prescribed dose by more than 50%. (35.3045 (1)(iii)).

"Both the patient and the referring physician were notified by the authorized user of the possibility the intended treatment site did not receive full dose.

"1. Patient had endobronchial catheter placed in Rt Bronchus in the endoscopy department. Catheter was taped in place and position was marked.
"2. Patient was scanned in CT simulation room by therapist to determine catheter location and treatment dwell positions.
"3. Patient treatment plan was created by physicist and approved by the authorized user. Second calculation check was performed.
"4. Patient was monitored by nursing during the treatment planning process.
"5. Patient was brought into HDR treatment room by therapist.
"6. Authorized physicist and authorized user connected the treatment applicator to the HDR unit.
"7. Technologist monitored patient on the camera system.
"8. Treatment was administered as planned.
"9. Patient was disconnected from the HDR unit.
"10. Technologist removed catheter post treatment, noted the catheter she pulled out was relatively short compared to the planning scan.
"11. Technologist notified the authorized user and authorized physicist.
"12. Both individuals notified the RSO.
"13. RSO investigated and interviewed individuals involved.
"14. AU not sure at what point the catheter moved.

"Patient may have dislodged catheter when coughing or wiping mouth secretions.

"Actions to prevent re-occurrence:

"1. Authorized user will remove all endobronchial catheters post treatment in the future to prevent any ambiguity with regard to length of catheter in patient.
"2. Check marked position of the catheter at CT and both pre and post treatment prior to catheter removal.
"3. Measure catheter length outside the naries prior to planning CT, prior to treatment, and post treatment as a second check to the marked position.

"The Pulmonologist and Authorized user will perform a bronchoscopy in about 2 weeks [to determine if misadministration occurred]. Treatment reactions outside the planned treatment site will be evaluated and determination of treatment in an unintended area will be determined."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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General Information or Other Event Number: 44734
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: AGRI INDUSTRIAL PLASTICS CO
Region: 3
City: FAIRFIELD State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDAL DAHLIN
HQ OPS Officer: JOE O'HARA
Notification Date: 12/19/2008
Notification Time: 10:23 [ET]
Event Date: 12/18/2008
Event Time: [CST]
Last Update Date: 12/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3)
CHRIS EINBERG (FSME)
ILTAB VIA E-AMIL ()

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

Event Text

MISSING NRD STATIC ELIMINATOR

"The Agency [Iowa Department of Public Health] was notified by the General License Registrant of a missing NRD Static Eliminator, model P-2021-8201, serial number A2FY911. The discovery was made during the annual renewal of the registration. The RSO for the company stated that the device was used to eliminate static on a part they were molding. The operators had the device hanging over a barrel and apparently the device became unscrewed from the gun and was disposed of in the trash. The registrant has developed a sleeve to assist in holding the device on the guns. In addition, the RSO instructed the shift foremen to check the devices to ensure they are properly secured to the guns. The Agency [Iowa Department of Public Health] called NRD. Inc. to verify that the device was not returned to the manufacturer. NRD Inc. stated they did not receive the device.

"Corrective Action: (1) Sleeve used to help hold the device on the gun, and (2) Additional oversight to ensure devices are properly secured to guns."

The Po-210 source activity is 10 milliCuries. The state considers the material to be lost not recoverable, and the event is closed.

Iowa Report: IA080003.

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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