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Event Notification Report for January 29, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/28/2010 - 01/29/2010

** EVENT NUMBERS **


45649 45654 45657 45658 45659 45660 45662 45667

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General Information or Other Event Number: 45649
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: JEWISH HOSPITAL OF CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 02120310029
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/22/2010
Notification Time: 15:44 [ET]
Event Date: 01/21/2010
Event Time: [EST]
Last Update Date: 01/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE

The following was received via E-mail:

"On January 22, 2010 the BRP [Ohio Bureau of Radiation Protection] was notified of a medical event that occurred at the Jewish Hospital of Cincinnati on January 21, 2010. The patient received 67% of the prescribed dose to the prostate implant with I-125 seeds. The physician is attempting to contact the patient. The BRP will investigate the event."

The prescribed dose was 144 Gy and the actual dose delivered was 96.48 Gy

Ohio Incident: OH100001

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: 45654
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NDE INC
Region: 1
City: TAMPA State: FL
County:
License #: 3404-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/25/2010
Notification Time: 10:01 [ET]
Event Date: 01/22/2010
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OCCUPATIONAL OVEREXPOSURE

The following report was received from the State of Florida Bureau of Radiation Control via facsimile:

"Employee's TLD recorded an overexposure of 6.261 rem. Date [of potential overexposure] was between 10 Dec 2009 to 9 Jan 2010. Affected employee claims he left his leather pouch with TLD [and pocket dosimeter] in work bucket over night, second shift used bucket not noticing TLD pouch at bottom. Pocket dosimeter reading was also off scale. Other employees who worked with him during same time period have no excessive exposures. RSO calculates dose should be approximately 195 mr during month as per records. RSO believes [that this exposure is] not an occupational overexposure. RSO contacted Licensing and Materials office on 22 Jan 2010. RSO received Landauer's dosimetry report on 21 Jan 2010. [The State of Florida] Tampa Inspection Office will investigate."

FL report #FL10-009

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General Information or Other Event Number: 45657
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: TEI ANALYTICAL SERVICES
Region: 1
City: HOUSTON State: PA
County:
License #: 37-28004-02
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/25/2010
Notification Time: 22:09 [ET]
Event Date: 09/23/2008
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE / RADIOGRAPHY SOURCE DISCONNECT

The following information was received via fax:

"Notifications: DEP [Department of Environmental Protection] received a phone call September 24, 2009 about the incident.

"On Wednesday, September 24, 2008 the PA DEP SWRO [Pennsylvania Department of Environmental Protection Southwest Regional Office] received a telephone call from TEI Analytical Services in Washington, PA notifying them of a source disconnect at a facility in Houston, PA. At approximately 1005 pm, Tuesday, September 23, 2008, a 99 curie Ir-192 source became disconnected from the cable while performing radiography on a gas extraction facility along PA Route 519. The source became separated from the guide tube and could not be returned to the camera. The company was notified and sent a rescue team to assist in the recovery and control of the source. No overexposures occurred and the team managed to get the source back into its camera via tongs. This operation was concluded at 12:08am. Doses are as follows: radiographer 51 millirem whole body; assistant 25 millirem; rescue radiographer 42 millirem whole body, 800 millirem extremity; second member of rescue team 160 millirem whole body, no extremity dose. The cause was found to be limitations of the work environment, i.e., the positioning of the exposure device was very limiting and darkness reduced visibility. No modifications in operating procedures to prevent a re-occurrence were mentioned."

Event Report ID No: PA080025

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General Information or Other Event Number: 45658
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ACUREN
Region: 1
City: ERIE State: PA
County:
License #: PA-1063
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 01/25/2010
Notification Time: 22:12 [ET]
Event Date: 02/19/2009
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE / RADIOGRAPHY SOURCE DISCONNECT

The following was received from the Commonwealth via e-mail:

"DEP [Department of Environmental Protection] received a letter dated March 9, 2009 from Acuren describing the incident. It was received March 16, 2009.

"Event Description: A technician was performing radiography in Erie, PA (Booth #2) at 8:55am. A few seconds after his fourth exposure, the technician heard the spool piece fall off the table. He immediately tried to retract the source but was unsuccessful. The RSO traveled to the facility, calculated the exposure rates and executed a safe retrieval of the source. He received 35 mrem of exposure during the retrieval. The damaged guide tube was disposed. A 1.75" lead sheet was used to shield the source while the guide tube was reshaped to allow a safe retrieval to the secured position. A whole body dose of 32 mrem was received by retrieval technician.

"Causes of the event: Spool piece was not properly secured in a safe position on the table. Piece was not properly blocked or braced, and located too close to the end of the table, so any movement would result in a fall. The jack stands that were available were not used, nor was shooting the parts on the floor considered. Guide tube and camera were not properly positioned to avoid contact with falling spool piece."

Event Report ID No, PA090016

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General Information or Other Event Number: 45659
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEATHERFORD INTERNATIONAL
Region: 1
City: ELDERTON State: PA
County:
License #: 42-29288-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/25/2010
Notification Time: 22:21 [ET]
Event Date: 04/18/2008
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING WELL LOGGING SOURCE

The following excerpted information was received via facsimile:

"Notifications: Phone call made to South West Regional Office on April 18, 2009 to notify PA DEP of the situation.

"The PA DEP SWRO [Pennsylvania Department of Environmental Protection Southwest Regional Office] was notified on Friday, April 18, 2008, by Weatherford International, who were doing reciprocity work in western PA, of a leaking well logging source containing 1.5 Ci of Cs-137. A rag used to clean of the tool was surveyed and was found to contain elevated radiation levels. The tool was removed from service and further leak tests were done, confirming the presence of contamination. It was found that the tool was leak tested in March 2008 and found to be contaminated then (at approximately 0.04 microcuries). No reason given why it was kept in service. On Saturday April 19, 2008 all likely areas of contamination were surveyed, with none showing higher than the 0.005 microcuries limit. Weatherford them contacted NSSI of Huston TX, and asked them to verify the test results and to inspect the tool itself. The source was packed and shipped to NSSI in Texas the week of April 20 for evaluation. NSSI conducted surveys and collected wipe samples of the facility before leaving and found no evidence of contamination at the facility other than the known area on the logging unit. The contamination on the logging unit was cleaned and re-wiped and showed no evidence of removable contamination after the clean-up. Urine samples for bioassays were collected from facility employees and sent to GEL Laboratories for analysis. Bioassay results for the employees were returned and showed no evidence of Cs-137 above the minimum detection limit of 10 pCi/L."

Event Report ID No: PA080008

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General Information or Other Event Number: 45660
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: INTEGRITY TESTLAB
Region: 1
City: CONOCO PHILIPS TRAINER State: PA
County:
License #: PA1181
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/25/2010
Notification Time: 22:30 [ET]
Event Date: 05/18/2009
Event Time: [EST]
Last Update Date: 01/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - DIFFICULTY RETRACTING GAMMA SOURCE

The following excerpted information was received via facsimile:

"Notifications: A letter dated June 6, 2009 was received by DEP [Department of Environmental Protection] on June 15, 2009 that described the incident.

"Radiography crew was performing their 7th exposure at a location within the FCC Scrubber Unit (PV-7923). Upon completion of the exposure time (2 minutes), the crew attempted to retract the gamma source to its shielded / safe position. It was during the retraction sequence that the crew had difficulty returning the source to the shielded position. Both individuals made several attempts to retract the source. The crew re-established the posted radiation boundary to where the radiation levels were at or below regulatory limits for this situation (2 mR/hr), and implemented their source recovery procedures."

Event Report ID No: PA090025

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General Information or Other Event Number: 45662
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY LP
Region: 4
City: ABILENE State: TX
County:
License #: 04590
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/26/2010
Notification Time: 14:34 [ET]
Event Date: 01/22/2010
Event Time: [CST]
Last Update Date: 01/26/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT

"On January 26, 2010, [The Texas Department of Health] was notified by the licensee that a source disconnect had occurred on January 22, 2010. A radiographer was cranking a 26 curie iridium (Ir) - 192 source from the camera when he began having difficulty driving the source. He decided to retract the source back into the camera when the source disconnected at the drive cable. The source was driven into the collimator at the end of the guide tube. The radiographer contacted his Radiation Safety Officer (RSO) and informed him of the event. An individual qualified for source retrieval was sent to the location. The source was returned to the camera, and the camera was returned to the licensee's facility. The individual performing the source retrieval received 120 millirem as indicated by his pocket dosimeter. The RSO stated that the failure appeared to be caused by a failure of the connector on the drive cable. The RSO stated that it was a result of normal wear on the device. [The Texas Department of Health] has requested copies of the last three maintenance records for the device. The source serial number is QH2505 manufactured by Spec. The camera serial number is 1203. Additional information will be provided as it is received."

Texas Incident #: I - 8706

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Other Nuclear Material Event Number: 45667
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-01222-05
Agreement: N
Docket:
NRC Notified By: KAREN McGUIRE
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/28/2010
Notification Time: 15:20 [ET]
Event Date: 01/27/2010
Event Time: [EST]
Last Update Date: 01/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
CHRISTINE LIPA (R3DO)
MARK THAGGARD (FSME)

Event Text

MOSITURE DENSITY GAUGE RECEIVED WITH INOPERABLE LOCKING MECHANISM

The Army Depot in Stockton, CA received at 1401 PST on 01/27/10 a CPN Moisture Density Gauge shipped from a field unit. Upon receipt inspection, they identified that the locking mechanism was separated from the guide tube. The source was in the shielded position at the time of discovery. The field unit which shipped the device on 01/26/10 was contacted and asserts that the unit was intact at the time of shipment. The device is a CPN, Model MC-1, S/N M1712089, manufactured in the 1970's containing two sources; 10 millicuries Cesium-137 and 50 millicuries Americium-241/Be. The damaged device is currently in secure storage and scheduled for disposal.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012