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Event Notification Report for July 28, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/27/2010 - 07/28/2010

** EVENT NUMBERS **


46116 46117 46118 46121 46124 46126

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General Information or Other Event Number: 46116
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BRIGHAM AND WOMEN'S HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 44-0004
Agreement: Y
Docket: 09-0003
NRC Notified By: KENATH O. TRAEGDE
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/22/2010
Notification Time: 09:24 [ET]
Event Date: 06/03/2010
Event Time: [EDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)

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

Event Text

AGREEMENT STATE REPORT - POTENTIALLY LOST RADIOACTIVE MATERIAL

The following was received via fax from the State of Massachusetts:

"On June 3, 2010, two packages containing I-125 seeds were received by the Medical Physicist [MP], who brought them to the radiation oncology hot lab. The MP removed the paperwork and left the packages in the lab while he went back to his office to update the inventory system. He returned to the hot lab to place the cartridges containing the seeds in the vault. He put one cartridge in the vault next to a cartridge that was left over from a canceled treatment. The MP thought that the other cartridge already in the vault was from one of the packages just received, and proceeded to remove the labels from the packages and survey the packages before discarding them. Since the seeds are shielded by a stainless steel cartridge, the survey measurement was indistinguishable from background. The event was discovered by him on Tuesday, June 8, when he was preparing for a treatment and noticed the serial numbers on the cartridges did not match the ones in the inventory system. He reported his findings to the Radiation Safety Officer. The event was reported to Massachusetts Radiation Control Program on Thursday, June 10.

"Approximately 43 milliCuries of I-125 seeds were disposed in the clean trash system. Attempts to locate the material in the trash were unsuccessful and they concluded on Tuesday, June 8, that the package had left the premises via the trash."

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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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General Information or Other Event Number: 46117
Rep Org: NV DIV OF RAD HEALTH
Licensee: WEST VALLEY IMAGING
Region: 4
City: HENDERSON State: NV
County:
License #: 03-12-0384-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/22/2010
Notification Time: 13:30 [ET]
Event Date: 07/21/2010
Event Time: 12:00 [PDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

"Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.

"Reported to the Nevada Radiation Control Program at around 3:00 p.m.

"The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too.

"Persons involved: Pediatric patient, mammography technician and nuclear medicine technician.

"Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures.

"Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient.

"Isotope Details: Tc-99m: 24.0 mCi.

"Procedure administered: MIRALUMA study.

"Dose intended: 17.5 mCi of Tc-99m

"Dose Administered: 24.0 mCi of Tc-99m

"Target organ: Breast

"Patient Informed: N

"% Dose Exceeds Prescribed: 37

"Diagnostic Study: Breast (MIRALUMA study)

"Radiopharmaceutical: Tc-99m MIRALUMA

"Effect on Patient: UNKNOWN

"Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM

"Manufacturer: Cardinal Health PSC

"Model Number: 190"

Nevada Report No.: NV100011

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: 46118
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OK DEPARTMENT OF TRANSPORTATION
Region: 4
City: ORIENTA State: OK
County: MAJOR
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 07/22/2010
Notification Time: 19:38 [ET]
Event Date: 07/22/2010
Event Time: 15:30 [CDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)
VICTOR DRICKS (R4PA)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The State of Oklahoma reported that on 7/22/10, at about 1530 CDT, a moisture density gauge at a construction site in Orienta, OK south of the intersection of Highway 60 and Highway 412, was run over by a tractor-trailer rig followed by 3 other vehicles. None of the drivers stopped.

The road was closed so that the area could be searched to locate the gauge. Initially the source rod (typically containing a Cesium-137 source) was not found after searching the scene.

The Oklahoma Department of Transportation (ODOT) was the licensee and owner of the gauge. The ODOT Radiation Safety Officer was contacted. At the time of this report the source rod was located and the RSO determined the source to be intact.

A major newspaper in the area posted information on the issue on their website.

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General Information or Other Event Number: 46121
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SHARON COATINGS
Region: 1
City: SHARON State: PA
County:
License #: PA-G0320
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 14:54 [ET]
Event Date: 07/22/2010
Event Time: [EDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

The following information was received from the State of Pennsylvania via fax:

"Event location: Sharon Coatings

"Event Type: Shutter Failure

"Notifications: A call from the licensee was received July 23, 2010 @ 1410 by the Department of Environmental Protection explaining the event. This falls under 24 hour reporting under 10CFR31.2 and 30.50(b)(2).

"Event Description: It was discovered on July 22, 2010 at 15:30 that during a calibration of an ESC Resources (Model #NDS-200, Serial #20938), by the vendor the shutter was stuck open. Vendor was able to make repairs and restore shutter. The device is currently in use. Vendor checked all other gauges and found one other (Model #SH-5000, Serial #80209B), to be stuck as well. Vendor restored both to operational use.

"CAUSE OF THE EVENT: Equipment failure

"ACTIONS: Both devices have been repaired and restored back to operation"

PA Event Report ID No.: PA100017

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General Information or Other Event Number: 46124
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: IBA MOLECULAR NORTH AMERICA
Region: 4
City: DALLAS State: TX
County:
License #: 06174
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 07/23/2010
Notification Time: 16:59 [ET]
Event Date: 06/09/2010
Event Time: [CDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)
PETER HABIGHORST (NMSS)

Event Text

AGREEMENT STATE REPORT - HIGHER THAN EXPTECTED DOSE RATE

The following information was received from the State via e-mail:

"On July 16, 2010, the Agency [Texas Department of State Health Services] was notified by the licensee that they had received notification from their dosimetry processor that an employee's badge had exceeded an annual exposure limit. The event was sent to the Nuclear Material Events Database on July 21, 2010. On July 23, 2010, the licensee reported that while conducting their investigation into the overexposure event, they found that an arrival survey conducted on June 9, 2010, exceeded the allowable limit for a type Yellow II package.

"The survey was on receipt of a package containing 494 milliCuries of Fluorine (F) - 18 and indicated that the package was reading 47 milliRem per hour at 1 meter. The dose rate on contact exceeded the measuring capabilities of their instrument. The Service Manager opened the package and found that a vial of F-18 had separated from its shielding. The vial was removed from the package by the Service Manager and taken to an appropriate storage location. A removable radioactive contamination survey was conducted on the package and found to be within the acceptable limits.

"The shipper has been notified of the event. This Agency will provide additional information as it is received."

Texas Incident #: I-8762

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General Information or Other Event Number: 46126
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: BURGESS ENGINEERING AND TESTING
Region: 4
City: MOORE State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 07/24/2010
Notification Time: 16:22 [ET]
Event Date: 07/24/2010
Event Time: 11:00 [CDT]
Last Update Date: 07/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

On 7/24/10, after doing work in Oklahoma City, an employee of the licensee put a Troxler Model 3440 moisture density gauge in the back of a pick-up truck. The gauge was in its locked case and was locked with a single chain to the truck.

When the employee arrived at his destination he found that the gauge was missing. The employee did not notice anything unusual while driving. The licensee searched the route traveled with no results. During the search the licensee informed the police of the missing gauge. The licensee will offer a reward for the proper return of the gauge.

The State of Oklahoma is investigating and is formulating a notice to the media on the incident.

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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