Event Notification Report for August 17, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/16/2011 - 08/17/2011
EVENT NUMBERS
47168471654716647391
Agreement State
Event Number: 47168
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: WEYERHAEUSER COMPANY
Region: 1
City: PORT WENTWORTH State: GA
County:
License #: GA1109-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: HOWIE CROUCH
Licensee: WEYERHAEUSER COMPANY
Region: 1
City: PORT WENTWORTH State: GA
County:
License #: GA1109-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/18/2011
Notification Time: 17:18 [ET]
Event Date: 08/17/2011
Event Time: 13:00 [EDT]
Last Update Date: 08/18/2011
Notification Time: 17:18 [ET]
Event Date: 08/17/2011
Event Time: 13:00 [EDT]
Last Update Date: 08/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)
ILTAB via email
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)
ILTAB via email
GEORGIA AGREEMENT STATE REPORT - LOST INDUSTRIAL NUCLEAR GAUGE
On 8/17/11, the licensee discovered that a nuclear process gauge was missing. The gauge was suspected to have been placed in the trash and transported to a local landfill. The landfill operators have been notified. Workers at the facility were interviewed but the licensee could not determine the disposition of the gauge.
The gauge, a BSI Instruments model NW201, serial number 1041, was last seen on or about August 4, 2011. The missing gauge, plus two others, were verified to be in temporary storage awaiting transfer to an outside organization. The gauge contained 0.5 mCi of Cs-137. The two other gauges are accounted for and stored properly.
Georgia Report #: GA2011-40I
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
On 8/17/11, the licensee discovered that a nuclear process gauge was missing. The gauge was suspected to have been placed in the trash and transported to a local landfill. The landfill operators have been notified. Workers at the facility were interviewed but the licensee could not determine the disposition of the gauge.
The gauge, a BSI Instruments model NW201, serial number 1041, was last seen on or about August 4, 2011. The missing gauge, plus two others, were verified to be in temporary storage awaiting transfer to an outside organization. The gauge contained 0.5 mCi of Cs-137. The two other gauges are accounted for and stored properly.
Georgia Report #: GA2011-40I
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
Agreement State
Event Number: 47165
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GEOTECH ENGINEERING AND TESTING
Region: 4
City: HOUSTON State: TX
County:
License #: L03923
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Licensee: GEOTECH ENGINEERING AND TESTING
Region: 4
City: HOUSTON State: TX
County:
License #: L03923
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/18/2011
Notification Time: 11:35 [ET]
Event Date: 08/17/2011
Event Time: 08:30 [CDT]
Last Update Date: 08/18/2011
Notification Time: 11:35 [ET]
Event Date: 08/17/2011
Event Time: 08:30 [CDT]
Last Update Date: 08/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
ANGELA MCINTOSH (FSME)
MICHAEL HAY (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT INVOLVING A DAMAGED MOISTURE DENSITY GAUGE
The following information was obtained from the State of Texas via email:
"On August 18, 2011, the Agency [Texas Department of State Health Services] was notified that a Humboldt model 5001 EZ, serial number 4220, containing a 44 milliCurie Americium-241/Beryllium source and an 11 milliCurie Cesium-137 source was run over by a dirt compactor. The user placed the device on the ground 12 feet from his truck to perform prior to use checks on the gauge. The sources were in the fully shielded position. When the technician went to the cab of their truck to record readings, a dirt compactor came up out of a pit near the truck. The technician could not get the attention of the compactor driver in time to prevent them from driving over the gauge. The technician contacted the fire department and [informed] his manager of the event. The licensee's Radiation Safety Officer (RSO) and fire department both responded to the scene. The RSO conducted a radiation survey of the device and determined that the sources were fully shielded. A service company was contacted and they took the device to their facility. The service company performed leak tests on both sources. The results were below the regulatory limit. Additional information will be provided as it is received."
Texas Report # I-8879
The following information was obtained from the State of Texas via email:
"On August 18, 2011, the Agency [Texas Department of State Health Services] was notified that a Humboldt model 5001 EZ, serial number 4220, containing a 44 milliCurie Americium-241/Beryllium source and an 11 milliCurie Cesium-137 source was run over by a dirt compactor. The user placed the device on the ground 12 feet from his truck to perform prior to use checks on the gauge. The sources were in the fully shielded position. When the technician went to the cab of their truck to record readings, a dirt compactor came up out of a pit near the truck. The technician could not get the attention of the compactor driver in time to prevent them from driving over the gauge. The technician contacted the fire department and [informed] his manager of the event. The licensee's Radiation Safety Officer (RSO) and fire department both responded to the scene. The RSO conducted a radiation survey of the device and determined that the sources were fully shielded. A service company was contacted and they took the device to their facility. The service company performed leak tests on both sources. The results were below the regulatory limit. Additional information will be provided as it is received."
Texas Report # I-8879
Power Reactor
Event Number: 47166
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] B&W-L-LP
NRC Notified By: CHANTELLE HURST
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] B&W-L-LP
NRC Notified By: CHANTELLE HURST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/18/2011
Notification Time: 15:26 [ET]
Event Date: 08/17/2011
Event Time: 18:45 [EDT]
Last Update Date: 08/18/2011
Notification Time: 15:26 [ET]
Event Date: 08/17/2011
Event Time: 18:45 [EDT]
Last Update Date: 08/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (R2DO)
SCOTT SHAEFFER (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
FITNESS FOR DUTY - PRESENCE OF ALCOHOL IN THE PROTECTED AREA
A non-licensed contract employee was determined to have alcohol in his possession while in the Protected Area. The contractor's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.
The licensee has notified the NRC Resident Inspector.
A non-licensed contract employee was determined to have alcohol in his possession while in the Protected Area. The contractor's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.
The licensee has notified the NRC Resident Inspector.
Hospital
Event Number: 47391
Rep Org: HOSPITAL METROPOLITAN DR. PILA
Licensee: HOSPITAL METROPOLITAN DR. PILA
Region: 1
City: PONCE State: PR
County:
License #: 52-252255-01
Agreement: N
Docket:
NRC Notified By: A. ALVAREZ de la CAMPA
HQ OPS Officer: DONALD NORWOOD
Licensee: HOSPITAL METROPOLITAN DR. PILA
Region: 1
City: PONCE State: PR
County:
License #: 52-252255-01
Agreement: N
Docket:
NRC Notified By: A. ALVAREZ de la CAMPA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/31/2011
Notification Time: 12:15 [ET]
Event Date: 08/17/2011
Event Time: 00:00 [EDT]
Last Update Date: 10/31/2011
Notification Time: 12:15 [ET]
Event Date: 08/17/2011
Event Time: 00:00 [EDT]
Last Update Date: 10/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)
NEIL PERRY (R1DO)
ANGELA MCINTOSH (FSME)
DOSE TO AN EMBRYO
"On 8/17/2011, an oral dose of 100.2 mCi of NaI-131 (sodium iodide) was administered to a female patient of childbearing age for radioablation of papillary thyroid carcinoma post thyroidectomy. The patient became pregnant approximately a week after dose administration, despite proper pre-therapy orientation and against medical advice. This was brought to [the licensee's] attention by the patient's OB/GYN physician on 9/28/2011. On that same date, the patient was contacted via telephone and was alerted and oriented as to the possibility of harmful effects of radiation to the embryo. On 10/4/2011, that same orientation was performed more thoroughly in person. Full dosimetric analysis was performed by [the licensee's] medical physicist on 10/5/2011. A complete medical report, including possible effects and complications was given to the patient and referring OB/GYN physician on 10/19/11. The list of possible complications included: Miscarriage, neurologic system damage, intrauterine growth retardation, mental retardation, and increased risk of development of cancer.
"To prevent recurrence of this incident, [the licensee has] created a barrier system, where the department secretary and then the nuclear technologist verifies the patient's paperwork before the physician. We have also revised our patient instructions for childbearing age patients."
The licensee has verbally discussed this incident with R2 (Bermudez).
"On 8/17/2011, an oral dose of 100.2 mCi of NaI-131 (sodium iodide) was administered to a female patient of childbearing age for radioablation of papillary thyroid carcinoma post thyroidectomy. The patient became pregnant approximately a week after dose administration, despite proper pre-therapy orientation and against medical advice. This was brought to [the licensee's] attention by the patient's OB/GYN physician on 9/28/2011. On that same date, the patient was contacted via telephone and was alerted and oriented as to the possibility of harmful effects of radiation to the embryo. On 10/4/2011, that same orientation was performed more thoroughly in person. Full dosimetric analysis was performed by [the licensee's] medical physicist on 10/5/2011. A complete medical report, including possible effects and complications was given to the patient and referring OB/GYN physician on 10/19/11. The list of possible complications included: Miscarriage, neurologic system damage, intrauterine growth retardation, mental retardation, and increased risk of development of cancer.
"To prevent recurrence of this incident, [the licensee has] created a barrier system, where the department secretary and then the nuclear technologist verifies the patient's paperwork before the physician. We have also revised our patient instructions for childbearing age patients."
The licensee has verbally discussed this incident with R2 (Bermudez).